AU & NZ
SG
MY
US
IE
Berkshire Healthcare NHS Foundation Trust - Case Study
Neighbourhood teams are increasingly focused on delivering holistic, person‑centred care that looks beyond clinical needs to support people’s overall wellbeing. Social prescribing plays a key role in this model, connecting individuals with community‑based services and activities that help address social, emotional, and practical needs as part of truly integrated neighbourhood care.
“We've seen a 71% reduction in waiting times as a result of using this solution, which is outstanding for us because it means that our clinical resources are being targeted in the right places and that our patients are still receiving the great care.”
NHS Trusts in England are further acknowledging and engaging with social prescribing to help provide holistic support for local populations. Berkshire Healthcare NHS Foundation Trust (BHNFT) is one of these trusts, and in this case study we explore their story, supported by onboarding our social prescribing solution, Access Elemental.
Berkshire Healthcare NHS Foundation Trust is an NHS Community and Mental Health trust that offers a range of services throughout the county of Berkshire. Almost one million people are served by the trust by approximately 5,000 staff over 60 sites – not to mention the work done in homes and the community.
They are working in partnership with The Access Group and have implemented our Elemental solution to utilise our unique software modules that can help providers manage a directory of services, case management, data analytics, and third-party integrations – integral aspects of their service delivery.
NHS Trusts in England are further acknowledging and engaging with social prescribing to help provide holistic support for local populations. Berkshire Healthcare NHS Foundation Trust (BHNFT) is one of these trusts, and in this case study we explore their story, supported by onboarding our social prescribing solution, Access Elemental.
Berkshire Healthcare NHS Foundation Trust is an NHS Community and Mental Health trust that offers a range of services throughout the county of Berkshire. Almost one million people are served by the trust by approximately 5,000 staff over 60 sites – not to mention the work done in homes and the community.
They are working in partnership with The Access Group and have implemented our Elemental solution to utilise our unique software modules that can help providers manage a directory of services, case management, data analytics, and third-party integrations – integral aspects of their service delivery.
The Trust
Berkshire Healthcare NHS Foundation Trust, like many trusts, has a Common Point of Entry (CPE). This is an on-demand triage, signposting, and assessment service. It supports all community and specialist mental health services across Berkshire.
The CPE team are primarily a telephone triage service that handle referrals, be they routine, urgent, or GP crisis referrals. These are determined by symptoms and clinical escalation based on a person’s presentation.
In many cases, the CPE’s clinical team ends up referring people to Mental Health Navigators because their needs are social, rather than explicitly mental illness. This is often anguish or anxiety around housing issues, addiction, financial difficulties or domestic violence, for example.
They also have ‘Let’s Connect’ - an informal social network designed to guide people into the community support options available without stress or anxiety.
Systemic Challenges
Berkshire’s decision to make the strategic move towards a deeper, fully integrated social prescribing service was informed by a series of systemic challenges identified across mental health pathways and wider third sector partnerships. While social prescribing had long been utilised as part of routine practice, its delivery remained fragmented, administratively burdensome, and operationally inconsistent.
Key gaps were identified in the referral process itself. Patients were not always being referred in a timely or appropriate manner, due to the absence of a streamlined, standardised workflow. Concurrently, link workers and partner organisations were required to complete extensive referral documentation and work across disconnected systems, resulting in avoidable delays and inefficiencies. Clinicians also faced increasing administrative pressures, highlighting the need for a more efficient and supportive workflow to enable quicker, better-informed decision making.
A significant concern related to the lack of consistent recording of community-based intervention outcomes on patient records. Without clear visibility of patient engagement or the effectiveness of community support, clinicians were unable to make fully informed choices regarding ongoing care, escalation, or discharge. This limited transparency hindered continuity of care and reduced the ability to evaluate the impact of non-clinical interventions.
These challenges emerged against a backdrop of growing waiting lists and increasing demand across mental health services. The organisation recognised the need to explore more innovative and integrated ways of utilising community assets to support patients during periods of delay, alleviate pressure on clinical teams, and enable safe, appropriate discharge where community support could meet identified needs.
Collectively, these operational, clinical, and strategic pressures underscored the necessity for a more cohesive and intelligent integration model - one capable of improving referral quality, reducing administrative burden, enhancing outcome visibility, and strengthening overall patient flow across the system.
Onboarding Elemental
To support Berkshire’s new ‘One Team’ approach, they introduced Access Elemental to enhance their delivery of social prescribing in Mental Health.
To paraphrase Daniel Clarke, Project Manager for Digital Marketplace Solutions at the trust, they wanted a quick win: Elemental was chosen and onboarded as it has a unique interoperability with the Rio mental health system.
Berkshire worked hard to make the business case and encourage involvement from VCSEs. By December 2024, their directory of services was well populated for the county, and Berkshire Healthcare was able to start using Elemental to its full potential.
Outcomes
With the surrounding support and staffing structures in place, Berkshire began to see the positives as they went through 2025.
Client Benefits:
The Trust has been able to provide faster and easier access to community and wellbeing services through Elemental, extending support far beyond clinical care and offering quicker help for social and practical needs.
Long‑Term Benefits:
Improved access to community support and social prescribing has helped Berkshire’s mental health teams reduce clinical pressure, prevent escalation through earlier interventions, and enhance overall patient wellbeing through timely, proactive engagement.
Staff Benefits:
Teams report that Elemental’s streamlined referral pathways save significant time, allowing staff to focus more on clinical priorities and direct patient care.
System and Community Benefits:
The new approach has strengthened collaboration across Berkshire’s six local authorities by using a shared directory of services, broadening reach and improving alignment. It has also deepened partnerships with VCSE organisations and demonstrated a scalable model that can be replicated across other health and care divisions.
Reporting Benefits:
For the first time, the Trust has full visibility of referral data, giving BHNFT clear evidence to support service planning, demonstrate impact to stakeholders, and guide smarter use of funding for both current provision and future improvements.
Increased Client Self‑Management:
With Elemental, clients can now access a comprehensive service directory that supports informed choice, encourages independence, and promotes self‑care approaches.
Sophie Trezise, Digital Transformation Manager, Berkshire Healthcare NHS Foundation Trust, spoke to The Access Group about the Trust’s work and flagged up some key statistics:
- An average of 120 referrals per month from the CPE Mental Health Team.
- Rising engagement in the 19-24 year age bracket, showing improved outreach.
- Reduced average time patients remained on caseload by 71%.
- 86% of staff very satisfied or satisfied with using Elemental compared to previous process.
- 100% of staff strongly agreed or agreed that using Access Elemental improved overall patient care and experience.
- 84% of staff strongly agreed or agreed using Elemental reduced patient waiting times for those with a primary need for VCSE support.
With an average time of four hours saved per referral, that works out at a potential saving of approximately 36,432 clinical hours each year – a huge benefit for Berkshire Healthcare and its staff.
The Future
Berkshire Healthcare NHS Foundation Trust is a great success story, seeing how they unlocked their full potential as a community and mental health provider through Access Elemental, but the work doesn’t stop there.
Moving forward, Berkshire plans to expand into community physical health or children’s services. There’s also the plan to do more outreach within local communities to make services more accessible, and the desire to expand the VCSE directory further – even into bordering counties whose provision might better serve patients.
In time AI will also play a part in these developments, with the potential to optimise workflows and automate referrals on the horizon – another big time-saving element.
