Reporting and measurement

The national infrastructure for social prescribing data collection and demonstrating impact

The Social Prescribing Information Standard has been designed by NHS England with the Professional Records Standards Body (PRSB), alongside a multitude of partners to aid the sharing and recording of information for the whole patient journey.

It mandates that GP IT suppliers, including EMIS and SystemOne, and registered social prescribing software providers (e.g. Joy and Elemental) can collect the information outlined in the standard.

The Primary Care Network DES 2024/25 states “a PCN must ensure referrals to Social Prescribing Link Worker(s) are recorded within GP clinical systems, using the new national SNOMED codes.” (page 86).

Part of the standard is a minimum dataset, which is four sets of terms underpinned by SNOMED codes (these are codes stored in health care systems, linked to pieces of information that enable standardisation of recording of scenarios across healthcare).

Patient demographic information
Needs and concerns
Support offered (including referred to activities)
Outcomes

The terms can be viewed in slides 26-27 here

The PCN DES 2024/25 (page 22) also states that:

“A PCN must share non-clinical data between its members in certain circumstances. The data to be shared is the data required to:

a) support understanding and analysis of the population’s needs

b) support service delivery in line with local commissioner objectives; and

c) support compliance with the requirements of this Network Contract DES specification.”

This information could help you work with PCN managers and colleagues to ensure the right data is collected to demonstrate the impact of social prescribing.

To hear more about the information standard and minimum dataset, including why and how it was developed and what it means in practice, watch the 17 minute recording below.

What is the value for managers and commissioners?

Using the Social Prescribing Information Standard means:

Improved Delivery and Experience of Care – as comprehensive patient level information can be captured and shared with referrers and other professionals within neighborhood teams

Health Service Utilisation – data can inform clinical workloads and help spot opportunities to reduce pressure on clinical services and pathways. Linking social prescribing data to existing data sets will allow to look at the impact of service utilisation across the whole system. This could inform ICS and place-based commissioning.

Supports Population Health Management and Health Inequalities – Good quality social prescribing data can provide insight into unmet needs and gaps in service provision when aligned with population health management (PHM) approaches. For example, identifying a gap, where proactive social prescribing could support a specific health inclusion group, to help reduce health inequality.

Outcome measures, their purpose and how they can be collected

There is a diverse range of outcome measures that can be used for social prescribing, and tools to collect these. The paper by Marie Polley and colleagues (2020) shares a comprehensive mapping of social prescribing outcome measures including those related to health, wellbeing, wider determinants and system usage.

There are different ways a system can support services to demonstrate impact, illustrated by the three case studies below.

Example: In North East London, they have a template for use across EMIS, SystemOne, Joy and Elemental. This includes ONS-4 as an outcome measure and local areas are able to collect additional outcome data as necessary. Hear how SPLWs use this in practice and see what it looks like in the video here. See a mock example of the template fields here. A detailed case study can be found here.
Example: In North Central London, the ICB worked together with a steering group to review outcome measures being used and developed a table of recommended measures for social prescribing, the outcomes and evaluation framework including logic model for social prescribing outcomes can be viewed here. The aim is to enable a more consistent approach to capturing social prescribing impact across NCL.
Example: In North West London, the VCSE sector alliance are developing an outcome framework, this will enable voluntary sector organisations that receive referrals from social prescribing services to understand how to demonstrate their impact. It may support reducing duplication of collecting data for different commissioners and support investment in local voluntary sector organisations from the health sector. A detailed case study can be found here.

Table of tools for outcome measurement

The below table outlines some common outcome measurements. Many outcome measures may be locally defined rather than be a nationally created and verified tool. There are benefits to both.

Nationally validated tools:

Based on extensive testing and scientific literature
Able to aggregate data across services and geographies
More likely to have existing benchmark to compare to

Local bespoke tools and measures:

Based on local need and intended impact
No cost attached
Can be co-produced and co-owned, leading to higher uptake and better data quality

Measure name	What it measures	Description
ONS-4 (Free)	Personal wellbeing – three types of wellbeing: evaluative, eudemonic and affective experience	Four survey questions to measure personal wellbeing and are asked to respond to the questions on a scale of 0 to 10
The Warwick-Edinburgh Mental Wellbeing Scales – WEMWBS (Free)	Mental wellbeing, covering both feeling and functioning aspects of mental wellbeing	14-item scale with five response categories, summed to provide a single score
MyCaW (Free for non-profit making organisations)	Evaluating holistic and personalised approached to supporting people – scope of outcome in change depends on what matters to the person	The participant shared their two top concerns, rate severity on a numerical likert scale and wellbeing is scored. Rescored on follow up alongside further questions
Patient Activation Measure – PAM (Paid for)	Assessing individual or collective activation through self management behaviours	10 or 13 item survey on knowledge, skills and confidence around managing own health
Well-being Star (Paid for)	To measure progress in eight outcome areas for people living with a long term health condition such as lifestyle, managing symptoms, feeling positive	Each area is scored on a 5 point scale using text descriptors from ‘not thinking about it’ to ‘as good as it can be’
Bespoke patient feedback surveys	Typical focus of surveys: – Experience and satisfaction with service – What worked well, what could be improved	This depends on type of question and local systems. Scales and option boxes make the data easier to collect and analyse in GP IT systems Examples are featured throughout this toolkit

Qualitative measures

You may periodically or as part of a one-off evaluation, undertake surveys, interviews of focus groups to gather qualitative data.

What are surveys useful for?

Getting the same data at multiple time points
Anonymous feedback
Ratings of the service, measures around wellbeing or satisfaction
They can collect both quantitative and qualitative information

What are interviews useful for?

Getting rich data at one time point
Asking people to look back, reflect on changes or how something is going
Understand people’s perspectives e.g. a GP on how working with a social prescribing link worker has impacted their work

What are focus groups useful for?

Understanding consensus or the group experience on something complex like an entire service
Creating a shared understanding around impact
Generating ideas, thinking about improvements, what could happen

Examples of how outcome measures have been collected (including example on linking different data using dashboards)

System wide approaches to data collection – North East London and North West London

In North East London, a clinical template was developed by the clinical effectiveness group for use in the GP IT systems (EMIS and SystemOne) and the same terms are used in case management systems such as Elemental and Joy. See a detailed case study for this project here.

This was developed in partnership with social prescribing teams and primary care and continues to be improved as people use it and feedback.

An example of the fields included in the template can be found here.

Data collected via clinical templates flow into an interactive dashboard, which can be used by NEL colleagues. This dashboard can be seen here.

Watch this 20 minute video explaining North East London’s approach with perspectives from the commissioner, social prescribers and a GP.

In North West London, the ICB has commissioned Joy across all seven boroughs to support social prescribing information capture for better management of patients, and to be able to capture the impact. The funding came from digital pots of money.

Gathering patient feedback – Barnet, Redbridge and Lambeth

Surveys or sessions can be held with patients to gather feedback on the service, see examples below:

In Barnet, they use patient feedback surveys to directly understand how people found the service and how it was beneficial to them. This compliments more specific measures of health, wellbeing and quality of life such as ONS-4. See the example questionnaire from Barnet here.

In Redbridge, they text all patients who have received social prescribing via AccurX (the GP texting system) asking them some simple questions to gather feedback over message. You can see the questions on AccurX here. As a one-off they also asked patients to record feedback about the service to make a promotional video for Social Prescribing Day in 2023.

In Lambeth, the social prescribing manager designed a process for evaluating and demonstrating the impact of social prescribing alongside the social prescribing link workers. This led to holding feedback events for patients, link workers, GPs and more and creating a patient survey. A summary of the project is here.

Case studies across London – Ealing and Redbridge

Case studies are commonly used to illustrate the impact of social prescribing, this might be an example of one patient’s experience of social prescribing to demonstrate how the service can work for people. This is useful where there is no quantitative data collected and to demonstrate how social prescribing can benefit specific types of patients or conditions.

They can be visual and like a poster, like this example of a patient case study in Ealing.

Or they can be in a simple text format, like these two examples in Redbridge

You should always make sure you have permission to use any photos of patients and include no personal information where possible.

Resources for data collection

Data can be collected in different ways but there are common things to understand in order to ensure high quality data is obtained that can measure impact. There is an e-learning module for social prescribing link workers on keeping records and measuring impact here.

Top tips around deciding on measures:

1. Look at the three R’s:

- - Reducing the number of different types of data collected to what is most important
  - Refinement in ensuring the most accurate possible measure is used, for example if we want to measure overall wellbeing, we don’t want to use a depression questionnaire, a one question about rating their overall wellbeing is most appropriate
  - Replacement of things that aren’t working, for example is the measure hard to use or patient don’t want to respond to it, is there an alternative that will yield more and better data?

2. Only measure what is important and will have an impact. Why is the data being collected? Is it about a funding decision? What is important to the decision makers? This workshop here explains how you understand your audience and choose what to focus on to influence them.

3. Use a theory of change. This maps out the activities you’re doing, outcomes and intended impacts. It will communicate easily to all stakeholders what the purpose of your service is and guide you to choose appropriate measures based on intended impacts. Templates for theory of change are here. And this workshop guides you through a simple theory of change and how to choose what data to collect based on that theory of change.

Systems to use:

GP IT systems – e.g. EMIS and SystemOne
Social Prescribing Referral Platforms – e.g. Joy and Elemental

Example Joy:

The Joy app has a range of functionality beyond collecting data which will help evaluate the service. This includes:

A directory of service – which is maintained by VCSE organisations who submit details, supported by an AI bot who detects when the information requires an update
Hosts referral forms to different VCSE organisations
Link to GP data and other sources such as EMIS, flowing information in both directions
You can see a case study of the implementation of Joy in Ealing here, which was followed by roll out of Joy for social prescribing in all boroughs in North West London