Numbers you can take to your board

Social prescribing enables healthcare professionals to address non-medical factors that cause poor health. In general, this means harnessing voluntary and community sectors to promote self-management of health. Most social prescribing schemes involve link workers who support clients to identify and achieve wellbeing goals. There is, however, no single model of social prescribing.

For this reason, evaluating social prescribing schemes is significant. Having evidence of the impact of a social prescribing scheme on clients eases the process of obtaining funding for social prescribing. In the long term, proving efficacy is key to convincing policymakers to invest in these types of interventions.

Here are the five key metrics to assess your social prescribing scheme.

1. Health and wellbeing improvement

Given its person-centred approach, a key metric to test social prescribing is wellbeing improvement. A shared definition of 'wellbeing' is now set in primary legislation through the Care Act 2014. This includes personal dignity, control over day-to-day life, positive relationships etc.

Wellbeing assessments ought to focus on what is important to people. This refers to personalised, self-identified outcomes at an individual level. One example is the ONS Subjective Wellbeing tool, which is recommended by What Works Wellbeing, an independent centre that develops and shares wellbeing evidence to improve decision-making.

This involves 4 personal wellbeing questions with a 10-point scale. Broadly speaking, its approach entails asking people how they felt yesterday rather than how they feel today. Many Richmond Group charities report preferring ONS 4 to other tools. Primary reasons cited for this include:

• being free to use;
• questions being adaptable to people with a range of needs;
• staff feeling comfortable using it;
• the 10-point scale being sensitive enough to track changes over short-term interventions.

Joy has various in-built, industry-standard wellbeing assessments within its system. However, social prescribers also have the option to create and customise their own. Such data is key to assessing the effectiveness of social prescribing schemes. It allows social prescribers to monitor wellbeing improvement over time and identify fluctuations whilst accessing services.

2. GP appointment reduction

Another key measure to test the efficacy of social prescribing is the change in demand for medical services. Narrowing it down further, reduced GP attendance is a primary outcome to record and measure.

Much research has looked at the effect of social prescribing on demand for GP practice. Social prescribing reduces the strain on NHS services. It also enables people to access more targeted support. Research shows that following referral to community services, there has been an average of 28% reduction in GP attendance.

Still, it is important not to conflate an increase in GP efficacy with cost savings. Reduced GP workload does not always equate to financial outcomes. Rather, the health and wellbeing of clinicians themselves have improved as social prescribing provides solutions for patients with complex social needs. Previously clinicians may feel ill-equipped to tackle these.

Joy tracks the frequency of a client's GP appointments. In this way, there is evidence tabulated on the impact of social prescribing on this metric.

3. Time elapsed between referral and first contact

The efficacy and speed of the social prescribing process itself are significant. Of primary importance is the time taken between referral and first contact. The shorter this interval, the better the experience is for the client. This reduces anxiety and improves the quality of life of patients. Clients will also feel supported through the social prescribing process. By extension, the more likely they will attend the service in question.

On Joy, link workers and/or healthcare professionals can make referrals via the platform. The system can then track the lifecycle of the referral. If a referral is outstanding for several days, community organisations are sent a nudge. This helps to improve the response rate.

4. Patient satisfaction with services

Gauging whether a client had a good experience with a community organisation thus far has been anecdotal. Yet, an organisation's ability to support a client effectively is paramount to quality social prescribing. This is not only relevant for service users but also social prescribers. Depending on the level of satisfaction, link workers may then determine, if an organisation should be receiving referrals.

For example, research on a social prescribing scheme in Northern England found that clients considered the flexibility of the service a strength. This enabled individuals to have control over when and how they accessed link workers and/or activities in the community. The study also notes that a good understanding of local voluntary and community sectors is key to its success.

Most community organisations on the Joy platform are commissioned by the local authority. These are all assessed using the SAFER framework. Social prescribers can feel confident referring clients to services using Joy, as all organisations have been quality-assessed and assured. Furthermore, Joy asks clients to rate their experience, providing tangible evidence by service users.

5. Demographics and need

Lastly, keeping track of the demographics and needs of those using a social prescribing service is important. This data highlights the key needs within an area, those who are using these services, and also informs gaps in provision that may need addressing.

Collecting demographics, e.g. age, gender, ethnicity, allows assessing effects in one group that may not be obvious in a broad sample. Level of education, employment status and housing situations are also useful data. These ensure strategies are in place to reach distinct groups.

Social prescribing empowers individuals to take control of their health and wellbeing. Yet, to ensure prolonged success, steps must be taken to evaluate social prescribing schemes. This helps assess the efficacy and reliability of the scheme itself and local community support services.

Joy allows all of these assessments to be completed within just a few clicks. Joy provides key data on all relevant metrics to help commissioners test how successful their scheme is at improving client wellbeing, reducing strain on the NHS, sourcing quality services for clients, and saving money.

1 in 5 patients consult GPs for problems that are more social than medical. Tackling these needs is important because social and economic factors affect wellbeing. Still, they may not always need clinical services.

Social prescribing involves referring these patients to community support instead. This may reduce unnecessary pressure on healthcare services. It also ensures people receive the most appropriate support to address key needs.

What are key issues patients approach clinical services for?

There is a consistent increase in demand for emergency services in England. Loneliness and social isolation are two key reasons in this realm.

Most people experience loneliness at some point in their lives. Yet, loneliness as a chronic condition is worrying. According to the UK government, loneliness is a public health threat and contributes to an increased usage of public healthcare services.

Social isolation is a related yet distinct phenomenon. Socially isolated individuals may not always experience loneliness. Still, they are less socially connected with their community.

Both loneliness and social isolation may link to depression. Depression is a mental health condition that also affects physical health and wellbeing. Yet, loneliness and social isolation may need solutions beyond healthcare settings.

Components of health and wellbeing are often correlated. They concern one’s participation in social, economic, and political life. Social prescribing has the potential to address these issues in an extensive manner.

Social prescribing enables increasing connectedness at an individual level. Link workers work with clients to address socioeconomic factors affecting health. They then refer clients to local community services. These include activities like gardening or ad-hoc services like financial advice. Through active participation within the community, individuals build new relationships and connections. They also develop interpersonal and communication skills.

The idea is that as people feel better about themselves and their lives, they are less likely to call on medical services. This includes non-physical needs like loneliness and depression. In the long run, healthcare services should experience more targeted and reduced demand.

What is the evidence?

A University of Westminster study found an average of 28% fewer GP consultations and 24% fewer attendances at A&E where social prescribing services were effective.

Another study within an English ambulance service found social prescribing to be beneficial. In particular, this was for those calling in about mental health, loneliness or social isolation. The main sub-groups here were older people and frequent users of 999 and 111 services. These groups can sometimes have complex conditions. Adequate interventions may not be possible in primary care settings.

Instead, social prescribing can support patients within pre-hospital emergency and urgent care. Link workers assist individuals to navigate their health and non-clinical resources available. The key aspect of any social prescribing service is this interaction. By embedding social prescribing, the demand for NHS services is likely to decline.

The social prescribing narrative is compelling. Qualitative evidence reveals that these services are backed by patients and GPs alike. More quantitative evidence is still needed to deduce proof of reduced demand for the NHS. Regardless, the growing scope of social prescribing remains promising. By developing a better understanding of local community needs, social prescribing can ease the burden on healthcare services in the long term.

Why Measuring ROI in Preventative Care Matters

The NHS faces unprecedented demand on primary and urgent care services, with GPs and A&E departments under immense pressure. While preventative care is widely acknowledged as a solution, many ICBs, Place leads, and PCNs struggle to quantify its financial and operational impact.

Without clear return on investment (ROI) metrics, it becomes difficult to justify funding for preventative initiatives. However, with the right digital tools and analytics, ICBs and PCNs can track how preventative care reduces system demand, improves patient outcomes, and delivers measurable cost savings.

Key Metrics for Measuring ROI in Preventative Care

1. Reduction in GP Appointments

Preventative care shifts demand from reactive to proactive services, connecting patients to community-based support before they require medical intervention. In areas using Joy’s digital referral and tracking tools, GPs report nearly 40% fewer unnecessary appointments, freeing up time for complex patient cases.

How to Measure It:

• Compare GP appointment rates before and after the introduction of a preventative care initiative.
• Use EMIS/SystmOne integration data to track referral volumes and primary care activity changes.

2. Reduction in A&E Attendances

Many patients present at A&E due to unmet social needs (e.g., housing issues, social isolation, mental health crises). Joy’s platform helps redirect these individuals to appropriate community services before they reach crisis point, reducing unnecessary hospital demand.

How to Measure It:

• Track the number of A&E visits avoided through preventative interventions.
• Use NHS data on emergency admissions linked to social prescribing and community referrals.

3. Increased Engagement with Preventative Services

One of the biggest challenges in preventative care is ensuring patients access the right services. In ICBs using Joy, referrals to community-based care have more than doubled, thanks to simplified referral pathways, clinician awareness, and digital accessibility.

How to Measure It:

• Compare pre- and post-implementation referral rates from GPs and INTs.
• Assess patient uptake and completion of recommended preventative interventions.

4. Referral Acceptance & Service Utilization

A high referral rate is only valuable if patients actually access services. Joy ensures seamless digital referrals, with real-time tracking of referral outcomes, helping ICBs understand service gaps and optimize commissioning.

How to Measure It:

• Monitor referral-to-completion rates for preventative services.
• Identify bottlenecks where referrals are not converted into active engagement.

How Joy Helps ICBs & PCNs Measure ROI

• Real-Time Data & Dashboards: Joy provides live tracking of referrals, patient engagement, and system impact, helping ICBs and PCNs prove ROI.
• Seamless EMIS & SystmOne Integration: Joy integrates directly with clinical systems, ensuring preventative care is embedded into existing GP workflows.
• Targeted Analytics for ICB Leads: Custom reporting features help ICBs demonstrate savings, service uptake, and patient outcomes to justify continued funding.

Take a look at some of the outcomes from our clients below:

• Average 39% reduction in GP appointments where preventative care is embedded into care pathways.
• 23% reduction in A&E visits where early interventions are in place.
• 110% increase in referrals from primary care to community support.
• 95% referral acceptance rate in some areas, ensuring patients engage with the support offered.

Making the Business Case for Preventative Care

1. Aligning with NHS Priorities

The Fuller Stocktake Report and NHS England’s Integrated Care System (ICS) strategy emphasize the shift to Integrated Neighbourhood Teams (INTs) and digital transformation.

Key alignment points:

• Preventative care reduces system demand for primary and secondary care
• INTs demand heavy resourcing, both in funding and staffing, so the need to deliver more with existing resource is there – simply put: less input for more output.
• Capturing measurable outcomes for preventative care – which are increasingly being tied to funding applications

2. Cost Savings & Financial ROI

Preventative care not only improves patient health, it delivers cost savings by reducing high-cost interventions in primary and urgent care.

Example Financial ROI Calculation:

• If one GP appointment costs £39 and Joy reduces 39% of unnecessary GP visits, a system with 50,000 patients can save £760,500 per year.
• If an A&E visit costs £419, and Joy reduces 23% of emergency admissions, a system serving 500,000 patients could save over £4.8 million annually.

Final Thoughts: Why Measuring ROI Matters

For ICBs, Place leads, and PCNs, the shift to preventative care is only as effective as the data supporting it. By tracking GP appointment reductions, A&E demand shifts, and referral engagement, NHS leaders can secure funding, optimize services, and deliver real impact.

More information from this fantastic article by NHS Confed - quantifying left-shift ICS investment.

Want to see how Joy helps NHS teams measure and maximize ROI on preventative care? Let’s talk.

The Role of Integrated Neighbourhood Teams in the NHS

Integrated Neighbourhood Teams (INTs) are at the heart of the NHS’s shift toward place-based, preventative care. By bringing together primary care, secondary care, social care, and voluntary sector providers, INTs aim to deliver more joined-up, person-centred services tailored to the needs of local communities. However, achieving seamless collaboration across these sectors remains a significant challenge. Disconnected systems, referral inefficiencies, and a lack of real-time data often slow progress, leading to fragmented care and delivery partners unsure of the benefits to the INT.

How Joy Digitally Enables INTs

Joy provides the digital infrastructure to help INTs function efficiently, ensuring that the right support reaches the right people at the right time.

1. Seamless Integration Across Health and Care Systems

Unlike traditional social prescribing tools, Joy integrates directly with EMIS and SystmOne, while also working alongside local authority and secondary care systems. This ensures that INT professionals can access and refer patients across different sectors without data silos slowing them down.

With 2-way data sharing capabilities, referrals, interventions, and patient outcomes can be tracked in real-time, reducing duplication and ensuring smooth handovers between different care providers.

2. Reducing GP and A&E Demand Through Preventative Care

One of the biggest advantages of INTs is their ability to shift demand away from overstretched GPs and A&E departments by proactively addressing health and social care needs earlier. Joy plays a key role in this shift:

• Joy reduces GP appointments by an Average of 39% - By enabling seamless referrals to community and social care services, Joy ensures that non-medical issues (such as housing, financial support, and social isolation) are addressed outside of primary care.
• Joy reduces A&E by an Average of 23% - Many patients present at A&E due to unmet social and preventative care needs. Joy helps redirect these individuals to appropriate non-clinical support, reducing unnecessary hospital admissions.

These reductions translate into significant appointment and cost savings for ICBs, as well as better patient outcomes through timely intervention.

3. Real-Time Data and System-Wide Insights

One of the biggest challenges for INTs is measuring how effectively organisations are working together and what impact preventative interventions are having on patient outcomes.

Joy’s analytics dashboard provides:

• Live data on referral volumes, closing the referral feedback loop, service utilisation, and patient demographics.
• Insights into how INTs are reducing system pressures across primary, secondary, and social care.
• Identification of gaps in service provision, helping ICBs and Local Authorities commission and scale the right interventions to what matters most to their local cohorts.

By providing clear, actionable data, Joy helps INTs continuously refine their approach, ensuring resources are targeted where they can deliver the greatest impact.

4. Reducing Administrative Burden for INT Staff

The complexity of working across multiple organisations means INT staff often face significant administrative burdens - from manual referral processes to inconsistent reporting requirements.

Joy automates workflows, enabling:

• Faster referrals (~1 min) to preventative and community services.
• Auto-population of patient data from EMIS/SystmOne and NHS Spine, reducing duplication.
• Secure messaging between INT professionals for better collaboration.

This not only frees up valuable clinician time but also improves staff satisfaction and efficiency.

Why Digital Enablement is Critical for INT Success

For INTs to reach their full potential, they need more than just strategic alignment - they need the right digital tools to support real-time decision-making, seamless collaboration, and measurable impact.

By bridging the gap between clinical, social, and community services, Joy ensures that INTs can deliver fully integrated, preventative care at scale.

Transforming INTs with Joy: Next Steps

For INT delivery managers, ICB and place leaders looking to accelerate their INTs' impact, the question isn’t why to digitise - but how you can enable this cross-functional mode of working with digital enablement.

From our work with regional INT teams, we know the phased approach seems to be working.

• Phase 1 has been identifying cohorts of patients within neighbourhoods that are likely to need the healthcare system in the future. However, identifying them is only the first step. That’s where Joy comes in. Joy is the “so what?”
• Phase 2 is then providing those cohorts with preventative and non-clinical healthcare interventions to improve patient outcomes and reduce pressure on the NHS; freeing up waiting lists and creating a cost saving.

Want to see Joy in action? Get in touch to explore how our platform can help your INTs improve efficiency, reduce system pressures, and enhance preventative care outcomes.