What everyone can learn from the North Wales Social Prescribing model

In today’s blog, Elemental’s CEO and Co-founder Jennifer Neff, shares why she feels organisations in North Wales are global, digital exemplars for social prescribing thanks to their social prescribing model, committed partnership working and enhancing their programmes through social prescribing software.

I remember where I was when I first heard about social prescribing. It was 2013 and I was in the Sandwich Company in Derry having lunch with a colleague. I told her about this idea that I had been working on with Leeann Monk where we wanted to help address health inequalities in disadvantaged communities by better connecting people into activities like walking groups, debt advice, art classes, mindfulness and housing support and how we wanted to help GPs, and other health and social care professionals, to be able to better address the social determinants of health. 

Leeann and I had been in community development for years, working with some of the most caring and creative neighbourhoods facing some of the biggest inequalities where life expectancy could differ by up to 15 years depending on where a person lives.

In our experience, there were so many things that people could engage in in the local community that improved people’s health and wellbeing but, we knew it wasn’t as easy as handing someone a leaflet or directing them to a website.  Many people needed more than that, and taking the first step to try something new was daunting especially if you were struggling with depression or were anxious about being in debt or evicted from your home. We knew that compassion and empowerment were key. 

I talked at length with passion about how we were planning to connect the dots when my colleague said, ‘That’s actually called social prescribing’ and key to the whole social prescribing model is a Community Navigator, a Social Prescriber or what’s often referred to as a Social Prescribing Link Worker. 

Pictured: Elemental Software Co-Founders, Jennifer Neff and Leeann Monk-Ozgul

Leeann and I listened to those involved in community health and wellbeing and those who were designing, delivering and commissioning social prescribing. We found that there were many challenges faced by all stakeholders at different parts of the social prescribing journey. It was often difficult to scale and even more difficult to measure its true impact. 

We decided that this was the challenge that we were going to overcome, having seen first hand the difference made when a person is connected into their own community, supported, and empowered. 

A couple of years before, Sir Ken Robinson had spoken to a packed audience in Derry about creativity and education and about the opportunity that Derry winning the inaugural City of Culture award was having on helping people find their passions.  He told us when someone found their passion, that they were in their element, and that anything was possible. 

Leeann and I were set on helping people find their passions through social prescribing. We knew that digital had a role to play so we set up Elemental with a mission to ensure that social prescribing was accessible to as many people as possible. For us, it had to be about people first and technology second. 


Fast forward to 2021 and we have been part of the formation of over 650 social prescribing hubs across England, Ireland, Scotland, and Wales. We work with fabulous people who genuinely care about empowering communities. They reach across sectors and across barriers to ensure that people have equal access to opportunities within their own communities that make a difference to their lives. 

Where I see this working really well is in North Wales. Social prescribing has flourished over the last year in particular across the 6 counties within the Betsi Cadwaladr University Health Board region. There are currently 8 projects that are leading the way, addressing some of the most extreme issues facing communities, helping people who are experiencing vast inequalities. These projects are strengthening partnerships between health, housing, community, local gov and education. 

The region has been on a journey. In April 2020 Elemental was commissioned by Betsi Cadwaladr University Health Board to provide 7 projects providing social prescribing services with the digital technology they needed. As the effects of COVID were emerging, these groups embraced a new digital platform that could enable them to receive electronic referrals for people who needed support, to enable their teams to work remotely and to cross-refer to a number of different organisations and to be able to track and measure the person’s journey throughout so that no one was left behind.

In October 2020, Glyndwr Wrexham University won funding from HEFCW for well-being and health, including mental health in higher education and established itself as a social prescribing university. For the first time, students were able to access student support services via the social prescribing model of care so that teams working with the university departments could better care for their student’s social needs. 


On Thursday 25 February each of the projects spoke at the 2025 Movement’s Community of Practice conference about their experience and what they have been able to achieve working together during the most challenging of times. The projects included:

  • Anglesey – Medrwyn Mon Voluntary Council
  • Conway – Conwy West GP Cluster 
  • Denbighshire – Arts in Health Project, Grwp Cynefin
  • Flintshire – Warm Wales
  • Flintshire – Voluntary Council
  • Gwynedd – Mantell Gwynedd
  • Wrexham – Penley Rainbow Centre
  • Wrexham Glyndwr University

The Elemental team has been with them every step of the way, and just before the conference I asked our Customer Success team why they think social prescribing works so well in North Wales. Here are our 3 reasons:

1.Strong leadership that understands inequalities: Each of the organisations providing social prescribing services have strong leaders within them who see the value in working together rather than in separate silos. There is also a movement in the region that has grown over the last five years from what started as three angry people in a pub to over 300 people and organisations all working together to create a fairer and healthier future for communities across North Wales. This movement is called 2025 Movement and it brings together small groups of people together in groups called ‘Just Do’ teams, where they collaborate on difficult issues in particular areas. I believe the values of the 2025 Movement collective provide the foundation for better community health and wellbeing. 

2.Compassionate partnerships: Groups, sectors, organisations and people in North Wales genuinely want to do what’s best with the communities they serve. Egos are pushed aside so that the community comes first. Many organisations refer to each other so that the person is always getting the right support. I have never seen such a willingness to work together. Organisations that could be competing against each other are partnering and playing to each of their strengths. 

3.Willingness to embrace new technologies: In the past 11 months all the projects have welcomed the implementation of the Elemental platform so that more people can access social prescribing and so that the projects can see the difference that social prescribing is making to the person, the community and the health and social care sector. It can be challenging learning to use digital tools, especially during a pandemic, however, each organisation has welcomed the introduction of the Elemental platform and is using it for even more than social prescribing. 


As a result over 2,500 people have been referred or have self-referred to the social prescribing projects using the Elemental platform. 35 Social Prescribers and Social Prescribing Link Workers have been trained to use Elemental and are receiving referrals. The main reasons for referrals across all projects and counties have been mental health, COVID-19 and social isolation. The majority of referrals are being made by GP Practices, Emergency Services and Single Point of Access. Some of the most popular services that people are engaging in as a result of social prescribing are Medicine and Prescription Collection Volunteers, Holyhead Town Council, Warm Wales People Support and Your Trusted Friend- Microcare. 

There are over 200 other community and voluntary sector organisations receiving referrals from social prescribers. 

We’re excited about the learning from the GP data as more and more GPs get access to the technology that Elemental has developed that enables them to make safe and secure referrals to social prescribing. What is exciting the GPs most is being able to better support their patients but also being able to see the follow-up carried out after the referral was made. 

The plan is for all referrals to social prescribing to be done via Elemental so that the projects can report more easily on when referrals are coming from and what they are for. This level of information will not only demonstrate the impact of social prescribing but also which services are most in-demand and the difference they are making to people’s health and wellbeing.

The biggest challenge for every locality right now is addressing the effects that COVID has had and is having on people’s mental health and wellbeing. Being proactive is key, so the opportunity to see in real-time where social prescribing and mental health services can and are working closely together can create instant benefits. I believe that the foundation of strong leadership within sectors, projects, and in services is what will make the difference, as well as the ability to empower and provide communities with situational support when needed. North Wales is demonstrating this on all levels and with that, only good things can happen. 


Jennifer is the Co-Founder and CEO of Elemental Software, a female led tech for good company based in Derry, Northern Ireland.

Jennifer is driven by a passion for ending health inequalities. She set up Elemental Software with Leeann Monk, to establish, scale, and measure the impact of social prescribing, connecting people, building communities, and improving lives.

Jennifer works every day on that mission, to spread the word about the social prescribing movement, the difference it makes to people’s lives, communities, and the health and social care sector.

Building upon her years of experience in regeneration and social and economic development, Jennifer helps organizations to enhance and evaluate the impact of their social prescribing programmes via Elemental’s award-winning portfolio of digital social prescribing products and transformational consultancy services. 

As the leading digital social prescribing software provider in the UK, Elemental is bridging the gap between health, housing, the VCSE sector, Local Government, and prison services with a range of digital solutions designed to enable the strategy and practice of self-care and independence.  

Jennifer believes this is a powerful route out of health inequality.


We are Elemental, an award-winning tech for good company with the purpose of empowering and enabling individuals, families and their carers to better connect into community-based programmes, services and interventions that make a positive impact on their lives.

We are a team of passionate community impact professionals who genuinely care about community health and well-being and reducing health inequalities.


If you’d like to find out how Elemental can enhance and scale the impact of social prescribing in your communities, get in touch or pop your details below to request a 1-1 online demo of the Elemental Platform and the Elemental Connector.

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