Our purpose is to enable change in the people and places that need it most. Our South Tyneside Social Prescribing Service employs 28 social prescribers working in four teams. The teams serve the 150,000 residents of South Tyneside, 49% of whom live in IMD 1 and 2 households. Three of our teams are aligned to the three local PCNs and embedded in general practices and are part of the primary care team. Their presence in the practice means that they are just next door. The teams receive referrals from members of the practice, local partners and self-referrals from people and their families.

Our fourth team is integrated into different pathways across the system, targeting some of the most vulnerable people in our community enabling them to enjoy the same experience and outcomes as everyone else. They work: with people living in deciles 1 and 2 who are waiting for an operation; as part of a multi disciplinary team working with people presenting with breathlessness; integrating into outpatient clinics and group support programmes; with people who are frequent attenders at Accident and Emergency; with people who struggle to engage in talking therapies or capability to successfully implement strategies learnt; with people working with the integrated care team roles and experiencing wider determinants of health; people who are not engaging with cancer screening; and with people whose home in impacting on their health and wellbeing.

Over the last 12 months more than 5,500 people have been introduced to us from more than 60 different partners. 71% are living in households in IMD 1 and 2, and 97% in IMD 1 to 4. Over half have chosen to have a face to face pesonalised care and support conversation, either in a clinic, in the community or in their own home. We have connected people to many partners, both locally and nationally who can support them to achieve the goals that matter to them.

We have recently transitioned to Dialog as our patient related outcome measure (PROM). Prior to that we used the Patient Activation Measure (PAM). More than two thirds of the people we worked with had low leves of activation, low levels of knowledge, skill, and confidence for self-care. After working with us, they improved their score by an average of 7 points, or the people who had the lowest levels of activation increased their score by an average of 10 points. For every 1 point increase, the evidence shows that the cost to the system decreases.

Impact on Primary Care: For a randomly selected sample of people we measured unplanned appointments in the 6 months before their intervention and in the 6 months following their initial contact and found that there had been a decrease of 55%.

All responders in most recent person feedback rated their experience as good or very good, key themes:

1. Support and Understanding: unwavering support, patience, and ability to actively listen. Feedback highlights the importance of feeling heard and understood, particularly during moments of vulnerability or anxiety.

2. Education and Empowerment: ability to explain complex health-related topics clearly and simply (e.g., diet, sugar levels). The guidance provided empowered patients to make better choices, fostering independence and confidence.

3. Kindness and Dedication: kindness, encouragement, and consistent dedication to patient well-being. Their friendly and professional demeanour created a safe, welcoming environment for sharing concerns.

4. Holistic Impact: improvements not just in physical health (diet and eating habits) but also in mental health and overall well-being. The long-term follow-up and personalised care were noted as vital to sustaining these improvements.

5. Transformational Experience: life-changing impacts: increased confidence, improved understanding of health, and a sense of empowerment. This speaks to the transformative role of the staff member in the patients’ health journeys.

Summary: The feedback emphasizes the staff member's pivotal role in providing person-centred care, characterised by empathy, clarity, and dedication. Their approach not only addressed immediate health concerns but also contributed to long-term well-being, making them a trusted and valued figure in the peoples lives. This analysis highlights the importance of a supportive, educational, and compassionate approach in healthcare.