Social prescription

Full Application: Not funded at this stage

By utilising physical and digital interactions to offer human-centred support before needs become critical we could save money on expensive high-need treatments and also ensure our population is happier, healthier and more socially active (win-win).

Social Prescription programmes are becoming more prevalent in the UK. Whether a model will succeed or fail will depend upon a number of factors (we identified 5 key areas in the chart below) – not all are technology based. If successful in bidding for this project, we would like to package the 5 elements to allow for any other organisation to pick and choose any parts that suit their needs. All our software and training packs will be free to use with no mandatory licencing costs.

In addition to the packaging, we would like to prototype functionality to enhance the service:

GP Integration

  • Ensuring the tool can speak to health systems is vital to improve engagement by GPs

Nudge Points

  • Exploring the embedding of council forms (e.g. library book renewal, business rates, service requests, etc) with embedded service offers (local fitness activities, debt help, community based activities, etc)

Pharmacy Integration

  • We would like to train pharmacists on the programme and trial the use of kiosks linked to the tool.

Enhanced Data Collection

  • To evidence the work we’re doing, we’d like to create a series of feedback modules that will survey users at regularly and ensure the efficacy of the programme
  • Automate the publishing of data on local need to foster asset based community development.

We would split into two parts:

  • Sutton project initiation and governance
  • Further service development

We will begin by meeting all Sutton stakeholders: CCG, CVS, LA to assess their capacity for implementation. They need full buy in to introduce a high functioning model, we will map the decisions made to share with partners. Once agreed on Sutton’s model a full project delivery group will be set up. We will then begin the initialisation of the project and agree on their timescales. All governance documents and key stakeholders will be published in a Project Initiation pack.

Whilst Sutton initiation is ongoing Kingston will procure a development partner, we intend to create new template development partner tender that will facilitate the varied nature of this style of development. Our learning so far suggests that a standard council procurement does not easily facilitate this type of working and a broader, development partner procurement approach could be developed to ensure this type of work is successful.

All elements published with on Github with documentation and licenced for re-use.


Month 1

  • Development and Co-Design partner procurement begins

Month 2

  • Sutton Project Initiation Mapped
  • Kingston tool launches to the public
  • Development Partner procurement Finishes and supplier(s) appointed
  • Co-design begins:
    • Health integration exploration
    • Pharmacy partners selected
    • Council forms for nudge points selected
    • Feedback surveys on efficacy and long term-benefits
      • Also publishing lists of unmet service needs (Asset Based Community Development)

Month 3

  • Begin rollout of Sutton Model
  • Planning begins for Agile delivery of User Stories
  • Agile Sprints Begin
    • All Code published to Github under Open licence

Month 4

  • Sprints Continue
  • Begin Packaging of Project Initiation Documentation
  • Begin Packaging of Culture Change Stories
  • Begin Packaging of Marketing Strategy

Month 5

  • Sprints coming to an end

Month 6

  • Finalise packaging of all workstreams for publishing

Although social prescribing is not yet empirically proven to be successful or value for money the signs are that it is being recognised as beneficial and it will be in the NHS’ 10 Year Plan from 2019. With this also said, our programme takes a slightly broader approach with a wide range of community connectors that are keen to signpost residents into services at the earliest possible sign of need. This brings about benefit from engagement but the underlying collation of local offers of services across the voluntary and statutory sector also reduces the difficulty in navigating local services.

For the Local Government sector there are a number of areas this programme will help.

  • Healthier and more resilient residents will have lower needs from the council
  • Open data on missing services will encourage Asset Based Community Development
  • Culture change of front-line workers empowering residents will create a workforce that expects and is able to help
  • Utilising Voluntary Sector organisations to assist residents will reduce the burden on council services
  • Encouraging knowledge of organisations that offer public good (e.g. good gym) will increase community engagement
  • Reducing social isolation will also offer health savings

The project will also, as previously mentioned, release all the modules of the programme to allow for reuse by other public organisations and the use of the Open Referral standard could help kick start reuse of the data by others.

A large amount of discovery work was completed to understand how residents became homeless, why they remained unemployed, or why they were unable to access the interventions that they needed. Links to research documentation are below and were included in our first stage application:

Key findings were that:

  • Citizens struggle to find the right support
  • They’re not aware of the support that exists locally
  • Services are being accessed too late
  • Services that citizens were accessing weren’t identifying any wider needs or signposting/referring to other services effectively or broadly
  • We’re not always the ones to provide the best outcome

Having spoken to residents previously, we began a second phase of user research to better understand user needs of workers across the sector:

We developed personas with high level needs

We will work closely with all our partners, we already work in a virtual method through weekly digital standups for stakeholders (using Google Hangouts). Sutton and Kingston already share a lot of services and our local Voluntary and Community Sector Support Organisations already work in a collaborative way with key coordination provided by both relevant Council for Voluntary Service organisations (Kingston Voluntary Action and Community Action Sutton) the local VCS infrastructure lead agencies. They will both be key players in  the implementation. The ability to work both flexibly and through cross-council networks that are already thriving will make the project resilient.

All stages from programme initiation through to the launch of the product to be mapped and published using X. Kingston will release its documentation, user stories, APIs  

We have an understanding that there are a number of areas of research and technical solutions and best practice would be of use to any organisation developing either social prescribing programmes or digital directories. By releasing all the documentation either via Google Drive or on Github we will be able to help others to either take their first steps into a digital offer or to implement a high quality digital referral mechanism at very little cost.

Locally we have been running events to raise awareness of the work we’re doing (show and tells) as well as blogging, tweeting and an email newsletter. We would continue to run these (including virtual show and tells using Google Hangouts).

Prevention is becoming a major focus in the health and wellbeing sector. By creating a fully documented modular program that will allow for other interested parties to cut and paste sections depending on their need we will  be able to offer other organisations a range of useful tools to help them tailor a local solution to a soon to be national focus (social prescribing). We anticipate that a fully functioning early intervention programme can save money in many areas, from health to housing, allowing residents to live their best lives.

As a council we have already co-designed a local programme based on consultation from a model launched in Mid-Essex. By extending this learning again to Sutton we will be in a position to refine the needs of those at an early stage, ensure buy-in is sought from the correct organisations and parties, create a local buzz and then deliver a programme of early intervention that will increase the lifelong wellbeing of the community through reduced hospital admissions, increased access to fitness, lower alcohol consumption, faster access to debt and housing support and a specialist pathway for those with greater health or housing needs.

Although we already have a tool (already freely available here), the funding would allow us to meet other identified needs set out in question 7. By adding the new functionality such as GP system integration, pharmacy integration we will be further increasing the reach of our product to allow for greater take-up of the programme and extending the reach of the software to be further accessible to non-council based programmes.

Funding will also allow us to co-design new council form nudge points where interactions on council forms e.g. for council tax payments or library books renewals could be harnessed to offer a service to residents. This would increase the reach of prevention activities and further increase the health of the general population.

Throughout the development of the digital tool, we have ensured the user feedback and testing are a key part of our development cycle:

Since we soft launched the tool a couple of months ago, we have been collecting feedback from users as to their experiences. This feedback from end users, administrators and service providers has shaped the second phase of our development, beginning next week (19th November 2018). This development phase will be focussed on fixing issues, polishing design choices, and iterating on existing features.

The research and engagement so far has mainly been aimed at pushing the tool to frontline workers and services, in order to to accumulate that critical mass of involvement, before marketing and pushing to residents. This has involved making sure:

  • Frontline workers are able to locate information on services that they need
  • That they are able to refer or at least signpost residents to these services
  • Services are able to effectively and easily promote and update information on their service
  • Admins are able to effectively maintain the site and ensure quality

Our next step is to further test the site with residents for self-referral. We aim to understand:

  • Are residents able to use the site to find what they are looking for
  • If there are any accessibility needs that we haven’t accounted for
  • If people trust information found on the site
  • What people do if they don’t find what they are looking for
  • Who they go to for help if they can’t use a certain tool

We will complete this research for both Sutton and Kingston, in order to understand if there is a divergent need between the two areas.

After we have launched the product more widely, we will also be analysing the data being generated, and look at:

  • Numbers of users
  • Numbers of referrals
  • Number of services
  • Locations in which people are searching for types of services
  • The organisations and frontline staff that are making the most referrals

Facilitated access to NHS, NHS Digital and DoH as appropriate to help work with GPs and NHS Choices on integration and use of data standard.

The MHCLG Homelessness Trailblazer funded the original development of this tool in Kingston (a digital tool was a part of the bid). Ideally we would like to ensure that the success of the tool locally can be extended to any council that wishes to pursue a similar programme of early intervention. We also feel that the more housing based approach to the project has been a major strength because it has become more community focused than a simple health tool.