Integrated Plus Evaluation Reports – April 2020 – March 2021

It’s been a far from normal year of delivery for both Integrated Plus projects. The team spent a large proportion of the year leading 6 Covid-19 Community Support Networks and arranging crisis support for over 900 local residents. In addition to this, they continued to support existing Integrated Plus clients and receive a further 814 referrals for social prescribing support.

Due to Covid-19 crisis support work taking precedent this year, both evaluation reports are based on a smaller sample of data compared to previous years. However, findings continue to demonstrate positive social outcomes for the people we support, significant reductions in hospital admissions and A&E attendances and a strong combined cost avoidance figure of over £1million for both services.

I am proud of how hard the team have worked, not only sustain the day to day service, but also to provide essential crisis support for local people, with the help of Dudley CVS colleagues, local volunteers and partners.

Please click on the images below to read the full evaluation reports:

High Intensity User Social Prescribing Service – Year 3 evaluation
Integrated Plus Social Prescribing Service – Year 7 evaluation

How Rebecca (Link Worker) has been supporting patients to regain their confidence post lockdown


As COVID-19 lockdown restrictions begin to ease Integrated Plus has been looking at ways in which we can adapt to meet people’s needs. A large percentage of the people that we work with have long-term health conditions, meaning that they have not left their home for several months due to shielding. Many live alone or do not have family and friends close by so their loneliness and need for social connection has been exacerbated by restrictions. 
As we are now in spring and the sunnier weather is approaching, we have seen an increase in people wanting to leave their homes, for social connection, exercise and sunshine, however they lack the confidence to walk out of the front door. Integrated Plus staff have been supporting these people by doing supported walks aimed at supporting both physical and mental health. Here are some recent examples: 
Mrs A is an elderly lady who lives alone and told me that she has not left her home independently in nearly 2 years. She told me that her goal is to be able to walk to her local corner shop, but she lacks the confidence to go on her own. Following this conversation, I accompanied Mrs A to her local corner shop on two occasions. Since those two walks Mrs A has been on a further two walks to her local shop with her gardener and cleaner. Being able to walk to the shop means that Mrs A has reconnected with the shop assistants and is gaining confidence to go back groups that she attended prior to lockdown. 
Miss B is a young girl who has autism, since the start of the pandemic she has not left her home independently. During a telephone conversation Miss B expressed to me that she wanted to walk into her local town but lacked confidence. I accompanied Miss B on a supported walk into her local town and visited several book shops and showed her where her local library was based. Miss B has since walked independently into her local town and has visited the local library to enquire about joining a book club. 
Mrs C is a recently bereaved lady with multiple health conditions. Due to her health and restrictions, she has not been able to leave her home in several months. Mrs C expressed to me that she is keen to start exercising by walking around her small carpark. I met Mrs C for a walk around her carpark and she said she enjoyed getting out of the house for a chat, exercise and some vitamin D! We are still working with Mrs C and hope to connect her with a volunteer befriender who can offer long-term walks and companionship. 
As we emerge from COVID-19 into what feels like a different world, social prescribing plays an important role in supporting the governments COVID-19 mental health and wellbeing recovery action plan (April 2021) and interventions such as connecting people with their community, physical activity and access to outdoor spaces play a key role in improving people’s physical and mental health.   

Rebecca Woodall – Senior Social Prescribing Link Worker (Halesowen PCN)

Integrated Plus share excellent outcomes from year 6 of social prescribing delivery in Dudley

The Integrated Plus social prescribing service is now into its 7th year with an experienced team continuing to provide 1-2-1 social prescribing support to vulnerable patients in the Dudley Borough aged 16 and over. The team continue to provide a valuable link to the voluntary and community sector and champion the non-clinical and social needs of patients within their GP lead multidisciplinary team meetings.

Dudley CVS are delighted to have witnessed the momentum that social prescribing is gaining. We’re proud to have been part of helping to gather valuable evidence to demonstrate the effectiveness of social prescribing interventions and to have contributed towards the roll out of social prescribing roles nationally.

Our annual evaluation report for year 6 shows that support provided by the service is continuing to result in significant reductions in A&E attendances and inpatient admissions, generating strong cost avoidance figures:

  • 731 patients accepted the service
  • Inpatient admissions reduced by 45% after 12 months – cost avoidance of £450,500
  • Attendances at A&E reduced by 32% after 12 months – cost avoidance of £22,885
  • Total cost avoidance of £473,385 resulting in a net saving to the borough of £28.30 per patient

More importantly, the support continues to result in positive social outcomes for patients. After receiving support the following reductions were made in the number of patients “not managing:”

  • Finance, 87% less patients
  • Physical Health, 91% less patients
  • Mental Health, 83% less patients
  • Social Contact, 88% less patients
  • Housing, 80% less patients
  • Safety, 83% less patients
  • Learning, 88% less patients

For more information about the service, including patient stories and reflections from members of the team, you can read the full report here:

Dudley High Intensity User Social Prescribing Service continues to achieve excellent results

Vulnerable patients are continuing to benefit from the High Intensity User (HIU) project in Dudley, which is now entering its third year.

Year one saw a 33% reduction in A&E attendance and a 41% reduction in inpatient admissions saving the NHS over £492,995. Our second annual evaluation report for year two has seen a 75% reduction in A&E attendances and a 78% reduction in inpatient admissions saving the NHS over £546,540. New data has shown a 66% reduction in West Midlands Ambulance Service call outs with an additional saving of £230,193.

Delivered by the Dudley CVS Integrated Plus social prescribing team and match-funded by Dudley CCG and the Department of Health, the service offers a robust way of reducing avoidable frequent user activity to 999, A&E, and hospital admissions, freeing up front line resources to improve care for all patients and reduce costs.

The two Link Workers have continued to work in a flexible non-clinical way providing tailored support to frequent users of emergency services. The service has benefitted from being able to spot purchase groups, activities and services from our Voluntary Sector Fluid Floating Fund. So far we have been able to commission five different organisations to deliver creative activities, counselling, peer support groups, outdoor learning and housing and benefits support.

In addition to this we have been able to allocate personal health budgets up to the value of £100 per client. This has been a really positive intervention enabling Link Workers to work in a person centred way. Personal health budgets have been used to pay for transport to peer support groups which was previously a barrier and also items such as tablet computers to enable isolated clients to connect with the outside world.

A local service user said, “I needed more than a worker, I needed a friend, someone who could help me get in touch with the outside world, I felt so lonely and isolated. When I first met Kelly I had been in hospital several times, I was suicidal, and had given up, whereas now I enjoy life and am reconnected with friends.”

Another said,“This service has been extremely helpful, from the first visit from Danielle I was put at ease, she listened to me and I truly felt my issues were understood, which in turn enabled her to help me identify new avenues to explore. I am looking forward to starting my new volunteering role and giving something back”

Dudley CVS are delighted with the positive outcomes that the project is achieving. You can read the full evaluation report below:

High Intensity User Social Prescribing Service helps reduce demand on emergency services in Dudley

Vulnerable patients are benefitting from a new High Intensity User (HIU) project in Dudley.

A one year evaluation of the project commissioned by Dudley CCG and Dudley CVS has shown a 33% reduction in A&E attendance and a 41% reduction in inpatient admissions saving the NHS over £492,995.

Delivered by the Dudley CVS Integrated Plus social prescribing team and match-funded by Dudley CCG and the Department of Health, the service offers a robust way of reducing avoidable frequent user activity to 999, A&E, and hospital admissions, freeing up front line resources to improve care for all patients and reduce costs.

Working together with partners, the HIU team uses a flexible and innovative non-clinical approach with the voluntary sector, to target high users of services and support the most vulnerable people within the community to flourish and find purpose in their lives.

This is in line with the Right Care Programme, which is part of the NHS Long Term Plan’s focus to better understand the needs of patients who are frequent users of emergency departments. Both will work to improve waiting times and response in emergency departments for those patients with the highest care needs is a priority.

Kelly Rea, (Urgent Care Link Worker), HIU Team said: “It all starts with a phone call, from which I am able to actively listen to understand the needs of patients accessing A&E departments. I like to arrange a face-to-face appointment as soon as possible to gain a better understanding of their situation. On the first visit, I try my best to make it very relaxed to allow them to tell their story.

It’s surprising how many people say after the visit it’s the first time they have been really listened to.

A local service user said, “This service, in my opinion, is vital to help other people from utter despair, I cannot explain in words what this service has done for me.

After another attempt to end it all, I was given a lifeline, introduced to my link worker from Integrated Plus, always at the end of the phone, caring and understanding, non-judgmental who listens to my every need in my recovery. My link worker takes me out for coffee and shopping and has enabled me to laugh again and understand a future without pain. I look forward to her visits helping me to feel normal again”.

Sarah Knight, Commissioning Manager, Dudley CCG, “We are really happy that the service is benefiting people in Dudley, we are always looking at new and innovative ways to meet the needs of our local population, and this is one way we are doing this”.

The programme initiated by NHS Blackpool CCG has also been rolled out in a number of other CCGs across the country.

The full impact report is available to read below:

Integrated Plus delivers a successful peer learning programme for staff delivering social prescribing schemes around the East and West Midlands

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During January – April 2019, Dudley CVS’s Integrated Plus service delivered a social prescribing peer learning programme for link workers around the country. The programme enabled existing link workers from across the East and West Midlands to connect with each other, share learning, successes, challenges and access training in areas such as motivational interviewing, mentoring and solution focused therapy.

25 staff from 9 organisations delivering social prescribing projects around the country attended the 10 day programme delivered over 3 months.

Participants shared that they had learnt:

  • More about what social prescribing is
  • Each other’s social prescribing models
  • Different approaches to supporting people
  • New techniques and coping strategies when working with vulnerable people

“Brilliant, invaluable, interesting and overall a fantastic and worthwhile training package” (participant who attended the programme)

“Spending time offering each other peer support has been incredibly invaluable” (participant who attended the programme)

For more information about the Integrated Plus service, please contact Kate Green on 01384 573381.

For National information and updates on social prescribing visit: