A Respiratory Proactive Social Prescriber in York reaches out to people who have breathing problems and ensures that they have access to the support they need.
Background
Long-term respiratory problems, such as COPD or asthma, can lead to social isolation, exacerbate mental health issues and have a lasting impact on people’s wider health. People living with these conditions can also become disconnected from services that could be supporting them.
The Proactive Social Prescribing service for people with respiratory problems was established by York CVS, a local charity, and the Humber and North Yorkshire NHS Integrated Care Board (ICB). It was designed to address the growing need for integrated care for people with long-term respiratory problems, connecting them to community support as well as the health system.
The programme proactively reaches out to:
- People with long term respiratory conditions who are at high risk of non-elective admissions to hospital.
- People who are isolated because of their poor respiratory health and related long-term conditions.
- People with long term respiratory conditions who live in socially deprived areas or who are on low income.
The service aims to improve overall wellbeing, prevent escalations in health needs, and reduce reliance on emergency services. It was set up as a two-year programme from April 2023.
Approach
The Proactive Social Prescriber (PSP) works across Primary Care Networks in York, contacting people directly, based on analysis of who might need support. This analysis was developed through an algorithm in Year 1 and by individual Primary Care Networks in Year 2.
By proactively reaching out to individuals with respiratory conditions and tailoring support to their unique needs, the PSP bridges critical gaps between clinical services and social support networks. The initiative addresses challenges like social isolation and digital exclusion, which are often overlooked but can significantly impact health outcomes.
York CVS is a key partner in the delivery of health and social care in York and has close relationships with the voluntary, community and social enterprise (VCSE) sectors. This benefits the PSP role greatly by providing resources from already established organisations as well as grassroots services that can offer a range of support for individuals in the proactive social prescribing cohort.
Through an initial phone call, the PSP offers to meet people in a way that is accessible, familiar and safe for them, either over the phone or through face-to-face meetings (for example, in a local, familiar café or community centre). He prioritises what matters to each person and what challenges they face and supports them to develop a mutually agreed personalised care plan.
He then might connect people to a wide range of support, including mental health support, access to groups and activities, physiotherapy, occupational therapy, or services that can advise on benefits, housing, employment or smoking cessation. In many cases, he also refers people for respiratory reviews if they haven’t had one recently.
The PSP uses a person-centred approach, giving choice and control back to people and attempting to educate and improve confidence in healthcare.
Results
In the first year of the programme, among patients who submitted feedback:
87% of patients stated the PSP helped them to set goals that were important to them.
79% of patients felt more in control of their health and wellbeing following support from the PSP.
92% of patients stated they would not have been aware or accessed the support without PSP intervention.
63% of patients felt they could manage their health more effectively after engaging with the PSP.
There were also significant improvements in ONS4 wellbeing scale scores, and some excellent patient feedback.
I cannot believe that someone I don't know has done so much for me, there are people out there struggling to pay their bills and pay for food, I can't believe I have been lucky enough to have found you. You’ve gone overboard with your help, it's amazing what you have done, and it has totally changed my life.
One of the respiratory nurses that the service works with said: "You are bringing people to my attention that may have been missed, or as is often the case people who tell me they are ok when I ring them, but in reality, they seem to be struggling when you see them in person.”
What worked well?
The PSP role is multi-faceted and acts as a direct link between the patient and the surgery team, significantly reducing waiting times for long term condition reviews and improving confidence in healthcare provision. The key to the PSP role is developing positive working relationships with people and exploring what matters to them and helping them to feel connected to their local community. In this way, the role can play a key part in an integrated neighbourhood health team.
The PSP has also been able to identify gaps in provision. For example, some patients were unable to attend an existing exercise and social club, because of its location and because of limited capacity. So he helped a local organisation to set up a new Eazy-Breathe! Exercise and Social Group to reduce social isolation and secure funding to ensure that this was free to join. The group is a collaboration with York St John University and takes place on a weekly basis.
One person who joined the group described the benefits it had for their respiratory condition, commenting “I can do everyday tasks a lot easier now.”
What were the challenges?
In Year One, introductory text messages were sent to patients including an NHS link to the social prescribing role. Some patients found this information overwhelming or were not digitally confident and were unable to access it. The PSP now routinely phones people instead to introduce himself and talk through what is on offer. This has led to a higher engagement rate in Year 2.
The issue with digital exclusion has also led to the PSP working with a local charity that supports York residents through “Digital cafes”, which can help people navigate health links sent by GP surgeries and other specialist health services.
Next steps
The project is currently funded to March 2025. Schemes like this, using data to reach out to people with long-term conditions who are likely to experiencing isolation or social deprivation, and working as part of a multidisciplinary team, could be replicated in other areas.
Thank you to Simon Daglish, Proactive Social Prescriber (PSP) – Respiratory health, for contributing this case study.
For further information, please email [email protected] or visit https://www.yorkcvs.org.uk/
Resources
Further resources and case studies on social prescribing and long-term conditions
