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Primary Care Networks making connections through social prescribing

With the introduction of primary care networks and the inclusion of social prescribing link workers in the new Primary Care Network (PCN) teams, GP Dr Marie Anne Essam sees new opportunities opening up for people and for practices.   

A safe, warm, pleasant home.

Enough money to feed the household.

People who care and would support me if I needed it.

A sense of belonging and a purpose to my days.

Opportunity to exercise and enjoy fresh air.

Peace of mind.

These are just a few of the things which social prescribing has made me realise are missing in some people’s lives, especially the patients for whom my ‘medical’ expertise has not provided the whole answer.

This is such a thrilling time to be a GP. We’ve been handed the key to new doors – a simple and effective way to address the wider ‘psychosocial’ determinants of health, and see people make progress which none of us imagined possible.

The advent of primary care networks is our opportunity in general practice to connect ourselves – via our link workers and their nearby colleagues – to the communities in which our patients and their families live. Some examples:

  • The isolated hoarder whose drains were unblocked, who found community, family and the joy of giving, who taught me how essential being wanted is for wellness, and how the ‘medical’ bits of care fit in so much more usefully once the really important issues are addressed.
  • The physically fit but workless, bitter man for whom everything I’d tried as his doctor had failed, including psychiatry and psychology. He is now confidently working in a garden centre, and restoring old furniture, as a result of careful mentoring which helped him find the courage to participate in the Building Better Opportunities Scheme.
  • The ‘high intensity user’ of A&E, whose repeated attendances for ‘non-cardiac chest pain’ boiled down to a series of interlinked anxieties, fears and longings. Gentle reassurance that each of these mattered and could be addressed in some way has resulted in better mobility in and out of the home, and his hospital visits have already reduced.

The ‘link worker’ is my colleague, who takes the time to build bridges. By building trust and taking a ‘what matters to you’ approach, rather than the ‘what is the matter with you’ route we tend to practise in busy primary care, a unique action plan emerges. Through active listening, mentoring, and coaching, the link worker is able to spark the previously missing motivation.

These are people who would add an information leaflet to a pile of already discarded dreams, but who respond to the relational approach of the link worker. The link worker works with them, often seeing them first at home, then typically making between six and 12 contacts with them until they are, for instance, clearly connected with a community group, or have a more secure and happy home circumstance. They might also have the support they need as a carer, or are on a new pathway to work, whether paid or voluntary.

Link workers do not need to work in isolation and are best seated in a local fraternity of other like-minded problem-busting colleagues – colleagues who will bravely advocate for people in the realms of housing, finance, family, probation, addiction, and community support, to name a few.

Of course, a lot still needs to happen in our communities to ensure the necessary resources are there. Investment in the voluntary sector, in community agencies, and in organisations providing grants, advice and access to education, work experience and so forth is mission-critical. But our links workers in PCNs give us the opportunity to connect ourselves to the communities in which our patients and their families live.

Collaboration and understanding will grow between primary care, local organisations and local authorities. This in turn will contribute to a changing landscape as commissioners and providers rearrange themselves into Integrated Care Systems. I believe what we will see on the large scale is the marvellous art of the possible which we are already seeing on an individual level as social prescribing delivers personalised, holistic and empowering care.

In the Long Term Plan NHS England committed to building the infrastructure for social prescribing in primary care:

  • 1,000 new social prescribing link workers in place by 2020/21, with significantly more after that, so that
  • at least 900,000 people will be referredto social prescribing by 2023/24.

This is part of the drive to Universal Personalised Care.

Information about the learning support offer for the new PCN link workers  can be found on the social prescribing web page.

Dr Marie Anne Essam is a GP in South Oxhey, social prescribing ambassador for the Herts and West Essex STP, and supports regional, national and international development of the link worker role. South Oxhey is an area of significant deprivation in South West Hertfordshire.

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