Social prescribing link workers in general practice have become a key support for shielded and vulnerable people across the North West during the Coronavirus pandemic.

Social prescribing was a relatively new role in general practice before the pandemic, working as part of multi-disciplinary teams to help patients address multiple issues affecting their wellbeing and connecting them to community groups.

Now staff have switched from home visits to home working, with patients being supported through phone and video consultations. Many social prescribing link workers have also taken on additional work supporting vulnerable and shielded people in the community:

• John Williams is one of a team of five social prescribing link workers with the Central Liverpool Primary Care Network, one of eleven primary care networks in the city. As part of Liverpool’s COVID-19 response, the team John works with are contacting almost 3,000 shielded and vulnerable patients on the list of their nine member GP practices. Other teams of link workers across the city are contacting a further 12,000 shielded and vulnerable people, collaborating with Liverpool City Council to co-ordinate support, including help with emergency food and medication deliveries. John and his team have also produced an online resource pack for local people signposting to local services and providing advice on everything from exercising at home to apps for mental wellbeing.
• In the first full week of lockdown, Manchester’s social prescribing service supported 1,101 people who needed immediate help with food and medication supplies. Support has switched rapidly from helping with long-term life changes such as coping with depression, getting people back into work and combatting loneliness to addressing people’s immediate needs during the pandemic.
• Action Together provides social prescribing for Tameside’s four primary care networks and has taken over 1,000 referrals for people in need of extra support from the voluntary sector, compared with around 100 in an average month previously. At their busiest, the service received 136 referrals in a single day Their work has included connecting more than 500 people to volunteers to help with tasks such as shopping and prescription delivery.
• Sefton’s social prescribing link worker service, delivered on behalf of seven primary care networks, has been receiving referrals of those on the shielded list that have been contacted by Sefton Council and requested additional support. They have supported 17 volunteers, registered with Sefton CVS, to enhance the assistance available to local people and provide an additional 163 hours of support over the phone to 64 people over the last five weeks.

Anthony Leo, NHS North West Director of Primary Care and Public Health, said: “Social prescribing link workers play a key role in helping to connect people to services that can support their wellbeing, and this has really come into its own during the Coronavirus pandemic.

“As well as ensuring that people have had continued access to primary and community services, social prescribing link workers have also supported our most vulnerable people at their time of need.”

Case studies

John Williams joined Central Liverpool Primary Care Network as a Social Prescribing Link Worker in September 2019. At the time, it was a new role, but interest quickly escalated and by March this year he had received 320 patient referrals.

By mid-March, the network – which is one of the biggest in the North West, made up of nine practices and covering a 100,000 population – had expanded its team of social prescribing link workers to five to manage demand.

The role was focused on helping people to tackle the non-medical root causes of their ill health, from resolving housing issues to getting debt advice, and then referring them into support services or social activities, which in many cases proved life-changing.

During the Coronavirus pandemic, John and the team have been working from their own homes to support patients over the phone and through video consultations.

John, who previously worked as a health trainer in Liverpool City Council’s Public Health department, said: “Our priority has been to make sure that we can continue to support the people who need our help. In addition to the patients already on our list, we are contacting almost 3,000 shielded and vulnerable patients. One of the people I helped was a homeless patient who was referred with Type 1 diabetes. He had nowhere to go and no food, but we were able to help him find a place and get emergency food.”

The team’s work during the coronavirus pandemic has also included creating a resource pack for patients with details of local services and information and advice, from mental health crisis services to tips on exercising at home. The pack appears on practice websites and links to it are sent out to patients by text.

Other teams of link workers across the city are contacting a further 12,000 shielded and vulnerable people, collaborating with Liverpool City Council to co-ordinate support, including help with emergency food and medication deliveries.

John added: “Initially the number of new referrals dropped, but we are starting to see them increase again now. Patients are really appreciative of what we do and our GPs tell me they feel so much better knowing we are there to help patients get the support they need.”

Dr Steven Heane, GP at Brownlow Health, one of nine practices in the Central Liverpool Primary Care Network, has used the COVID-19 resource pack to a number of patients who were experiencing challenges during lockdown.

He said: “Our link workers have become an integral part of the Network team since we first recruited in 2019.

“Although clinicians can still make referrals, much of their focus during the COVID-19 pandemic has been to work with the CCG to contact vulnerable patients and offer them wellbeing support.

“Verbal and written feedback from staff and patients has been overwhelmingly positive. Prior to the COVID-19 pandemic, patient wellbeing scores were also being collected, which certainly appeared to improve with link worker input.

“I am really looking toward to seeing how the service develops over time, whilst continuing to provide much needed support to our patient population.”

Heather Etheridge, Head of Service at Manchester’s social prescribing service, the Be Well Service, Big Life Group, says support has switched rapidly from helping with long-term life changes such as coping with depression, getting people back into work and combatting loneliness to addressing people’s immediate needs during the pandemic.

She said: “We are helping people who face hunger, domestic abuse and financial challenges. However, we are still using all of our tools and skills to do this; connecting people, building relationships, letting people talk about what they need and want right now, just generally being a kind human to the person we are working with.

“In the first full week of lock down we supported 1,101 people across Manchester.

We are partnering with the Care Navigation service in Manchester to deliver medication to vulnerable people across the city and we are working with the Manchester City Council Food response team to ensure people don’t go hungry.

The service has also found new ways of continuing business as usual, taking on 10 new primary care network social prescribers and completing their inductions via video teleconference.

Heather added: “Their role is going to be crucial in enabling GP practices to support the patients who are within the government’s shielded group. They will be contacting each one and offering weekly ongoing help during COVID 19, supported by the wider Be Well Team of Coaches and Link Workers. This extra capacity is essential right now, and, one of the most amazing things that has happened in our city is the way services are pulling together at a much faster pace than usual, without hesitation.

We’re embracing this renewed focus on partnership working – if we all work together, we can get the people of Manchester the support they need, whenever they need it, so they can stay home and stay safe.”

Action Together provides social prescribing for Tameside’s four primary care networks and has taken over 1,000 referrals for people in need of extra support from the voluntary sector. Their work has included connecting more than 500 people to volunteers to help with tasks such as shopping and prescription delivery.

A spokesperson said: “The Council’s COVID Support Hotline referred a man to us for support. He is shielding, but because of his health conditions he has been almost housebound for over two years and he told his social prescribing officer he was ‘well-versed’ in being indoors/isolated.

“His social prescribing officer told him about some different local organisations offering befriending opportunities and he chose one that is based within a local church, streets away from his home. This community group usually do home befriending visits and have adapted their services to provide him with a weekly telephone call. They have matched him with a volunteer who will be able to visit him at home once restrictions are lifted.”

In Sefton, the seven Primary Care networks (PCNs), supported by both CCGs, have taken a partnership approach to developing the new social prescribing link workers (SPLW). The service is commissioned through Sefton CVS involving a wider voluntary sector partnership, working alongside their Living Well Service. The approach is showing promising early results for patients as well as seeing PCN SPLWs play an important role in the borough’s response to Coronavirus.

Their work has included:

• Receiving referrals of those on the shielded list from local GP practices and from Sefton Council to respond to requests for additional support.
• Discussing the person’s needs through completing a wellness check with them remotely.
• Working with the patient to develop a short plan which covers their practical, physical and emotional needs, setting appropriate personal goals.
• Linking with the wider offer of support from Sefton CVS and the wider VCF sector including Health Trainers, Macmillan Navigators and Living Well Mentors. • The Link Workers are also supporting 17 volunteers, registered with Sefton CVS, to enhance the assistance available to local people and these volunteers and have provided an additional 163 hours of support over the phone through 222 phone calls to 64 people over the last five weeks. ‘The response I have had is marvellous. The whole system has worked so well. Thank you.’ – Patient receiving support

Notes to editors

All information accurate as of 3 June, 2020
Photograph attached of Central Liverpool Primary Care Network social prescribing link worker John Williams
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