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When services become seamless: a Social Prescribing story

8th February 2022

We wanted to share a story from one of our Social Prescribing Link Workers, Deborah. She passed us this patient story as a great example of what happens when services work together to provide patients and clients with seamless support.

But first: what is Social Prescribing?

Social Prescribing allows GPs and other care staff to refer patients who have social or other non-clinical needs to a Link Worker, based at the surgery. Link Workers work with patients one-to-one, offering direct support and signposting to help them take control of their own health and wellbeing. They have a wide network of community contacts, and they use their experience and knowledge of local activities and services to co-ordinate ‘whole person’ support.

Sally’s story*

By Deborah Living, Social Prescribing Link Worker

When Social Prescribing is fully integrated into a person-centred GP practice, good things start to happen. Sally’s story shows how.

From my first morning at the surgery where Sally is a patient, it was clear to me that the practice knew their patients well and took an active interest in their wellbeing. Because of this, at the end of my shift, I spoke to the Practice Manager and the surgery team about the work she had done for the patients who had been referred to her. This informal communication structure continued to develop as time went on, with the Practice Manager popping in to see me to give insight into new patient referrals. Before long, the join between the surgery and the Social Prescribing service seemed seamless.

One morning, the Practice Manager came to speak to me about a patient called Sally. Sally had been to a routine doctor’s appointment at the surgery and the Practice Manager – who knew the patient well – had spotted her and felt something was not quite right. The Practice Manager told me how she had run out of the surgery after Sally checked how she was. Sally became upset as she tried to speak and the Practice Manager said, “I know someone who could help.”

One referral to Gateway later and I was on the phone to Sally. Sally told me how both her brother, who had Down’s Syndrome, and her sister had died during the first wave of the Coronovirus pandemic. Sally had become anxious and depressed as a result, was having trouble sleeping, and had closed herself off from the world. She was scared to go out because of Coronavirus and had also got into a mess with her finances. She sat indoors by herself, frightened her landlord was going to evict her at any moment because of her rent arrears.

I consoled Sally over her loss and current situation, and Sally agreed that she would like a referral for bereavement counselling and to a befriending service. I said I could also support her to take steps to separate the other difficulties that were overwhelming her into more manageable chunks, and Sally agreed to a face-to-face appointment at the surgery so we could make a plan together and begin to put it into action.

During the consultation, I made calls on Sally’s behalf so that she could get to grips with what money was owed and when it needed to be paid. She said she now felt able to speak with Citizens Advice for money management advice. On Sally’s request, I mediated between her and an advisor from her housing association and a payment plan was devised that Sally felt was affordable and the advisor was happy with. The advisor said they had no plans to evict Sally, but would like to speak to her about moving to a smaller property as her current home was under-occupied.

When I called Sally a couple of weeks later to check in, she sounded much brighter on the phone. She said she now had people to talk to, and was also in contact with her housing association and Citizens Advice. Sally said she felt more in control of her finances, and had decided to look at a property her housing association was offering her. Now, with Sally taking steps forward, I felt confident about stepping back.

I’m really happy about how Social Prescribing has become a part of practice culture here. It made every contact count for Sally, and will continue to do so for other patients in the future.

*Sally’s name has been changed

More information

Social Prescribing Link Workers are provided to a number of Birmingham PCNs by Gateway Family Services CIC. If you are a GP practice or federation and you’d like more information about service delivery, contact Balvinder Kaur at Gateway on 0121 456 7820. If you’re a patient and think a Link Worker could help you, you’ll need to be referred, so ask your GP practice about social prescribing.

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