Dr Sam Hullah, Mosaic Healthcare’s Clinical Director, commented that both surgeries have noticed the immediate positive impact social prescribing has had for approaching 700 patients in just a matter of a few weeks. Many of these patients have had 2 or 3 contacts with Sarah, and as a result have not been seen by a GP, freeing up valuable time for us whilst giving the patients prompt access to the services they need.
The Coronavirus pandemic has created a particularly challenging environment for primary, community and integrated teams to deliver patient care. Through previous work undertaken with SCW, Mosaic Healthcare PCN were well placed to re-focus their Social Prescribing capabilities to support the population through these challenging times.
Mosaic Healthcare PCN wanted to identify and deliver new models of care focussing on the specific needs of their population and how these needs could be met by working collaboratively with local voluntary and community services, drawing on their skills and assets to meet patient needs.
Working in partnership with SCW, Mosaic Healthcare PCN was supported to:
- understand the care needs of the population through population health analysis.
- develop an understanding of the non-clinical needs of people attending primary care services.
- identify providers of care in the geography – health, care and voluntary / charitable sector.
- develop non clinical models of care such as social prescribing approaches built around the specific needs of the population.
A population care segmentation model was used to identify the needs of the population, using both primary care and secondary care data, mapping it to illustrate geographically where those of greatest need reside.
A community-based asset mapping exercise was conducted through both desktop research and on the ground interviews to identify providers of care and additional community resources (assets) in the geography and map these against the needs of local residents, highlighting gaps in provision where they existed
Facilitated stakeholder workshops with the public, patient participation groups and clinicians were delivered with the aim of developing a shared vision for the population and the exploration of opportunities to work differently to meet their needs.
- In investigating the health needs of the population, the team identified that many of the non-clinical issues patients brought to the surgeries were of a technical nature such as housing and benefits, and therefore beyond the experience of the medical teams. In addition, there was an apparent lack of provision for the frail elderly population.
- The outcome of the review was a clear focus on social prescribing in support of the frail population, and a requirement for closer relationships with social services and voluntary organisations.
- In response to the Covid-19 outbreak the role of the Social Prescriber was extended to focus on supporting those at-risk of the virus including the shielded population.
As a direct result of this work the PCN recruited a Social Prescriber who, supported by an administrator, is connecting patients in primary care with sources of support within the community. This approach has provided GPs with a non-medical referral option that can operate alongside existing treatments to improve health and wellbeing.
As a valued member of the team, the Social Prescriber contacts and screens those patients identified as being at high risk, directing people to clinicians or community services as appropriate. In total, since the outbreak, in excess of 600 people have been contacted through this process and all have been offered reassurance and guidance.
In the March to May period the Social Prescriber was also able to support an additional 73 people with Covid-19 related queries.
“The Covid 19 pandemic has seen many of our patients needing support, namely with food and medication deliveries during this time. It has also been a time of financial worries and increased isolation and loneliness. Due to local knowledge and good links with community groups we have been able to sign post and refer patients to the appropriate support services for their area. Services that we have linked patients to include local community hubs, CAB, NHS Responders Scheme, Hospital from Home RVS Scheme, MIND and Adult Services. Being able to help with Covid 19 high risk screening calls provided reassurance and guidance to those patients during these uncertain, challenging times. “ Sarah Elkins, Social Prescriber, Mosaic Healthcare
‘Thank you for taking the time to listen to me and for checking that I am well and have everything I need’ ‘You’re the first person I have spoken to in a long time, thank you for giving me the local support information and putting me in touch with a befriender’ ‘I didn’t know your role existed within the surgery, what a great idea, it’s good to know that you are there to help with non- medical related issues’
Mosaic Healthcare PCN contact:
Paul Butterworth, Practice Manager,