Granta Medical Practices Social Prescribing Story

Granta Medical Practices

By Kelly Austin


Granta Medical Practices is a group of 5 merged practices in South Cambridgeshire with a patient population of 44,000

Through grant funding from South Cambridgeshire District and Council councils we set up the service for an initial 2 year period.

164 patients were referred to the social navigator service within the first year, 20 patient over the quota agreed in the funding agreement.

Although the service has seen mainly the older population it has been well accessed by the younger age groups.


Referrals were initially taken from Clinicians within the surgery via a referral pathway built into SystemOne which also indicted whether the patient was Housebound and so would require a home visit and sent a task direct to the service.

Now we take referrals from the community teams included reablement as well as Self referrals via referral forms or as tasks from reception.


Myself or my Colleague will telephone the patient, or appropriate nominated person identified by the referrer, to arrange a visit or appointment at one of our surgeries. This is a helpful fact finding opportunity, as is accessing GP records.

On meeting the patient we can spend time with them to co-produce a Wellbeing plan unlock any issues which is a barrier to them, as well as;

  • What matters to them
  • What their interests are to improve engagement
  • Signpost/refer or accompany to identified resources and services.


  • Where appropriate patients are asked to complete the SWEMWBS and UCLA loneliness scales as per our funding contract to give us some outcome measurements, which should be repeated at certain time intervals.
  • Within the first 6 months of year two we have seen a 20% decrease in GP attendance with the patients seen by the social navigation service.
  • We are currently looking at moving from this to the PAM (Patient activation Measure) in line with the new NHS funding.

” Within the first 6 months of year two we have seen a 20% decrease in GP attendance with the patients seen by the social navigation service.”

Since the start of our service we have engaged in our community further by:

  • Hosting a Dementia support service from Alzheimer’s UK in the surgeries once a month, allowing patients and families to access further support and allowing GP time to be more focused in appointments.
  • Becoming a Park run practice and promoting these with in our surgeries
  • Working with local council initiatives to set up New Age Kurling schemes
  • Hosting Cambridgeshire Hearing Help to deliver 2 hour “Living well with hearing loss” workshops to patients
  • Delivering Group consultations to patients with similar medical conditions i.e at risk of diabetes to which social prescribing is crucial
  • Taking part in the Macmillan cancer care pilot to enhance our service for those patients who are living with cancer.
  • Becoming a Dementia Friendly organisation and training staff to have a better awareness
  • Engaging our PPG to support initiatives such as the Chatty Café scheme within our patient population area.

And much more………….

Kelly Austin- Social Navigator at Granta Medical Practices

Kelly is National Association of Link Workers Champion for East of England providing localised leadership and support to Link Workers. Granta Medical Practices achieved an outstanding CQC rating (Social Prescribing contributed to this)

Connect with her on twitter!

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