85% of Frimley Health and Care Integrated Care Board’s deprived population lives in Slough; one of the most ethnically diverse towns in the UK where over 150 languages are spoken. The health of people in Slough is varied compared with the England average. About 15.1% (5,540) children live in low-income families. Life expectancy for both men and women are lower with a 4-year life expectancy difference between Slough and the England average.

Over recent months we have seen a significant decline in our residents’ health outcomes. As the cost of living rises sharply it’s crucial that we think carefully about the impact on patients and citizens and make sure we use data-driven decision-making to provide the best possible care. Taking the time to understand what matters to an individual and their most pressing needs will enable a more holistic, meaningful relationship, affording residents the time and headspace to take more control of socio-economic factors impacting their health.

In line with the national Core20PLUS5 approach to reducing healthcare inequalities, residents living in the most deprived areas, with multiple chronic conditions including diabetes and hypertension, were identified through a population health management approach, and asked to take part in a questionnaire. This would help us identify those who were most likely to benefit from a needs assessment and the support of our social prescribing teams as well as identify areas of perceived burden, like payment of household bills, lack of food or clothing, mental well-being, and digital inaccessibility. Responses and subsequent targeted interventions were all coded digitally to create a powerful dataset that informed our social commissioning offer through richer, deeper insights into patient reported needs.

As of January 2023, over 3,000 questionnaires have been completed with 28% of people reporting fuel poverty needs, 25% concerned about isolation concerns and 17% had mental health issues.

Following interventions from our social prescribing link workers there has been an increase in the number of completed health checks among our diabetic and hypertensive population. There was also a reduction in A&E presentations, NHS 111 and emergency calls and inpatient admissions for those who completed the questionnaire.

The Slough Place team led on the design of service delivery between general practice and the community services. Social prescribing link workers in the primary care network workforce spearheaded the implementation and tapped into alliances within the community, including housing support, citizens advice bureau, food banks, clothing, mental health and drugs and alcohol support. They also developed a strong network with community development workers from the local authority, faith leaders and the voluntary sector to support residents from diverse cultural backgrounds.

The project has led to the setup of a monthly poverty forum and a WhatsApp group to share information and ideas. This spurred the development of an online directory of services which was launched in celebration of Social Prescribing Day on 8 March 2023. Residents are now able to ‘pull’ or self-refer for listed services at any time helping to improve access for the Slough population.

Understanding the experiences of our residents is key to improving their health outcomes and narrowing inequalities. Through this social engagement process and the leadership of the social prescribing link workers, we are addressing the wider determinants of health and have seen an increase in chronic health check-ups with a reduction in urgent care use in the identified cohort. Social prescribing is supporting the shift in care from reactive to proactive care and providing better overall outcomes for our population. We hope by scaling up this support and reaching out to more of our residents, we will have a better understanding of the needs of our population as whole and address the underlying health inequalities as well as changing the future of our residents.