Proactive social prescribing and its benefits explained

Proactive social prescribing is more than just social prescribing, it identifies targeted groups with unmet needs to offer improved access to social prescribing so no individual goes without the support they require. 

In March 2022, the Directed Enhanced Service for Personalised Care announced that proactive social prescribing was to be part of a broader social prescribing service. It identified that the service  will support tackling health inequalities as well as ICS integration and population health management approaches.  

The aim of proactive social prescribing is to ensure every individual classified in your identified cohorts gets offered the same level of high quality provision to encourage more person-centred care, improve outcomes, and make sure no individuals are left with unmet needs.

Proactive social prescribing is important as it can help PCNs work more collaboratively across a community to overcome the challenges they are currently facing. Proactive social prescribing helps to reduce health inequalities, prevent a further decline in mental health and wellbeing, and helps treat communities equally so everyone has the same opportunities. 

Primary Care Networks (PCNs) are struggling to manage their demand, stretch their resources, and stay within their budget, whilst improving their patient outcomes. This often leads to individuals not having access or receiving the care and support they need putting them more at risk of further decline, isolation, and loneliness.  

With 1 in 5 GP appointments being used for non-clinical issues, proactive social prescribing offers a great opportunity to ensure individuals have the best access to all non-clinical support services possible to reduce their dependency on GP practices and NHS services.  

Proactive social prescribing prevents groups with more specific needs decline in their mental health and wellbeing further by giving them the support they require so no individual is left with any unmet needs, regardless of what they are. This helps to ensure no one is left feeling anxious, isolated, or trapped in their own homes as their needs change, and instead gives them confidence they will receive the support they need.  

Through taking information from population health management records, intelligence from social prescribing services, and data from health inequalities dashboards simultaneously, patient cohorts with unmet needs can easily be identified as patients’ needs change. This is important as it encourages independence and more person-centred care so even the most vulnerable are not limited to what services they have available to them. This, in turn, allows great opportunities to better measure the impact of social prescribing to secure future social prescribing funding through establishing multi-funding streams instead of relying on a singular stream. 

Proactive social prescribing works by building on the health inequalities that your local area are already tackling. It is recommended that PCNs should identify a population with their PCN who are experiencing an inequality to develop a targeted plan to tackle those needs. 

The Network Contract DES recommend that in order to deliver proactive social prescribing PCNs may wish to: 

1. Ensure there is a proactive social prescribing strategy  

Having a good proactive social prescribing strategy allows your PCN to easily form outreach teams which work collaboratively with local partners to make co-producing and informing service design a lot easier. This then allows your PCN to develop an accessible and sustainable provision for your identified cohorts. 

2. Use multiple data sources when identifying your targeted population 

Throughout your proactive social prescribing journey your PCN will be relying on gathering data across multiple sources to help identify your targeted population and goals, as well as track and monitor performance.  

Datasets can include qualitative data from public health teams in local authorities, analytical teams in Clinical Commissiong Groups (CCGs), to using The Health Inequalities Improvement Dashboard to bring together a range of indicators to help identify your targeted population.  

Using data from multiple sources is imperative at the start of proactive social prescribing as it helps to identify a variety of things including: where current health inequalities exist in your area, what is driving these health inequalities to ensure there are provisions in place to prevent them, and what local insights can be taken to drive improvements. 

3. Set targets for improved access and monitor their performance  

Once your targeted population has been established from analysing data across your local area, the next stage is to establish the targets and goals your PCN want to achieve within the specific targeted population.  

The Network DES Contract are aware PCNs are all different and the way they work will replicate that. No PCN is the same and because of this all PCNs will be at different stages of their proactive social prescribing journey. 

For example, the size of some targeted populations may be different to others, as well as its capacity. It is understood that proactive social prescribing is a journey for PCNs much like the patients themselves.  

When co-producing your proactive social prescribing strategy your PCN must be aware of how individuals’ needs change just like the resources your PCN has available. Your strategy must be flexible to adapt to these changes therefore, so all your targets can factor in these changes but still be achievable. 

4. Increase Service Capacity where possible  

At this stage of proactive social prescribing, your PCN should be strongly deciding how proactive social prescribing will reduce health inequalities and how this will be done.  

Regardless of the size of your PCN, in order for proactive social prescribing to be successful PCNs should be employing specialist social prescribing link workers that can help improve outcomes for your targeted population.  

In order to afford this financial support is being given to recruit more social prescribing link workers through NHS England’s Additional Roles Reimbursement Scheme. 

During the implementation stage of proactive social prescribing, it is crucial for PCNs to see how the Additional Role Reimbursement Scheme will help to ensure your PCN can deliver the service demand needed for your targeted population. 

Completing these key 4 steps therefore when establishing your proactive social prescribing strategy will enable your PCN to deliver a more targeted approach to improve access to social prescribing and consequently your PCN’s social prescribing outcomes too. 

Ultimately one of the biggest benefits for proactive social prescribing is that it enhances the access to social prescribing for people in your PCN. However, the benefits of social prescribing go further than that. 

By establishing a successful proactive social prescribing strategy your PCN can prevent any additional decline in patients’ mental health and wellbeing.  

Proactive social prescribing improves patient outcomes which creates great evidence for social prescribing. This in turn helps PCNs gain more funding to help expand their proactive social prescribing strategy to more targeted populations.  

Benefits for social prescribing link workers 

• Through using population health management their proactive case findings become more efficient 
• Working collaboratively with other stakeholders means the hidden needs of a community can be easily identified so more accessible and sustainable services can be co-produced quicker to help reduce the demand on GP services 
• Using and collecting data from multiple sources encourages a collaborative working approach whilst enhancing GPs’ knowledge on your PCN’s population  

Benefits for patients  

• Embedding social prescribing link workers into PCNs gives patients more opportunities to access non-clinical support (especially patients with long-term conditions) 
• Improves patient outcomes such as reduced loneliness and isolation as well as encouraging increased independence  
• Individuals can co-produce their own enriched, personalised care which meets their specific goals  

Benefits for GP Practices 

• Health and wellbeing outcomes improve  
• Reduced workloads  
• Reduced pressure on GP Practices  
• Reduced GP attendance  

Benefits for Primary Care Managers

• Increased focus on preventative measures to help reduce demand  
• Reduced A and E attendance and outpatient appointments  
• Saves money by less medical treatments being needed  
• Reduced reliance on medical prescriptions
• Reduces GP attendance generating more cost savings

As discussed, measuring the impact of social prescribing can be difficult, digital social prescribing makes it easier to show both the Return on Investment (ROI) and Social Return on Investment (SROI).  At Access Elemental Social Prescribing we have seen how digital social prescribing has helped record how their GP attendance has reduced, which in most cases has been above the national averages of 28%. For example Action Together has seen GP reductions of 49% and Age Barnet UK seen a reduction of 65%. 

Our ROI calculator for proactive social prescribing across primary care therefore  demonstrates how if we helped reduce your GP attendance across the different primary care settings in your community reduced by 40%, we can help save you £144,681.56 each year on the basis that each in-person GP appointment costs £42 and there are on average 8,611 GP appointments delivered in each GP Practice each year for social reasons.

In order to have successful proactive social prescribing, collaboration with other stakeholders within your PCN is essential.  

Social prescribing link workers will be need to handle a variety of data from different sources and by not using a software which helps centralise all this information in one place, your PCN is at risk of data being lost, provisions not suiting individual needs, and patient outcomes not improving.  

At Access Elemental we offer digital social prescribing software that helps social prescribing link workers connect individuals to a wide range of social, emotional and practical needs. This helps communities become better connected whilst helping you measure the impacts of your community investments more accurately.  

Our analytics dashboards within Case Management help link the multiple datasets your social prescribers will be working with and can display them in a bespoke dashboards so you can track the specific targets you have selected for each targeted population. This in turn, easily provides you with comprehensive data on your service uptake, impact, and how your services can improve in the future.  

We pride ourselves in knowing we have the best experience possible to help your PCN overcome the challenges you are currently facing to reduce health inequalities. We know proactive social prescribing is an enabler approach to help communities develop their understanding further of what support they have already, what is working well, and what is needed to deliver a person-centred approach to your targeted population.  

Lorn and Oban Healthy Options, one of our customers, found from working with us their patients GP attendance reduced by 17% in the first year alone, saving over £8000 to be reinvested in strengthening their services further. 

Our social prescribing software offers the flexibility needed to track and monitor your targets depending on your local areas needs to ensure you can proactively identify your targeted population. Our software also offers the functionality to integrate with leading clinical software including EMIS Web and Vision to make managing social prescribing referrals easier to track the outcomes of your targeted population more effectively.  

Our bespoke solution makes it easier for your PCN to offer support services to multiple targeted populations at the same time, without any data or information being lost.  

Hopefully having read this you understand what proactive social prescribing is, its importance, its benefits, and most importantly how your PCN can achieve the best outcomes from developing the best proactive social prescribing strategy.  

We've demonstrated how our social prescribing platform offers a range of functionality and the flexibility needed whether your PCN is at the start of their proactive social prescribing journey or you are working on expanding your services to deliver to multiple targeted populations simultaneously.  

For more information in how our social prescribing software can help implement your proactive social prescribing strategy to improve outcomes in your PCN, contact us today and let’s get the ball rolling.