Resources and Events – Case Studies

West Lancs CCG Patient Focus Case Study: January 2019

About The Project

Using Elemental’s social prescribing platform, GPs across seven practices in West Lancs CCG are now actively making, managing, and reporting on instant referrals to local social prescribing hubs, as well as tracking the impact of their referrals.

In an effort to tackle growing health inequalities and the social isolation epidemic in Skemersdale, West Lancashire CCG have been using Elemental Software’s Core social prescribing platform to make direct referrals to non-medical sources of support within the community. This allows healthcare professionals such as Community Specialist ParamedicsGeneral Practitioners and Community Matrons to refer patients directly to the Skelmersdale Social Prescribing Team.

We caught up with Jacqui Sutton, Link Worker from the Social Prescribing Team at West Lancs CVS to find out how things have been going and to hear more about their social prescribing project.


“The Social Prescribing Team along with our Community Specialist Paramedics from the North West Ambulance team have been able to carry out some very effective joint working.  An example of a recent successful referral is from one of our GPs related to a patient who was frequently “blue lighting” for non-medical reasons.”

Jacqui Sutton, Link Worker at West Lancashire CCG

The patient, an elderly lady, presented to healthcare professionals from a number of community teams numerous times. This was recognised by the GP and referred to Jacqui through Elemental’s Core Platform.

After her first interaction with the patient, Jacqui found that she had just came back from A&E, was distressedshort of breath, experiencing a burning sensation in her throat and chest, and was dizzy – symptoms that Jacqui later found were similar to how the lady had been presenting to paramedics and her GP with.


As part of the Social Prescribing Team, it’s Jacqui’s job to source and connect resources in the community that are readily available for patients, and so, she reached out to the Community Paramedic team, in particular Kieran PottsCommunity Specialist Paramedic in Skelmersdale.

The North West Ambulance Service, via the local Community Specialist Paramedic, worked with Skelmersdale Social Prescribing Team to meet with the patient and establish her fearsconcerns and expectations.  They soon realised that the physical sensations the patient had been describing regularly in the middle of the night were causing social anxiety and affecting this lady’s confidence.  in fact acid reflux. The burning feeling in her throat sparked major health anxiety for the patient which then spiralled her into a panic attack which led the lady to call 999 in fear that she was dying.

“As a Community Specialist Paramedic, I work for the North West Ambulance Service, linking in with the Skelmersdale Social Prescribing team and West Lancashire CCG. I am regularly finding that patients I see with long term medical conditions not only require medical support, but also social support. As part of our joint working, I have witnessed collaboration of the highest standard, focusing on providing holistic health and social care for our West Lancashire population.”

Kieran Potts, Community Specialist Paramedic, North West Ambulance Service


The next step was to connect the Medicine Management team with the GP.

The GP previously prescribed antacid medication which the Medicine Management team now helps her to obtain.  The Community MatronsCommunity Paramedics and the Social Prescribing Team are supplied with a medication checklist from the Medicine Management team which means that when they are either called to the lady’s house or are making a visit, they can check if the lady has received her prescription, been taking her medication, and in the correct way.

The Community Matrons then referred the lady into a Luncheon Club in her community. The lady was reluctant to attend at first but Jacqui and her colleague from the Social Prescribing Team attended the first few lunches with her, settled her in and realised that she soon connected with old friends and members of her neighbourhood. Jacqui arranges a taxi to pick up and drop off the lady every Wednesday.


Through the Luncheon Club, the lady has been invited to other community events and clubs which have significantly improved her social life and created a sense of belonging for her amongst her neighbours.

By working together and liaising with other health and social care colleagues Skemersdale Social Prescribing team have been able to reduce calls from the patient to the ambulance service by 92% and subsequently the patient has improved a positive shift in her physical and mental wellbeing.

“For us, this is an inspiring example of social prescribing and ticks every box when it comes to what’s required to make a social prescribing project successful. The collaboration between each team is incredibly impressive and shows just how effective joining up with others services can be and how beneficial it can be to someone in need. The fact that West Lancs CCG are creating efficiencies and improving lives through a joined-up social prescribing approach like this makes us extremely proud to be in partnership with the entire team.”

Leeann Monk Ozgul, Elemental Software CEO

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