Strengthening community support through digital social prescribing during Covid-19

How to strengthen community support through digital social prescribing during Covid-19

How Elemental is enabling NHS, Councils, housing and VCSE organisations to work better together for support for the most vulnerable during COVID-19

Elemental is the platform of choice for over 200 digital social prescribing hubs across England, Scotland, Wales, Northern Ireland, Republic of Ireland, so when The World Health Organisation(WHO) announced that Covid-19 was officially classed as a global pandemic, we knew we had to respond quickly with a contingency plan, not just for our team, but for our customers and the hundreds of thousands of people they collectively support.

We’ve enhanced the capabilities of our digital social prescribing platform to provide teams with the technical connectivity they need for partnership working, leadership and the measurement of mobilisation of support where needed during Covid-19.

We’re continuing to share how healthcare and community organisations around the UK are delivering their Community Support plans, as well as how our customers are using Elemental to:

cohort group

establish cohort groups

and assign different levels of urgency and support needed.

diverse seniors

Prioritise your focus and efforts

by connecting those known to you and not yet known so that they can access helpful information, services and online interventions.

increase capacity

increase capacity

Increase capacity to deliver on your plan by connecting Commissioners, clinicians, Link Workers, health and community providers and citizens.



-Including befriending services, online resources and services that can be used from home, grocery collections, pharmacy delivery services, local food bank access, NHS App Library and more.

banner devices8

track and measure progress

by running reports on the overall and specific progress being made across a number of different levels and see the effectiveness of your coordination, whilst identifying any gaps in provision.

What we found out during our recent webinar…

poll: We asked delegates;

What is the biggest challenge that you are facing now in implementing your community plans?

Knowing what’s working - measuring the impact 48.89%
Identifying where the gaps are 47.41%
Coordination of non face to face interventions 45.93%
Lack of IT equipment - such as tablets and IT systems 30.37%
Not being able to get remote access/access to referrals 25.19%

Question: We asked delegates to give us examples of their community response and support plans

Bethan Jones, United Welsh said: “United Welsh – Our workers are carrying out telephone calls to monitor the welfare of vulnerable clients. We have provided an online information hub that includes links by area and ideas for activities that keep people connected, e.g. virtual choirs and neighbourhood volunteers.”

Joanna Seymour, Warm Wales said “We are from Warm Wales delivering our support via the phone, we are going through our old cases and calling and checking in to see what help or support they need. We are new to Elemental so are keen to hear from you and others. We are covering North Wales and identifying all of the support available.”

Matt Jon-Hutcherson from Wellbeing4U said”At Wellbeing 4U we have had to transform the way that we are working. As a service based in GP surgeries, attending sessions with patients is obviously no longer viable for us. Essentially, we are now delivering phone consultations only so elemental has been a huge support to us with its texting / emailing facilities. We are also using Elemental to pull off certain cohorts of people to contact. EG over 65’s etc. We are supporting the advice and guidance around CV19 and befriending along the way. We are also delivering online classes and workshops via Zoom.”

Narinder Dosanjh, Ruils said they are offering “Online telephone befriending from our Link Workers, referrals to local charities for shopping and prescription pickup/drop off, supporting with low mood, increased anxiety, indoor activity packs being dropped off, library service dropoff/pickup of books and CDs.”

Tara Byrne, Age Opportunity Ireland said, “I represent Age & Opportunity Ireland and we aim to help people stay connected during this time. We have been offering online movement videos to help people stay active, online resilience training and we are approaching artists to see what they can offer older people at this time, as well as gathering all of the current arts resources out there.”

Nicola Wheeler, Catalyst said “We’ve brought colleagues from across our business (housing association) who currently have capacity to take part in a coordinated ‘wellbeing project’ carrying outbound welfare calls to our 30,000 tenants. Referring to local services (befriending, food distribution) and into our own services e.g. money and benefits advisors and employment and training advisors. We have made funding available to provide emergency fuel and cash vouchers to vulnerable tenants

Clare Cook, SPRING Social Prescribing (Scotland and NI) said “We have created a new Connect Well service where social prescribers are contacting clients via telephone, texting, video calls, facebook, whatsapp etc. In Scotland, a lot of our clients are understandably and incredibly anxious with money and food issues. Our 10 delivery partners in Scotland are responding by providing a range of support from being a listening ear to referring to food banks, money advice services, sending videos on meditation, mindfulness and physical activity etc. They are brilliant!”

Thomas Hayes, South Liverpool Homes said “Regular wellbeing calls to vulnerable tenants. Providing advice on local services. Our benefits and affordable living team also providing support and advice over the telephone.”

Rachael Holden, Imagine Independence said “We have created action plans for each service, created business continuity plans, completed service-wide risk assessments and individual risk assessments for every person we support.”

Veronica Franklin Gould, Arts4Dementia said “Please let participants know that is signposting #DailyArtsMedicine and our website signposts only Remote Access arts stimulation for dementia at present.”


We’re also continuing to share knowledge, best practice and examples from our customers around the UK and Ireland who’ve been applying their own Covid-19 specific models to enhance the effectiveness of their mobilisation plans and measure the effectiveness of their efforts. Including:

the liferooms (Liverpool)

Following Covid-19 public health advice, the Liferooms took the difficult decision to close all their centres to the public for the safety of clients, volunteers and staff. 

The Liferooms is a free NHS service, which provides a safe and welcoming space to meet others, access opportunities and learn about community resources. They offer support for those wanting to take the next steps in their life.


The service is using Elemental to help focus all efforts on coordinating the support of their communities during this unprecedented period of worry and disruption.

The Liverpool based service had to quickly come up with alternatives around how to support people in their own homes, versus people being able to physically access their sites. Pathways advisors at Liferooms began to provide an over the phone to people they identified through Elemental as being vulnerable, and those in marginalised communities who now find themselves more isolated than ever.

Their focus also switched to digital, and they have created a suite of nine online learning opportunities, including activities such as:

-A week long fit camp, delivered by a Liferooms personal trainer, with videos being released each day

-Three online cooking sessions

-Learning opportunities around how to stay well at home – #StayWellStayHome

How digital has fast tracked community response to combat total isolation | Part 2


Merton has always been an area with really strong partnership working between local authority, health, community and voluntary sector and housing partners. GP and London Regional Clinical Lead, Mohan Sekeram has been a major part of the coordinated approach to community health.

Mohan uploaded a video on Twitter to show how social prescribing Link Worker, Ray Hautot, at Wide Way Medical Centre is using Elemental to identify vulnerable patients, contact them and connect them to vital services during Covid-19.

the bureau

Following Covid-19 public health advice, The Bureau in Tameside & Glossop suspended all group and home visits for the safety of clients, volunteers and staff. The community wellbeing charity are using Elemental to help focus all efforts on coordinating the support of their community during this unprecedented period of worry and disruption.

The Bureau are using Elemental to help them coordinate referrals from their local neighbourhood resilience hub (an integrated team of district nurses, social workers, GP’s and the local hospital NHS trust (T&G ICFT). Using the platform to track people and onwardly link them into local volunteers and community groups offering support such as Glossopdale Foodbank, and telephone befriending. 

Mobilising the people of Glossop is key to the work being done by the Bureau, as they are in need of volunteers to help making social telephone calls to people in isolation, distributing food and medication, and assembling food packages.

Digital Social Prescribing Movement Strengthens Response To COVID19
How digital has fast tracked community response to combat total isolation | Part 2

Enable (Wandsworth)

Similar to Care Merseyside, Link Workers at Enable, an organisation which provides leisure and cultural services for the benefit of local communities in Wandsworth, are now proactively calling people who have been identified through Elemental as being vulnerable and isolated, to perform well being check ups. 

During the initial call, Link Workers offer support and ensure people are safe and able to access vital supplies such as food and prescriptions. 

They encourage people to stay as well as possible by keeping physically and mentally active and maintaining social connections remotely.

The team is working in partnership with the local voluntary sector response and are referring or signposting people to support or resources when needed. 

The Link Workers are playing key roles in ensuring that people who are isolated are connected with the amazing practical support that is being provided in the community.

Care Merseyside

Care Merseyside is a social prescribing charity based in Knowsley and a partner of the Dr Maassarani & Partners (Tower Hill). They have redesigned the delivery of their schedule of activities, which previously involved things like creative writing classes, exercise and drama classes, and are contacting all their beneficiaries to offer support. 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 are working remotely and are calling those most vulnerable in their community on a daily basis for a chat and help with any needs, such as delivering groceries.

By using Elemental, the Care Merseyside team identified up to 300 vulnerable people, and have called them to see if they would wish to be supported by this service.

Each of the Care Merseyside team are using Elemental to find out how the person is feeling and is using a validated measurement tool to measure social isolation levels, which will show a baseline to how isolated the vulnerable people are. The impact of the service will be tracked using Elemental, and this score will be reviewed in a week or two to see if the volunteer system has helped them feel less isolated.

Care Merseyside have contacted local schools to offer their staff and pupils to get involved. The aim of this initiative is to provide enrichment activities for pupils to take part in while working from home, such as letter writing skills and arts and crafts skills. One school came back thanking Care Merseyside for contacting them and described the initiative as “incredible”.

How digital has fast tracked community response to combat total isolation | Part 2


Following Covid-19 Public Health advice The Old Library Trust closed its 20,000ft Healthy Living Centre in Creggan, Derry two weeks ago. Moving quick to come up with alternative methods to connect their community, the OLT now engages with service users, programme participants and the local community in several different ways, including:

– Daily phone calls to check in with residents, providing a listening ear

– Private group messages

– Facebook live sessions and videos

– Online health and wellbeing sessions

The Healthy Living Centre is using Elemental to locate, identify and contact those most in need who have engaged or are currently engaging in the range of programmes and services offered. Using Elemental has also enabled the organisation to categorise people by address, age, associated health conditions and number of dependants, helping to speed up the community response, and ensuring that those in most need are recognised early and given person centred care and support.

The Old Library Trust is using Elemental to support the wider community response during these unprecedented times by tracking people whilst onwardly linking them to the local Neighbourhood Renewal response package, which includes food bank referrals, local shopping delivery referrals and local, regional and national health and wellbeing support structures. They include benefits advice, counselling and Lifeline.


Wellbeing4U have adapted their services by coordinators being home-based to reduce the footfall of people in GP surgeries and to carry out telephone consultations rather than face to face appointments.

The social prescribing service have adapted their way of working to meet the needs of the current climate and the lifestyle/behaviour changes people are being forced to make.  They have created a wellbeing plan to help them have a conversation with patients around what matters most to them in the current situation, connect them with available help with shopping, collecting prescriptions and to connect with other people during this period of isolation.

Wellbeing4u are also offering our patients the option of having a weekly telephone call from the co-ordinator not only as a way of checking in with them but to be a person they can have a conversation with which many people are really appreciating right now.  The service has also adapted to only receiving digital referrals through Elemental where COVID19 advice and guidance has been added as a referral reason, or through email. They have also adapted their Healthful Network courses to be delivered online.

“Using Elemental has helped Wellbeing4u to create a Cohort of patients referred specifically for COVID-19 which will assist us to provide data to the Health Board how we have responded to the current situation and will assist massively in our reporting over the next few months.” – Emma South, Health and Well-being lead


Feedback received from patients is showing how helpful the weekly check in calls are. The opportunity to talk through anxieties and worries around Covid-19 is clearly benefiting patients during this time.

“I think the online class is a great idea, giving us a change not only to exercise in the comfort of our own home – which otherwise we would not do ourselves, but also to communicate live with the people who are in the same boat – thanks to you all.”

“I am extremely grateful that Rhian has been keeping in touch with me. It’s so reassuring to know that she actually cares enough about my well-being in these very unprecedented times. Rhian is totally natural in all our interactions. She shows me such empathy and I can fully relate to everything she has said and done to help me. WB4U has suggested so many positive activities for me to try to quell my anxieties in these extraordinary times. I really want to praise their persistence in thinking of so many ideas to keep me calm. I appreciate their value and time spent in contacting me.”

17 Apr Remote working enhanced through digital social prescribing during Covid-19
17 Apr Remote working enhanced through digital social prescribing during Covid-19


In response to the Covid-19 Pandemic, Tandridge District Council had to quickly adapt their Wellbeing Prescription Service, which has now been operating remotely for over 3 weeks. 

Although the team understood the necessity, they were apprehensive about temporarily pulling their service from GP Practices and pausing home visits. They were concerned about what this would mean for the service and if we would be able to adequately support our clients. However, they have been pleasantly surprised by the positive response from established clients, new clients and our key partners.

A lot of the services Tandridge would usually signpost clients to have temporarily closed, so to ensure they can continue to offer a high level of support, they have utilised Elemental’s social prescribing platform. Elemental has allowed the council to quickly collate a category of support specifically related to COVID-19 which allows their advisors to easily browse the support on offer in the client’s local area or online and signpost them to services such as:

  •  A local mutual aid group that can offer prescription or food parcel delivery
  •  A telephone befriending service
  •  NHS IAPT telephone
  •  Online therapies – how to remain active at home
  •  And so much more.

In the last month Tandridge District Council have made over 105 signposts to COVID-19 specific support.

Although the service temporarily doesn’t have a physical presence in GP Practices, they are in regular contact with them, receiving new referrals daily and they are pleased to be able to confidently direct their worried patients to Wellbeing Prescription who can offer advice, support, be a listening ear or signpost onto other services.

In addition, Wellbeing Prescription has been supporting the wider Tandridge District Council COVID-19 response. As a team of Social Prescribers, they are well equipped to support the most vulnerable residents and are therefore assisting the outbound calls to residents on vulnerable people lists.  As a result of the call, some residents are becoming permanent Wellbeing Prescription clients and will continue to be supported by the team over the phone and then face to face once our usual service resumes.

“Elemental has enabled Wellbeing Prescription to make a seamless transition from face to face to telephone support. We are pleased we’ve been able to continue the vital work of social prescribing both to our current clients as well as to new clients. Elemental has allowed us to keep track of the ever-increasing list of COVID-19 specific services as well as ensuring we can accurately record the support we are offering while demonstrating how our service has benefited the local community.” – Nicola Boreham, Wellbeing Prescription Manager


If you’d like a 1-1 demo or run-through of the Covid-19 functionality within our social prescribing platform.  Simply pop your details in the form opposite, and we’ll be in touch within 24 hours to arrange your demo.

gp it futures social prescribing

request a full demo of our Covid-19 Social Prescribing Platform