Rotherham Social Prescribing Service


Rotherham’s Social Prescribing Service has been operating for eight years. Initially funded by the Clinical Commissioning Group (CCG) and now by the Better Care Fund, the scheme provides case management for the 5% of people with long-term conditions who are at the highest risk of unplanned hospital admission. The scheme is managed by Voluntary Action Rotherham (VAR) – a local infrastructure organisation which employs staff and distributes funding among the scheme’s wide range of voluntary and community sector partners – and works with individuals to address their practical, social and emotional needs, identifying support in the community which can help them stay connected and well.

Initially, 10 GP practices in the community were involved in a pilot and now all 31 practices are part of the services. The scheme is managed and coordinated by VAR, and GP practices are funded by the CCG for their role in the scheme – in particular their participation in monthly meetings bringing together primary care professionals with voluntary and community sector advisers.

How people are referred into the scheme

People are referred into the scheme based on a risk stratification tool. The scheme also now works with people who use secondary mental health services. There are seven voluntary and community sector (VCS) advisers, employed as part of VAR’s Social Prescribing team, working across the long-term conditions cohort. Two advisers also focus on patients with mental health issues referred via Community Mental Health teams. The scheme covers targeted patients in primary care, registered with a GP in the Rotherham Borough. Most of the service users who are referred by GPs in the long-term conditions scheme tend to be older people, with the most typical age group being 80 to 85. Ethnicity data shows that BAME people are underrepresented among service users. However, the scheme is working to address this by building stronger links with GPs in communities serving BAME populations which tend to make fewer referrals. Two thirds of referrals are female with one third being male.

The total cost of both schemes (long-term conditions and mental health) is £750,000 per annum. Ongoing independent evaluations have demonstrated that both schemes make a significant impact on health system usage.

Impact of the scheme on people’s health

Service user outcomes across both schemes are measured using a specially developed wellbeing outcomes tool. Loneliness is often a key issue for service users being referred to the service. Spending a bit of time with people can reap rewards in terms of helping people to unpack many of the non-medical barriers they face.

Evaluation from 2016 by Sheffield Hallam University showed that across all service users:

• non-elective inpatient episodes were reduced by 7%
• non-elective inpatient spells were reduced by 11%
• Accident and Emergency attendances were reduced by 17%

It found that the reductions in health system usage were greater among younger participants in the scheme. The evaluation also found that ‘social prescribing is particularly effective at improving wellbeing, and reducing social isolation and loneliness for people with long-term conditions, enabling them to become more independent and engaged in their community’.

You have done a vital job in supporting me and I want to make you aware of my gratitude. Life hasn’t always been this hard for me and although it’s “just a phone call”,the effects of the contact are immeasurable when dealing with acute loneliness. I have gone from being a “social butterfly” to a virtual recluse. I am becoming adjusted to my new reality and your input and support gives me the impetus to carry myself forward towards the light at the end of the tunnel. I hope you realise that the role which you play in people’s life gives reason and value. You are doing a GRAND JOB!

 – Feedback from a service user referred to a service by Voluntary Action Rotherham’s social prescriber.

This case study was taken from supplementary material released in 2021 as part of Promising Approaches Revisited.