“The app was a great resource to have. It meant that pretty quickly we were able to share details of what support was out there as the situation changed.”

Mel Bond, link worker

Supporting innovative practice in social prescribing

Challenge / problem identified

When the COVID-19 lockdown was imposed, it left thousands of vulnerable people at risk of being isolated at home.

The South West Academic Health Science Network’s Institute for Social Prescribing supports innovative practice in social prescribing across the South West of England and beyond to help address a range of issues that impact people’s health and wellbeing.

During lockdown, the Institute has been supporting community groups in Devon and Cornwall, whose work usually involves bringing people together, to find alternative ways to provide support to the most vulnerable.

Actions taken

St Austell Healthcare

St Austell Healthcare general practice working with the charity Volunteer Cornwall, devised a process to systematically identify and prioritise support to vulnerable people. They then created and trained a team of staff and volunteers to contact people, deliver food and medicine, and provide social interaction where it was needed.

With technical support, the social prescribing team rapidly repurposed their existing mobile app, Help at Hand. The app – a directory of the latest support services in St Austell available by telephone and online – quickly became an essential tool for supporting those most in need.

A protocol document setting out different processes was also developed to help the social prescribing team and wider surgery staff. The protocol included a script for telephone calls and a process to enable practice staff to flag patient and residents who might benefit from contact.

The South West AHSN (SWAHSN) has been capturing learning emerging from the St Austell Healthcare and supporting the practitioners through its Spread Academy to exchange and develop their methodology.

“Working in partnership with St Austell Healthcare meant that vulnerable and isolated members of the community were able to be identified early on and the required support put in place quickly.”

Gemma Sutcliffe, High Intensity User Coordinator from Volunteer Cornwall

One Ilfracombe

In the North Devon town of Ilfracombe, the Institute works with One Ilfracombe, a community partnership group who focus on improving the health and wellbeing of local residents through social prescribing projects. Ilfracombe has significant pockets of deprivation, and a high incidence of long-term chronic health conditions. Nearly a quarter of the population in North Devon are aged over 65, compared to 18% nationally. This means many people are classed as vulnerable and have had to self-isolate during the pandemic.

In March, One Ilfracombe had to react to the challenges brought about by the emergence of COVID-19 and reconfigured their provision to respond to local needs.

By working together and utilising existing networks, a team of volunteer support was quickly recruited and mobilised.

The town was divided into 11 areas, with each assigned an overall coordinator and a sub-coordinator designated to each street. Each area set up a closed Facebook group to organise themselves and allow administrators to monitor the situation and share information from a central point.

The local team also developed a ‘cascade’ system to delegate jobs according to local needs and respond to changes in the national situation. This was critical for shifting focus throughout the pandemic.

A leaflet was designed, printed and delivered to 7,000 homes. This offered people without friends or family nearby shopping and prescriptions deliveries, wellbeing checks and help with other tasks.

To maintain control of this major logistical task – including the organisation of multiple partners – the team developed a work plan, which became essential and enabled them to share learning more widely in the region.

Through the Institute for Social Prescribing, the SWAHSN has been working with One Ilfracombe and other groups to spread their learning through the development of a case studies, blogs, virtual events and training. These materials are helping to inform how healthcare in the region becomes more resilient through the COVID-19 pandemic experiences.

“I’m 86 and live on my own, so I don’t know what I would do without the volunteers. It’s absolutely fantastic otherwise I would not have anything.”

Mo, Ilfracombe resident

Impacts / outcomes

St Austell Healthcare’s approach (optimising use of data, digital technology, people, partnerships, and processes) enabled the social prescribing team to support hundreds of vulnerable people in the town during the COVID-19 crisis.

The team called nearly 1,600 residents to check on their health and wellbeing and offer assistance. Volunteers also delivered prescriptions to around 300 people and prepared and delivered hot meals to people in need. The team also supported people with diabetes by facilitating a virtual support group online.

The Ilfracombe team is one of seven ‘One Community’ groups in North Devon. Together, they recruited a combined volunteer workforce of more than 1,000 people who carried out over 2,000 essential tasks for vulnerable residents. These included:

  • 600 shopping deliveries
  • 940 prescription deliveries
  • 300 befriending check-in calls
  • 160 other acts of kindness, like dog walking and letter posting.

Lessons learned

The St Austell project highlighted the importance of partnership working and using data and digital resources to overcome challenges. By working alongside data managers and app developers, the team were able to respond quickly and accurately, and focus their efforts on those that needed their support the most. The repurposed Help at Hand app meant essential information was organised, searchable and could be easily accessed.

The relationships between team members – many of them volunteers – and professional staff proved to be another important aspect. Clinical links were particularly critical, providing the team with access and insight from doctors, district nurses, pharmacists and others.

Providing members of the community with the opportunity to contact the social prescribing office team was also highly beneficial. In several cases people called the team for support, even though many had said they were well on the initial wellbeing check-in call. This was particularly important at a time when people were hesitant to contact an under-pressure NHS.

The Ilfracombe team was able to respond effectively to the challenged posed by lockdown thanks to the whole-system approach to social prescribing that had been developed over previous years. This groundwork, which focused on building relationships across and within the community, formed a strong base on which to draw, helping to develop the quick, comprehensive and cohesive community response in a time of crisis. Developing the system of volunteer area coordinators was also essential given the small existing team.

In Ilfracombe they also learned the importance of clarity in defining what you are providing and for whom, and to set out precise boundaries. They were clear that the support on offer was for those people that do not have friends and family nearby.

Future plans / next steps

The SWAHSN is supporting a social prescribing learning community.

Through its Institute of Social Prescribing, the AHSN is working with test beds, including St Austell Healthcare, and researchers in the region and nationally to generate models of effective practice for other primary care and voluntary sector organisations nationally and internationally. They have also teamed up with the South West Institute for Personalised Care Team to enable the Ilfracombe team to take part in the AHSN’s Spread Academy in order to ensure their great work can benefit other communities.

“I do hope that when we are over the crisis, some of the skills learned, friends made and services given are not forgotten and we come out the other end in a better state than we went into it.”

Councillor Val Gates, Mayor of Ilfracombe