Social prescribing scheme just what the doctor ordered 6/10/15


A PILOT scheme to improve the quality of life and promote independence for people across Rugby has been rolled out across the Warwickshire town.


ConnectWELL was the county’s first social prescribing scheme when it was launched at four GP practices back in September 2014.


The service is run as a partnership between the NHS Coventry and Rugby Clinical Commissioning Group (CCG) and Warwickshire Community And Voluntary Action (WCAVA) and is also part of the Warwickshire Cares Better Together programme.


ConnectWELL provides health professionals with a single, easy, referral route to the many voluntary and community sector organisations (VCSOs), groups and activities that can address underlying social causes or manage compounding factors of ill-health.


The scheme sees Volunteer Project Navigators, based at the GP surgeries, who signpost and provide information about possible groups and activities that are available. Volunteer Health Buddies also provide support on a one-to-one basis for those who have been referred.


Warwickshire CAVA has created a database of more than 840 voluntary and community groups and activities across Rugby to signpost patients to if appropriate.


This approach has shown to help improve people’s mental and physical health outcomes, improve community wellbeing and reduce social exclusion.


Gemma Smith, ConnectWELL Administrative Coordinator at Warwickshire CAVA, is delighted the scheme will continue.


She said: “Social Prescribing aims to improve quality of life, promoting independence for all and values communities and the range of assets they possess including supporting the role of volunteers and community champions working within their community.


“What the pilot has demonstrated is that the help and support the scheme has provided has made a real difference for the better on the lives of the people referred into ConnectWELL.”


Reviews of the pilot were carried out after six and 12 months which have led the CCG agreeing to roll-out and fund the scheme across Rugby over the next year.


Dr Jeff Cotterill, a Rugby GP and Clinical Lead for Rugby at NHS Coventry and Rugby CCG, said: “National research has shown that GPs across the country are increasingly keen on the ‘more than medicine’ approach of social prescribing.


“I think that in some cases it can make a real difference to a patients’ quality of life. Innovations in medical treatments have transformed life expectancy but they don’t solve everything. Social prescribing is about giving patients more than medicine, introducing new habits to patients’ lives such as healthy eating or joining a walking group.”


Over 75’s:  

The Over-75s Project was initiated by South Warwickshire GP Federation (SWGP) in conjunction with Age UK, to run from January 2015 until March 2016.  The project aims to evaluate a proactive programme that addresses the unmet social and medical needs of the population aged over 75 years and reduce the number of unplanned hospital visits, which are typically high in this patient group.


Patients over 75 years of age who are categorised as being frail by their GP Practices are contacted by an Age UK Care Navigator and are offered an enhanced clinical review based on the British Geriatric Society Comprehensive Geriatric Assessment.


Below is a case study about how this approach is improving people’s lives.



Mr. F is a gentleman in his mid-70s who lives alone. He is very independent, but has lost his confidence and is very afraid of what the future holds for him.



A GP referred Mr. F to me, as his sister in law had accompanied him to the surgery, as his mood was low. Mr. F had lost his sight completely in one eye and only had 30% vision in the other; this was due to untreated/undiagnosed Glaucoma. Mr. F was too afraid to tell anyone he could no longer see, as he feared he would have to go into a home.


His son who does not live nearby discovered the enormity of the situation when his father gradually stopped going out and eventually refused to leave the house. Previously Mr. F was always out and about in the village where he lives.


Mr. F had become completely isolated, as he was afraid to leave his home, as he could not see. He relied on his neighbours to get his shopping and his sister in law to help with everything else. Mr. F’s sister in law said she could no longer cope with the responsibility, as she was in her 80’s.



I telephoned Mr. F and he asked me to speak to his son, as he was feeling completely overwhelmed by the whole situation. I spoke to D, Mr. F’s son and arranged to visit Mr. F with his son present. During my visit Mr. F appeared withdrawn and feared he would no longer be able to live independently. I reassured Mr. F with the right support things would get better and he would be able to remain in his home if this was his wish.


Mr. F’s son said he would like to move from his local authority housing in Coventry, to be near his father to provide the care he needs. Mr F was delighted with this idea and D said he would then be able to visit his father daily and take him out.


With Mr. F’s consent I made a referral to Social Services for an assessment, requested an Attendance Allowance claim pack and provided information on what support Warwickshire Vision Support had to offer. In addition I provided information to D on how to apply for housing locally.



Following my referral, Mr. F received an assessment from Social Services and is receiving a direct payment, which his son is going to manage. This has enabled Mr. F to have meals delivered daily, equipment to help him around the house and someone to take him shopping.


Warwickshire Vision Support are now involved and Mr. F is having regular visits, they have provided aids and adaptations to enable Mr. F to live safely and independently at home. In addition someone to support him to go out in the local community. He is also considering attending one of their clubs, as his confidence increases.


The application for Attendance Allowance was successful and Mr. F is now paying a gardener and cleaner, to maintain his home. Mr. F’s son D has applied for housing and is now in the process of bidding for a suitable property to live near his father.



Mr. F said he feels as though he is getting his independence back and I could hear the difference in his voice, previously his tone was flat and disinterested, now it was lighter and positive. He said he feels as though he is getting his life back and knows he will be able to remain in his own home.


I also spoke to his son D, he said the difference in his father already is incredible, his confidence is growing and he has even been out a couple of times on his own. He said they had no idea of how and where to go for help. He said, “you arrived like a breath of fresh air, guided us through the system, always asking my father what he would like. Within 2 hours you had helped us come up with a plan of action and we are now seeing positive results, thank you!


D is going to keep me informed with regards to his move.



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