Resources and Events – Case Studies

Digital social prescribing accessible by all as NHS Knowsley Clinical Commissioning Group deliver vital services to their community

About The Project

NHS Knowsley Clinical Commissioning Group is part of the Cheshire and Merseyside Integrated Care System. Consisting of local Primary Care Networks and GPs and healthcare professionals from 25 member GP practices across Knowsley, the region has been leading the way with data-driven social prescribing.


NHS Knowsley Clinical Commissioning Group is part of the Cheshire and Merseyside Integrated Care System. Consisting of local Primary Care Networks and GPs and healthcare professionals from 25 member GP practices across Knowsley, the region has been leading the way with data driven social prescribing.


Social prescribing has been available in the region for over a decade thanks to the creation of the Care Merseyside Charity. More recently, Knowsley CCG, has set about ensuring that everyone in the region can self-refer or be referred to social prescribing. All GPs and Multi Disciplinary Teams can now make and manage referrals to social prescribing locally.



In 2009, social prescribing was still very much in its infancy in the region. The Care Merseyside charity, in the heart of Knowsley, was the first GP funded social prescribing charity in the UK. Founded by GP Dr Faisal Maassarani, the national charity works hard to relieve poverty, provide education and training opportunities and recreational activities for people of all ages.


Knowsley CCG needed a solution that could help organisations to establish and scale social prescribing across the region by connecting health, housing and the community and voluntary sectors. They also wanted to be able to measure the impact of their investment in social prescribing and ensure that people were accessing services that helped address their social needs.


Referral pathways for social prescribing were still manual and a paper-based form of informal signposting. However, more and more GPs began referring to non-clinical services. They needed a safe, secure, and accountable way for programmes like Care Merseyside’s Tower Hill Community social prescribing programme to receive referrals and provide updates for those making referrals.



In 2019, Care Merseyside chose Elemental’s social prescribing platform as a solution to the challenges they were facing around enhancing and reporting on their Towerhill Community Centre social prescribing programme.


Elemental’s exploration of the project requirements included scoping of all key stakeholders, the VCSE landscape in Knowsley and the deliverables and KPIs expected from commissioners within the CCG, led to the creation of Care Merseyside specific social prescribing model, referral pathway by GPs and multidisciplinary teams and the referral pathway for beneficiaries.

Care Merseyside

Care Merseyside’s Social Prescribing Model

Using Elemental, GPs within the Maassarani Group Practice surgery began connecting individuals into Towerhill Community Centre social prescribing programme where they were then prescribed non-clinical sources of support to enhance their health and wellbeing, such as employment initiatives, debt advice, nutrition programmes, floristry and makeup classes.


In partnership with Big Help Project and Knowsley Foodbank, the aim of the Towerhill Community Centre social prescribing programme is to significantly reduce pressure on GP services by supporting individuals to take greater control of their own health and well-being.


2020 brought about a new challenge with the arrival of Covid 19. Traditionally people would have access to social prescribing via GP referrals from appointments. However, as less people were seeing their GP in person due to Covid 19, the challenge was how would Knowsley CCG GPs and their teams help people to get the social support they needed when they needed it most.


They quickly set up a new programme intervention to adapt to the current crisis called ‘Phone a Friend – You’ll Never Walk Alone’. Their team of Link Workers worked remotely, calling those most vulnerable in their community to offer help with any needs, such as delivering groceries.


Elemental also provided Care Merseyside with Self Refer, a front-end website extension that allows any community member to register themselves instantly to speak with a Link Worker or request support. All referrals made through the website feed through into the Elemental Core Platform.



To date, Care Merseyside have received 1827 referrals from 11 practices and have been able to report on various data points including referral source, reason for referral, status with the journey (waiting, active, discharged etc.) uptake of referral, demand for activity, caseload management, health impact.


Impacts to date:

  • In the first year of their social prescribing programme, patients referred to Care Merseyside by The Maassarani Group Practice reduced General Anxiety Disorder in patients by 43%.
  • 43% uptake in engagement in social prescribing services
  • Mental Health, Healthy Eating and Covid 19 have been the three main reasons for referral
  • People were connected into services such as Befriending, Counselling, Social Support, Mental Health Support and Physical Exercise.
  • A trend in increased GAD-7 scores due to Covid 19 meant that Care Merseyside knew they needed to increase services and support for Mental Health in 2020.
  • Reduced GP appointments due to the addition of Elemental’s Self Refer on the Care Merseyside website which GPs text a link to all patients.


As a result of the partnership with Elemental, providers of social prescribing services have been able to report the following:

  • More time spent with people and less on admin
  • Quicker response times to referrals
  • Sharing caseloads between Social Prescribing Link Workers
  • Strengthening of relationships between GPs and community partners
  • More people accessing social prescribing in the community


Cathy Connolly, CEO, Care Merseyside

“Elemental has provided us with a platform to present our findings with authority, encourage more partners to collaborate with us, allowed us as an organisation with a small number of staff to help provide a service to a large number of people and made it so easy for GPs and Clinicians to buy in to making a social prescription at a single click of a finger in consultation times.”


The future of social prescribing for NHS Knowsley CCG

Innovate Volunteering manages a range of successful projects across the local authority and voluntary sector that focus on volunteering, individual progression and community cohesion. New users are currently being set up and trained on Elemental via our online learning academy that can be accessed remotely and on any device. Although in the early adoption stage, Innovate Volunteering has already received 255 social prescribing referrals with plans being put in place to partner with Knowsley Council Adult Social Care Team in a bid to further streamline support services.


Further scaling of digital social prescribing across the region continues as Kirkby PCN, South & East Knowsley PCN and West Knowsley PCN are in the process of implementing Elemental and due to go live over the next few months.

Fancy A Demo?

Let’s discuss your plans for mobilizing your communities and explore if and how we can help pop your details and we’ll call you back within 24 hours.

All fields are required.
Full Name
This field is for validation purposes and should be left unchanged.