Case Study: Clapham Park Practice

Case Study: Clapham Park Practice

Using digital social prescribing to support and maximise the impact of SAIL - Safe and Independent Living

Last year, we announced an innovative social prescribing partnership with Clapham Park Practice and SAIL  – Safe and Independent Living, a social prescribing programme run by Age UK Lambeth.

Using digital social prescribing technology, the aim of the partnership was to support and maximise the impact of SAIL  – Safe and Independent Living by embedding a practice-based model which would enable GP’s to make direct referrals to community-based support, including social support, diet and nutrition, benefits advice and mental health.

The Objectives

Provide enhanced support through better connectivity, personalisation and self-directed support methods

Use digital technology to improve health and well-being outcomes in the area

Demonstrate how digital can be used to support better mental health and well-being outcomes across the region

The Solution

A SAIL in Practice Coordinator was located at Clapham Park Practice to signpost individuals to suitable programmes that will address long term issues, reducing GP workload and waiting times for GP appointments.

Using Elemental’s social prescribing platform, the SAIL in Practice Coordinator was able to:

  • Report on project outcomes and provide detailed evaluations for stakeholders
  • Connect key delivery partners using one central platform
  • Save time and resource by reducing administrative pressures on staff
  • Track and monitor the impact of social prescribing referrals
  • Make direct referrals to programmes and services
Leeann Monk-Ozgul, Co founder and Co-CEO of Elemental
“With GPs under increasing pressure, this pilot demonstrates the impact that digital technology can make to enhancing social prescribing projects, as well as relieving pressure on primary care services. We’ve been working closely with the teams at Clapham Park Practice and SAIL to co-design a referral pathway that would help to enhance the impact of their existing social prescribing programmes and services and we’re delighted with the results in such a short period of time.”

– Leeann Monk-Ozgul, Elemental Co-Founder

- Leeann Monk-Ozgul, Elemental Co-Founder


Throughout the six month pilot, 63 patients were referred to social prescribing programmes and services in their community, 49 of which were engaged by the SAIL In Practice Coordinator.

Over 60% of the social prescribing referrals were related to social isolation, with a third of the total referrals due to mental health issues.

Of the 49 patients connected, 28 received referrals to social support, 11 to Age UK Lambeth’s befriending service and 11 to physical exercise.

“Piloting Elemental software at our GP practice in London demonstrated ‘real world’ application of a digital platform that quite simply, works. With minimal training, clinicians were able to refer patients simply and securely direct from our existing clinical system, and the social prescriber was able to review referrals, assess patients and refer onwards as needed. Elemental allowed for easy capture of data which was vital for monitoring and evaluation when assessing the impact of the intervention. Social prescribing in primary care relies on a trusted person-to-person working relationship, and Elemental software supports this efficiently and effectively, without getting in the way of the human touch”

- Dr Andrew Boyd, GP and lead clinician


Mrs M

Working collaboratively with the patients, the SAIL In Practice Coordinator codesigned a social prescription that would suit the needs and wants of the individual. One such individual was Mrs M, a member of the public who lived close by the practice and visited almost daily for a chat as she was lonely.

The SAIL In Practice Coordinator visited Mrs M’s home and identified a number of needs including a bathroom grab rail as Mrs M had poor mobility and trouble getting around her house. Age UK Handifix also carried out a safety check and renewed her CO2 detector.

Although Mrs M’s grandchildren visited her at weekends, she often didn’t see anyone on weekdays. To help alleviate her loneliness, the SAIL In Practice Coordinator matched Mrs M. with another patient in Clapham Park who now visits her every Tuesday. They have afternoon tea together and Mrs M bakes cakes or scones now she has someone to bake for. Mrs M also gets a call from ‘Call in Time’ every Thursday for 30 minutes, which she has said has made her feel less isolated and lifted her mood.

Mr G

Mr G, aged 54 has also been working with the SAIL In Practice Coordinator after he had been made redundant and was starting to lose his confidence. Mr G had started to feel really low and depressed because he couldn’t find a job which had resulted in him putting on weight and affecting his mobility, causing leg pain.


Mr G also started worrying about his financial situation as he felt that he couldn’t do anything with his young boys with his income. After a lot of encouragement from the SAIL In Practice Coordinator, Mr G attended seated exercise classes in Brixton. He now feels better and the pains in his legs have improved. He is able to take his young sons to the park, walking there and back and he has also been able to reduce his reliance on his medication as a result of the exercise classes.

The 'SAIL in Practice’ pilot 2018-19, supported by AgeUK Lambeth, Elemental software and funded by Guy’s and St Thomas’ Charity, via Lambeth CCG South West Local Care Network

Get in touch

Want to know more about how we can enhance your social prescribing programmes? Get in touch, request a demo or give us a call. We’re ready to talk social prescribing.

We can help

We know that every social prescribing programme is different as it responds to the needs of each unique community and some communities are at different stages in their social prescribing journeys.

Depending upon where you are with your social prescribing project, we can help you;

Identify what gaps exist i.e. training, funding etc

Overcome challenges or barriers for social prescribing

Understand and embrace potential opportunities and benefits to the Person, NHS, Council and the VCSE sector

Help develop your vision and strategy – where you want to be and how you are going to do this

Determine the best way to roll out social prescribing and/or digital

More than just a platform

Our team has helped over 100 organisations shape and deliver their approach to social prescribing across England, Scotland, Wales, Ireland, the Middle East and soon to be Finland.

We were selected to help the Mayor of London, Sadiq Khan, develop his vision for social prescribing in London. 

Some of the team who will be supporting you in your quest to mainstream social prescribing are listed below:


Jennifer Neff


Jennifer has over 17 year’s experience in extensive engagement and consultation with vibrant and diverse stakeholder groups drawn. Her work has informed strategies for renewal – economic, physical and social, building stronger and more vibrant communities.


Leeann Monk


Leeann has over 15 years experience in community development & health, engaging and activating the hardly reached across areas of disadvantage in particular families, older people at risk of isolation, carers and children at risk of or suffering from obesity.


Clare Cooper

Project Manager

Clare has held a number of roles in community health improvement aiming to reduce health inequalities and improve the health and well-being of the community.

enhanced social prescribing

Denise Dillon

Head of Projects

Over 16 years experience working within the community and voluntary sector, working in community development, mental health, training and project management working with some of the most marginalised communities in Northern Ireland.


Phil Veasey

Community Partner

Phil has a strong background in scaling high impact, sustainable strategies and programmes in local communities including ‘Sportivate’ – a major Olympic Legacy Programme and The National Mini Tennis Programme, now the way children are introduced to the sport globally.


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