Healthy Communities and Social Prescribing

ICOS’ Migrant Health in Sunderland project will provide holistic, one-to-one support to clients who struggle to access services and other opportunities online due to language barriers or lack of awareness. The service will improve the health of migrant people by offering holistic advice/advocacy/casework and support with accessing benefits and other essential services such as housing, registering with GP practices, rights, and wellbeing sessions. The project will focus on migrants experiencing exclusion from support networks, such as women affected by domestic abuse or individuals who have recently been granted refugee status. 

Help for Health is a partnership project between West End Refugee Service and Walking With in North Tyneside that seeks to address health inequalities among refugees and people seeking asylum. The project will empower refugees to navigate the complex UK healthcare system, understand social prescribing activities, build resilience through mental health education and establish connections to vital community-based social prescribing models for wellbeing. 

Edberts House’s Demonstrating Impact project centres on the HAY (How Are You) tool, a person-centred assessment tool designed for social prescribers to use with patients. HAY helps patients reflect on how they manage different areas of their lives and allows link workers to track progress. Currently, HAY supports around 3,000 patients annually in Gateshead across a wide demographic. Initially developed as a paper-based tool, the project will pilot the digital HAY tool across three areas in NENC: Gateshead, Darlington and Cumbria, helping GPs and other stakeholders understand the influence of wider determinants on health and wellbeing.  

Men’s Pie Club is a movement of male-friendly, member-led clubs where men at risk of social isolation and loneliness connect through the simple, shared act of making pies at weekly clubs in community venues across the North East. In 2024, Men’s Pie Club piloted Xtra Ingredients (XI), a structured 6-week wellbeing programme that could act as gateway for men who may be unwilling or unable to commit to long-term groups, offering an achievable entry point into sustained peer support. Through the pilot, it became apparent that XI requires additional tools to robustly track food literacy, healthy habits and behaviour change. This new project will enable the co-design, testing, and embedding of a new monitoring and evaluation framework for Xtra Ingredients, turning evaluation findings into practical guidance for delivering, adapting, and sustaining XI in other parts of the region. 

Cultivate Northumberland is a partnership that connects a network of grassroots groups, each managing local green space or allotment provision, with the shared aims of improving health, wellbeing, and environmental outcomes in their communities. Many operate in areas of high deprivation, where barriers to physical activity, limited green space access, and poor health outcomes are prevalent. The project, which is overseen by Groundwork North East, aims to build on the successes of the existing network to establish a social prescribing culture within the Cultivate Northumberland partnership. A framework for referrals into the sites will be developed through increased partnership engagement to create strong links with social prescribers, health networks, and local infrastructure organisations to ensure activities reach more of those most in need.

Healing Roots to Rise is a new pilot project in North Cumbria seeking to better understand and establish access to racial healing spaces with and for Black and Brown young people. It will unite three organisations together – Carlisle Youth Zone, Anti Racist Cumbria and PAC Therapy – to co-facilitate a dedicated weekly safe space for Black and Brown young people to access and shape culturally affirming and racial trauma-informed support. Interwoven throughout the project will be an embodiment theme, with group and one-to-one workshops plus a Nurture Through Nature programme delivered in collaboration with Cumbria Wildlife Trust. Aligned to the principles of social prescribing, Healing Roots to Rise will connect people, increase access to and opportunity for activities designed to improve health and wellbeing, and create a pathway to co-create better youth racial-healing support. 

Catalyst Stockton have developed a volunteer-led project to support clients of social prescribers to access community-based activities and support. Support through the ‘Link the Way Project’, will be tailored to the individual and may include calling clients to remind them to attend the activities or support and/or helping boost their confidence to go along. It could also include attending activities with them to discuss the benefits of attending events or planning travel options.

‘Link the Way’ will receive referrals for clients from Social Prescribers in Stockton-on-Tees and the Volunteer Recruitment Officer also co-chairs Stockton’s Social Prescriber Network group in partnership with a colleague from Pioneering Care Partnership (PCP).

Read more about Catalyst Stockton's project in this Spotlight article. 

Connected Voice is a charity that supports and connects voluntary and community organisations in Newcastle and Gateshead. They have developed capacity to support smaller VCSE organisations in Newcastle to be informed in the development of health and care system working and social prescribing. 

They are running regular Newcastle VCSE Health and Wellbeing events with updates from the Integrated Care Board (ICB) and VCSE Partnership Programme, working in collaboration with Newcastle Place ICB and Newcastle City Council to support social prescribers and VCSE organisations. 

They are also supporting Newcastle Council Locality Officers who deliver the locality events for VCSE, Primary Care Network (PCN), link workers, and statutory services and delivering monthly health bulletins to include information on social prescribing and local health systems.

Cumbria CVS is a membership organisation that supports and represents charities, community groups and social enterprises in Cumbria. The Healthy Communities grant is being used to fund the role of a Health Partnerships Support Officer, who is working alongside link workers from a variety of employers and third sector colleagues to improve connectivity, trouble-shoot issues and provide some clarity around the different roles. 

They are running monthly events - themed 'Link and Think' meetings and ‘Connect the Connector’ community of practice networking events. You can find out about their training and events here. They are also now hosting the system-wide Social Prescribing and Personalised Care Steering Group, following changes within the ICB.

Read more about how Cumbria CVS champions social prescribing in our Spotlight article here.

Darlington Connect is a busy town centre base which has been set up by key voluntary sector agencies and hosts a range of local organisations.  The site offers mental health and wellbeing support to Darlington residents, including cost of living support.

VONNE’s Infrastructure Investment Programme supports Darlington Association on Disability to provide support for those with barriers to accessing Darlington Connect’s town centre location. This support is based on people’s specific needs, often including home visits and referrals to other VCSE organisations and statutory services.

The project is also engaged in ongoing strategic work to ensure close links between Darlington Connect and social prescribing link workers and close working relationships between organisations. Read more about the project in our Spotlight article here. 

Durham Community Action (DCA) works across County Durham, supporting community organisations by providing advice, training and resources. Their Healthy Communities funded project is building on the successful County-wide Social Prescribing Link Worker Network, part of DCA’s ‘connector’ work to support the interface between integrated health and social care colleagues and the wider VCSE sector in County Durham. The funding allows DCA to further explore neighbourhood and place-level connections between the local VCSE sector and health and social care partners, build VCSE capacity in delivering social prescribing activity and support and strengthen connections with Social Prescribing Link Workers.

Edberts House is a charity based in Gateshead and the name comes from their very first community house. They are building on their social prescribing knowledge and expertise to pilot a bio-medical, psycho-social integrated neighbourhood team model.  Recently launched in East Gateshead, it brings together all the community groups into the HOPE network (Health Of the Population in the East), as well as the clinical and non-clinical professionals in the area to work together to create better support, opportunities and health interventions.  The joined-up working means that local people get better support at the earliest possible opportunity, preventing crisis and reducing demand.  They are also trialling a Palliative Care Link Worker in Secondary Care.

Read about the the HAY (How Are You?) personalised care tool that Edberts House are developing in our Spotlight article here and hear from one of their link workers here.

Hartlepool Community Trust are a community interest company based in Hartlepool, helping people reduce their fuel and transport costs by providing energy advice and support, a car hire club and other support services. Their social prescribing capacity building project addresses challenges faced by voluntary organisations delivering services and activities for young people – by providing bespoke support from a Development Worker. The main challenge is to deliver new activities requested by young people working with young people social prescribing link workers – including learning to cook, arts and crafts sessions, football coaching (particularly for young people with additional needs), counselling services and mentoring services for children seeking positive adult role models.

Read about Hartlepool Community Trust’s Anime on Prescription social prescribing project in our Spotlight article here and watch a video about the project here.

Helix Arts is a North East based arts organisation that works with artists and communities on various projects. Their creative health programme Better Connect offers regular creative opportunities, workshops and experiences across North Tyneside, for people of all ages, to improve health and wellbeing, reduce health inequalities and live healthier lives.

It has a broad offer, ranging from dance for falls prevention, music for mindfulness and creative walks and talks. Supporting the creative practice for professional artists is pivotal too.

The programme delivers from various community spaces to improve people’s health and wellbeing, confidence and self-esteem, enable people to connect with others, reduce isolation, build peer support and create a safe space for self-care and self-expression.

Read more about Helix Arts’ forty years of working at grass roots in our Spotlight article here.

Inspire South Tyneside is the infrastructure organisation for the VCSE sector in South Tyneside, providing information, advice and support to improve the capacity and sustainability of the sector.

Inspire South Tyneside are currently supporting the VCSE sector in South Tyneside to have active and strong partnerships with social prescribing services through the delivery of a new community engagement and impact platform called Plinth. 

Plinth is a dynamic platform that allows VCSE organisations to promote their services and activities, supports residents to book directly onto these services and captures data and insight including outcome and impact measures.  One of the main advantages is that Plinth is able to give greater visibility to smaller organisations, who may not be as well known to social prescribers, increasing the range of organisations that social prescribers are able to engage and work alongside.

Redcar and Cleveland Voluntary Development Agency (RCVDA) support social action in Redcar and Cleveland by working with communities to help them achieve positive change. They are working together with Tees Valley Rural Action (TVRA), who support rural communities, to develop and convene an open, inclusive space in which social prescribers can come together with communities across Redcar and Cleveland in order that the sector can better understand the social prescribing process, increase knowledge around opportunities available and understand how capacity can grow to meet demand.

In mapping the extent of provision currently available within communities, and by exploring the challenges around social prescribing, they are co-creating a shared resource that clearly describes the referral process, including the roles and contact information of both social prescribers and community organisations.

The Sunderland Voluntary Sector Alliance (SVSA) has been developed to support the sustainability and growth of VCSE sector organisations in Sunderland and to attract additional funding and investment into the city for the sector. It is a conduit between VCSE sector organisations, local commissioners, and national funding organisations, to strengthen relationships for public benefit.

SVSA’s social prescribing community mapping project has been developed to scope and map the current social prescribing offer and models of delivery across Sunderland. The aim is to highlight areas of good practice, gaps in provision, barriers to development, opportunities for collaboration and areas for growth.

Having the social prescribing community mapping officer employed within the SVSA provides the opportunity to work collaboratively across sectors, share local intelligence and influence the ongoing development of the Links for Life social prescribing model in Sunderland. 

Teesside Mind are Teesside’s leading mental health charity and are a host organisation for social prescribing within Middlesbrough, employing twenty-two Social Prescribing Link Workers, who work within the three Middlesbrough Primary Care Networks.

They are working to develop an evaluation framework for social prescribing, connector services and destination services, to create a sustainable evidence base for this work.  This is raising the profile, benefits and impact of these services in Middlesbrough.

Additionally, they are aiming to understand and increase partnership work across social prescribing and connector services in Middlesbrough and to develop and deliver a local plan for proactive work around health inequalities. This includes greater engagement of people who do not currently access social prescribing services.

Thriving Together was awarded the commission from Northumberland County Council to provide VCSE support in the area.

The underpinning ethos is to give all organisations within the sector the opportunity to thrive and achieve potential. The organisation’s aim is to showcase the work of the sector through collaboration and partnership working to make a positive impact on the lives of Northumberland residents. They enable a strategic partnership offering best fit representation, building sustainability through their presence. Their approach is to be inclusive by offering non-membership support to all VCSE organisations throughout the county.

The Thriving Together Healthy Communities Project is to expand the current engagement of the Link Workers and the wider VCSE sector to create meaningful collaborations and opportunities to address the fundamental issues that are widening inequalities and exacerbating health issues in and across Northumberland.

You can read more about Thriving Together Northumberland's work in our Spotlight article here.