Case studies

Social Prescribing is a way of linking people with non-medical support to improve their physical and mental wellbeing, connecting them with their local communities and supporting them to feel more empowered in living their lives.

Across London, and throughout the COVID-19 pandemic, there are countless examples of how Healthy London Partnership’s Personalised Care Team supports local communities embrace this more holistic approach to people’s health and wellbeing.

Jump to section

  1. Personalised Care in Secondary Care case studies
  2. Supporting Personalised Care Roles through Training Hubs case studies
  3. Health inequalities case studies
  4. Social prescribing – video case study
  5. Social prescribing and COVID-19 vaccine hesitancy
  6. Social prescribing through the pandemic
  7. Best practice case studies from around London



Personalised Care in Secondary Care case studies

Personalised care roles providing person-centred holistic care to individuals or patients can help to address wider social determinants of health. This improves patient experience and outcomes, through taking a ‘what matters to me’ approach. Using Personalised Care roles effectively in secondary care enables proactive targeting of ‘at risk’ groups with inequality in access, experience or outcomes to reduce health inequalities, helping to improve population health and prevention.

There are lots of exciting examples across London where Personalised Care, including Social Prescribing, Care Coordination or Health Coaching are directly impacting secondary care. Read our case study series to find out more:

Supporting Personalised Care Roles through Training Hubs case studies

Supervision for social prescribing link workers – commissioning an external supplier in Waltham Forest

Read how the training hub in Waltham Forest compared options for supervision to enable social prescribing link workers to access the support they need and the impact it had on them

Recruiting local people into local jobs – personalised care roles in Wandsworth

Read how the training hub in Wandsworth worked in partnership with VCSE organisations to raise awareness of roles available in primary care to support recruitment and retention.

Champion ARRs roles running monthly peer sessions in South West London

Read how the training hub in South West London supported individuals to develop and lead sessions to their peers to support learning and problem solving within a specific staff group.

Health inequalities case studies

How are social prescribers, care coordinators and health and wellbeing coached tackling Inequalities across London?

These five case studies, show case how leaders in social prescribing and personalised care are tackling health inequalities across London, through social prescribers, health coaches and care coordinators. It shows the challenges they faced and gives top tips and resources for carrying out similar work in your area.

Reducing Health Inequalities: deprived areas and long term conditions in Richmond

This case study by Healthy London Partnership shows how colleagues from SWL ICS worked with Hampton PCN in the Complete Care Community programme by NHS Arden & GEM CSU to target people living with long term conditions in specific areas of deprivation in Richmond. They have hired a specialised Social Prescribing Link Worker to outreach to this group.

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Reducing Health Inequalities: health inclusion and homelessness in Lewisham

This case study by Healthy London Partnership shows the Care Coordinator model being used in Lewisham to tackle health inequalities. This includes partnering with charity Groundswell to hire a Care Coordinator with lived experience of homelessness.

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Reducing Health Inequalities: health inequality strategy development in Sutton

This case study by Healthy London Partnership demonstrates how a place based approach to coproduce a health inequalities strategy has been taken in Sutton. At the core of this is social prescribing and personalised care.

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Reducing Health Inequalities: long Covid-19 clinics in Merton

This case study by Healthy London partnership shows how a Care Coordinator in Merton proactively set up clinics to support patients with Long COVID. The group video clinics involve a GP, Care Coordinator and Health and Wellbeing Coach.

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Reducing Health Inequalities: supporting refugees and migrants in Croydon

This case study by Healthy London Partnership explains how refugees and migrants are being supported by Croydon Voluntary Action through sports activities. Their We Stand Together Programme has a strong track record of supporting these communities alongside their Croydon Refugee and New Communities Forum, which involves over 40 refugee organisations.

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Social prescribing – video case study

The Royal London Hospital Barts Health NHS Trust 

Watch how The Royal London’s specialist clinical nurses work in partnership with Social Prescribing Link Workers to support the needs of children and young people by providing safe, friendly and inclusive community activities that help build confidence, gain skills and better manage living with long term health conditions.

The Well Centre

Watch how Lambeth’s youth health hub The Well Centre supports local children and young people to improve their mental health following the closure of so many services during the Covid-19 pandemic. The film features young people Ama and Esther sharing their personal experiences, health and wellbeing coordinators Stefan, Elliot and Jhonelle on the challenges and opportunities for social prescribing services and clinical director and hub founder Dr Stephanie Lamb on the critical role social prescribing plays in addressing young people’s mental health needs holistically.

Crawley Posh Club brings people from the local community together for social events once week. From cream teas to raffles, and live entertainment to coffee mornings it enables people to socialise and have a good time – taking them away from the day-to-day. For many, it’s the one time a week they get together with others.

Social prescribing and COVID-19 vaccine hesitancy

Social Prescribing Case Study_Covid-19 Vaccinations – Understanding and supporting faith groups and their practices

London Borough of Hounslow has a large Muslim and Asian population. There are 15 Mosques, several Mandirs, Gurdwaras and community centres, and many Churches. People in the Muslim community have been reluctant to have the Covid-19 vaccine due to concerns it may contain pork, and the side effects.

There are a high number of people with underlying health conditions that would be recognised as vulnerable and in high-risk groups. There was a low number of vaccinators from the Muslim community; some women felt uncomfortable having their vaccine
administered in a public area.

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Social Prescribing Case Study – Covid-19 Vaccinations – Understanding people and their individual circumstances

A 40-year-old Caribbean woman was concerned about the Covid-19 vaccine and did not want to have it. She also has a 20-year-old son with learning disabilities who is nonverbal. She was worried about him having the vaccine and what the possible side effects may be for the two of them. Their family and close friends were advising against the vaccine which put a lot of pressure on the patient.

There had been a Covid-19 outbreak at their son’s school, which was of great concern to the patient and meant they were having to isolate at home – with limited support from the school. There were many factors causing pressure to the patient, not only from their peers but also due to the support needed for their son in being able to access his vaccination too if they were to change their mind.

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COVID-19 vaccination centre
Social prescribing has played an important role in helping communities combat misinformation around COVID-19 vaccination.

Social Prescribing Case Study_Covid-19 Vaccinations – Utilising your networks to reach communities in Waltham Forest

Waltham Forest has many different community groups living within the borough. There is a lot of scare mongering about the Covid-19 vaccines, conspiracy theories and people telling others not to take it across different age groups.Farah Ahmed and Saiba Salam are both Social
Prescribing Link Workers (SPLW).

Farah is Pakistani and Saiba is Bangladeshi, they both hear the different stories and concerns spreading across their communities about the Covid-19 vaccine that are stopping people from having them.

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Social Prescribing Case Study_Covid-19 Vaccinations – Utilising opportunities to support people and address concerns about Covid-19 Vaccines in Newham

Social Prescribing Link Workers (SPLWs) have played a big part in their Primary Care Networks (PCN) vaccination programme. Some patients have preconceptions and misconceptions about the vaccines which have been challenging to break through. The SPLWs have received Covid-19 vaccinator training and have attended various trainings offered to voluntary sector organisations and SPLWs by the Social Welfare Alliance (SWA), focusing on community engagement and support initiatives.

The SPLWs have linked in with Newham’s Vaccine Peer Support Champions (VPSC), they are volunteers from the community that have signed up to support their peers, sharing up to date and factual information to help people make well informed decisions.

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Social Prescribing Case Study_Covid-19 Vaccinations – Working together to break down misconceptions in Southwark

London Borough of Southwark has the second highest concentration of Latin Americans in the UK. The leading health inequalities in the borough are Mental Health, Obesity and Covid-19, people are not always accessing the health services they are entitled to. A large proportion of the Latin American population do not speak English which has made sharing information about Covid-19 vaccines challenging.

There are networks and organisations across Southwark and other areas in London that are well established and provide support to the Latin American communities.

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Social prescribing through the pandemic

Social Prescribing Case Study COVID-19: Welfare Checks

A patient was referred to a Social Prescribing Link Worker by their GP after an initial Covid-19 welfare check identified that the individual was suffering with severe anxiety, as well as stress due to work and health. Support was requested to help with anxiety and headaches caused by this; and the general need for “someone to listen”.

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Training Social Prescribing Link Workers during Covid-19 – NWL CCG

The Social Prescribing Link Worker (SPLW) roles were rolled out across West London CCG from March 2020, at which point the COVID-19 pandemic hit. To support the newly appointed SPLWs, at a time when limited training was available and having to hit the ground running to support GPs with welfare checks for the ‘shielding’ patient cohort; the Clinical Commissioning Group (CCG) worked closely with the third sector provider of the SPLWs and our Primary Care Network (PCN) Clinical Directors leading on SPLW to develop a training programme.

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Lewisham – Working in partnership to meet community need during Covid-19 – Case Study

Pre-pandemic, Community Connections was a social prescribing service run in partnership between Age UK Lewisham and Southwark, Lewisham Local and Voluntary Services Lewisham (VSL) and funded by Lewisham Council (LBL). On the 20th of March 2020, LBL asked the service to pause all regular activities to deliver a collaborative service supporting vulnerable members of the community to access food, befriending services and other support.

Community Connections brought their knowledge of local services and provided a phone line for people isolated by the pandemic.

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North Southwark – Building a high performing team in the time of Covid-19 – Case Study

Delivery of social prescribing in North Southwark began in April 2020 delivered by Quay Health Solutions CIC, a federation of 17 GP practices. There are now 11 link workers (a mix of full and part time) in place who all began their roles working remotely through the provision of laptops and mobile phones, using the Elemental case management system to track cases.

Although there have been significant challenges to building a high-performing team in which most members have not met, the organisation has shown that it is possible where there is determination to succeed and appropriate measures put in place.

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In Southwark, to inform the community about the pop-up clinics, the Social Prescribing team reached out to various partners; Southwark Culture Health & Wellbeing Partnership, and various statutory and voluntary organisations to help develop a digital map to show locations of the pop-up sites.

Case studies from around London

Ealing – Guided meditation for wellbeing – Case Study

Social prescribing in Ealing is delivered by the Ealing GP Federation. Corina Pall is one of four link workers employed by the Federation and covers nine GP practices accepting referrals from GPs and other healthcare professionals for clients experiencing mild anxiety and depression. However, since the pandemic hit, many of the referrals began presenting with more complex mental health issues and lots of severe anxiety, with some clients unable to leave the house, despite not falling into the shielding category.

Corina has used her background in coaching and meditation to support clients to manage their anxiety and find ways of relaxing. She uses a range of techniques to support clients and has seen deep impact in the way they respond to guided meditation in sessions.

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Barnet – Community Embedded Social Prescribing – Case Study

The Barnet Wellbeing Hub is the “front door” of the Barnet Wellbeing Service, where individuals are supported and guided to appropriate mental health services. It arose out of Barnet Clinical Commissioning Group’s Reimagining Mental Health Programme and workshops that were part of that process. Formally launched in April 2017, it is delivered by a partnership of community and statutory services and provides community-based services to residents experiencing mental health conditions.

The service is managed by CommUNITY Barnet, a community development and infrastructure charity for the voluntary and community sector (VCS) in Barnet. While the service is funded by Barnet CCG, the Wellbeing Steering Group includes charity partners, Barnet CCG, Barnet Council and those with lived experience.

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Hadlery Barnet Flyover
In Barnet, their Wellbeing Service aims to empower residents to self-manage their emotional well-being, remain independent and reduce their reliance on emergency health. and social care services

Bromley by Bow Micro-commissioning – Case Study

The Bromley by Bow Centre piloted a cancer-specific social prescribing service, funded by Macmillan Cancer Support and delivered across primary and secondary care in four East London boroughs from 2015 to 2019. Through ongoing service improvement from embedded feedback, the team identified a gap in provision for people living with cancer in their area in terms of creative activities and low-impact relaxing exercise. Macmillan signed off on use of the budget to fill this gap enabling the service to meet the needs of its clients in a truly holistic way.

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Hammersmith and Fulham – A holistic and integrated approach – Case Study

Social prescribing in Hammersmith and Fulham is overseen by the borough’s GP Federation. The first primary care network (PCN)-based DES-funded link worker was in post in October 2019, with services beginning in December. The team has steadily grown since, with a total of 12 team members now in post, spread across the five PCNs in the borough.

Funding is derived from multiple sources including the Clinical Commissioning Group (CCG), Macmillan Cancer Support and the PCNs via DES funding, but the services largely operate as a single team.

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Stockwell – Clinicians taking the lead – Case Study

Social prescribing in Lambeth went live in December 2019 after the nine Primary Care Networks (PCNs) in the borough made the decision to work together to deliver a uniform approach for local residents. The process was led by a task group of primary care leads including Stockwell GP, Dr. Vikesh Sharma, who has long taken a more holistic approach to health and wellbeing through working with others in the community. Age UK Lambeth who were wellestablished locally were engaged to support the set-up of services.

Dr. Sharma has been able to utilise his clinical role and strong community connections to ensure social prescribing has been well integrated not only into his practice but also with what was already happening on a community level.

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