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Social prescribing projects

Description of the project; who is involved; how it works; scope with regard to coverage and methodology.
The submission facility is under review and we will not be accepting new project submissions until further notice.

Aneurin Bevan University Health Board

Torfaen Neighbourhood Care Networks (NCN) Social Prescriber Project.  Torfaen North and South NCN, working in collaboration with Torfaen County Borough Council (TCBC) developed a pilot project to test a model of social prescribing based in general practice, involving the use of two Social Prescribers working across GM Practices.  This is a fixed term Project funded by the NCN.  Outcomes have been monitored and are available.  For further information contact: Emma Davies  Social Prescribing in Torfaen; 
Torfaen North Cluster Project

Living Well Living Longer Health Check Programme; A healthcare support worker led cardiovascular risk health check which signposts participants to lifestyle services in the community. This is a fixed Term project targeting areas of deprivation and is currently funded until March 2018. Phase two has commenced October 2018. Evaluation in progress; Information provided by: Sarah Aitken 
Living Well Living Longer Project

Community Connectors; Community Connectors work throughout Aneurin Bevan (Blaenau Gwent, Caerphilly, Monmouthshire, Newport, Torfaen) and aim to connect people to their communities and find activities that can help to improve their wellbeing. The project is funded by the Intermediate Care Fund; 
Community Connectors

Practice Based Social Work Pilot in Caerphilly; The current scope of the programme is to support people so that they feel more confident and in control of their lives. Fixed term; Primary care cluster funded; Evaluation for 2016/17 at year end; Information provided by: Tracey Deacon Practice Based Social Workers project has now come to an end.

Collaborative approaches to Well-being and Prevention; Led by Monmouthshire County Council to develop place-based well-being teams to overcome departmental and agency silos and make best use of the resources already available in the community. Develop an infrastructure and resource to help people find the right assets to stay well. Information, Advice and Assistance is available from a range of providers, across client groups, offering various activities (e.g. Signposting to support, debt advice, accessing food banks).  Services will be well networked and able to direct citizens to the most appropriate support. This is an approach to system-wide working rather than a service, and is in the early stages of development. No evaluation or progress reports available currently.  Information provided by: Nicola Needle.

Ffrind i Mi/Friend of Mine; Funded through the Health Technology Wales Scheme and 1,000 Lives, Ffrind i mi (or Friend of mine) is a new  initiative that Aneurin Bevan University Health Board and its partners are developing to try and make sure that anyone who feels lonely or isolated are supported to reconnect with their communities. Working with Community Connectors and existing volunteer befriending services, the project will aim to recruit as many volunteers as possible to support those who are lonely and/or isolated.  The service seeks to match the interests of people to volunteers with the same interests e.g. gardening, watching sport, dog walking etc; For further information contact Tanya Strange (Aneurin Bevan UHB - Primary Care Unit). 
Ffrind i me / Friend of mine

Newport Care Facilitators. Age Cymru Gwent Care Facilitators support older people to create a personal ‘stay well’ plan to enable them to remain in their own homes for longer and to support the reduction of unscheduled hospital admissions.  For further information contact Tony Husein (Age Cymru Gwent).
Newport Care Facilitators; Stay Well Plan

Betsi Cadwaladr University Health Board

Social Prescribing in South Flintshire Cluster; 2 GP Practices in South Flintshire tested an approach of risk stratifying patient's according to risk of attending surgery on a regular basis, where clinical management was not their primary need and/or a more holistic approach could be beneficial. Fixed term Cluster funding; No current evaluation but case studies can be provided with agreement from project lead; Information provided by: Chris Roberts  
South Flintshire Social Prescribing

Arfon Social Prescribing Scheme (Mantell Gwynedd)A community link officer is the first point of contact for patients referred from GP surgeries / Primary care / community nurses etc with social, emotional or practical needs to a range of local, non-clinical services. Arfon Community Facilitator Project commenced 11 August 2016, funded by Intermediate Care Fund (ICF) committed until 2017; Evaluation begun and ongoing via update reports; Information provided by: Sioned Larsen 
Arfon Social Prescribing Scheme

Anglesey Social Prescribing; Services established during 2016-17 to provide support and signposting to various community based support groups and activities for individuals to improve health and wellbeing as well as information on practical support.  Referrals are made via Linc Cymunedol Mon / SPoA. Fixed term Cluster funding. No evaluation information available currently.  Further information available from Sian Purcell Anglesey; 
Anglesey Social Prescribing

Anglesey Short Breaks; Short Breakes for disabled children with Complex needs and / or learning disability (LD); Futher information available from Sian Purcell 
Anglesey Short Breaks

Anglesey Men's Sheds; The choice of which activites to undertake is completely down to the shed members; Evaluation / Reporting; Specifically designed entry / exit questionnaires will be completed to determin the wellbeing impact of the service.  Further information available from Sian Purcell 
Anglesey Men's Sheds

Conwy West Community Navigator; Primary Care is utilizing resources such as Dewis - an up to date, easy to access website offering patients a choice of resources to support their wellbeing. Patients can take ownership of their own health and can gain advice and support. Fixed term; Cluster funded, ongoing evaluation; Information provided by: Sharon Walter 
Conwy West Community Navigator

Singing for Lung Health - British Lung Foundation (BLF) community singing group for people with lung conditions. National Lottery funded until 2019. Information provided by Rebecca Rickard BLF 
Singing for Lung Health
Singing for Lung Health Impact Report 2018

Cardiff & Vale University Health Board

Cardiff and Vale (City and South Cardiff)

Somaliland Mental Health Organisation is a Non Profitable mental health organisation aiming to improve and support those who suffer with mental health conditions; Project Status; Based at Enterprise Unit 3 Loudoun Square, there are no details available with regard to funding or reporting / evaluation. Further information is available from:
Somaliland mental health

Helpful Peeps is a new social network born from a collective brief that life is better when we help one another; and its coming to Cardiff. Founded by Saf Nazeer and Simon Hill Helpful Peeps seek to bring back community spirit in an increasingly disconnected world. Project Status; Inactive currently, planned but with no published start date. 

Dementia Friendly Cafe; Provide information to carers for someone with Dementia, Providing information for people worried about memory loss.  Project Status; Located at the Wyndham Street Diner and funded via the Alzheimer’s Society. No details available with regard to reporting or evaluation; Further information is available from Anne Mears Rees or Catherine Morgan Cardiff City and South Dementia Care
Dementia Friendly Cafe

Cardiff and Vale (East Cardiff)

Social prescription scheme; Centred in East Cardiff, Llanedeyrn and Pentwyn and provided through Communities First. Social prescription form completed with patients who are contacted by Communities First to discuss their needs and appropriate activities e.g. physical activity initiatives.  Project Status; Cluster based with funding coming from Communities First Fund and consequently the lifespan of the project is linked to the future of Communities First: Further information is available from: Anna Ros-Woudstra
Cardiff East Communities Social Prescribing Scheme

Cardiff and Vale (North Cardiff)

Independent Living Services; Trialling a service in GP practice – visiting officers based in practice giving advice on a range of issues to help people stay living at home.  Project Status; Funded by Cardiff County Council; Funding is permanent for ILS but this new concept is in trial form; Further information is available from Carolyne Palmer Service Development & Strategy Manager
Cardiff North Independent Living Service

Cardiff and Vale (Cardiff) 

Healthy & Active Partnership: The project aims to target services at preventing unnecessary entry into statutory health and social care services or to prevent or delay an increase in existing care package interventions.  Project Status; Ongoing; Further information is available from: Mathew Coffin
Age Connects Healthy & Active Partnership
Age Connect HAP Report 2016/17

Cardiff and Vale (South East Cardiff)

Cluster pharmacist & Communities First lead. Visits and information pack on Communities First activities to community pharmacists.  Project Status; Funded via Communities First piloting in SE Cluster; Further information is available from Cluster Pharmacist and Communities First Lead; Su Wade
South East Cardiff Cluster Pharmacist

Time Credits: Pilot project supporting practices to use Time Credits across Cardiff and Vale UHB.  Project Status; Funded through various sources during start up but intention is for self sustaining as attendees will pay privately; Further information available from: Gemma Hicks; Lorna Collisson; Joe Redmond; Lucy Melody
Cardiff South East Time Credits

Cardiff and Vale (Central Vale)

Community Wellbeing Coaches; For families / children wanting to improve their well-being, be more active and healthy.  Project Status; Funded via Communities First operating in Central Vale with no formal reporting or evaluation to date; Further information is available from C Davies
Central Vale Wellbeing Coaches

Age Connects: The aim of the Vale Ageing Well Programme and the Senior Health Shop ( SHS ) is to improve the health and wellbeing of older people in the Vale of Glamorgan.  Project Status; Ongoing; Further information is available from: Mathew Coffin 
Age Connects Senior Health Shop
Age Connects Senior Health Shop report

Cardiff and Vale (South West Cardiff)

ACE Service; "ACE prescription". These leaflets include information about ACE services. GP’s can tick appropriate services and give to patients who can then access them directly. Project Status; Funded via Communities First Ely / Caerau Cluster area; Information provided by: Hazel Cryer Health & Wellbeing Co-ordinator Ely Caerau
South West Cardiff ACE Service

Wellbeing 4 U Coordinators are based in Caerau Lane and Lansdowne surgeries one day week. Project Status; Is a fixed term project operating across the Cluster but funding source has not been specified; Impact Report 2016 - 2018; Further information available from Karen Tipple
Wellbeing 4 U Coordinators Co-ordinator Programme
Wellbeing 4 U Co-Ordinators surgeries

BRG, Communities First; "BRG prescription". These leaflets include information about BRG services.  GP’s can tick appropriate services and give to patients who can then access them directly.  Project Status; Operating in the Riverside area it is funded via Communities First operating in SE Cluster; Further information available from Tony Hendrickson 
South West Cardiff BRG Prescription

Community Exercise Programme Grow Cardiff; Set up community gardens to promote health and wellbeing in vulnerable and socially isolated people. Patients referred by GP’s.  Project Status; There are no stated details with regard to funding, reporting or evaluation; Further information available
South West Cardiff Grow

Welfare Action and Advice Service.  ACE; Time credits pilot. GP’s can refer patients who need support to change behaviour or who are socially isolated. Patients are signposted to ACE services and receive time credits. Project Status; Pilot project in Ely and Caerau cluster area with no details of funding, reporting or evaluation. Further information is available from Hazel Cryer Health & Wellbeing Co-ordinator Ely Caerau

Dementia Friendly Cafe’s; Provide information to carers for someone with Dementia, Providing information for people worried about memory loss.  Further information is available from Catherin Morgan
South West Cardiff Dementia Friendly Cafe

Cwm Taf Morgannwg University Health Board

The Cwm Taf Community Coordinators are funded by the Integrated Care Fund and are hosted by the County Voluntary Councils, Interlink & VAMT.  The team consists of 5 Coordinators who work with older people (50+) across Cwm Taf to connect them to services, activities and groups in their community, preventing loneliness and isolation.  They provide information, advice and either signpost or refer older people to non-medical sources of support within the community, these might include opportunities for arts and creativity, physical activity, learning new skills, volunteering, befriending and self-help, as well as support with employment, benefits, housing, debt and legal advice.  The service operates Monday to Thursday 9am to 5pm and Friday 9am to 4.30pm.  Referral can be made by simply contacting one of the team via the given details on their leaflet Referral Local Community Coordinator.  Further information contact: Ann Morris: 01443 846203; Sharon Richards 01685 353932
Referral Local Community Coordinator Leaflet

General Practice Support Officers (GPSO); the project is piloting the use of Social Care trained staff working in practices, integrating with community multi-disciplinary teams (MDT).  This project involves collaboration with Local Authority Social Services and is funded by Merthyr Tydfil Cluster.  Furter information is available from Sonia Lloyd-Williams
General Practice Support Officers (GPSO)

Practice based Lifestyle Champions; The Clusters are working in partnership with Public Health where in house Champions will be trained to take the role of patient advocate and link to the third sector and statutory partner agencies.  This service is located in the Cynon and is being evaluated. Further information is available from: Rebecca Stewart
Practice Based Lifestyle Champions

Warm Wales - Healthy Homes; Healthy People - HHHP takes a person-based approach to address need with the aim being to improve health & wellbeing by creating a home which is safe, warm and secure for all.  Community workers (CWs) visit households in their own homes, providing free space face to face advice and support.  Project Officer Leigh Forman. 
Warm Wales - Healthy Homes; Healthy People (HHHP)
HHHP Project Overview

Carers Champion Network; Dementia Third sector/carers/primary care event took place in 2016 to facilitate development of a dementia locality resources roadmap. Developing a social prescribing tool is planned for 2017.18. Project Status; this is a Cynon based project with no stated details with regard to funding, reporting or evaluation.  Further information is available from: Rhian Webber
Carers Champion Network

Care and Repair; Managing Better Project; Nominated practice pilot / tests an approach to engage inaccessible patients into a service providing a variety of practical interventions e.g. benefit advice, home safety checks, falls assessments.  Project Status; This is a Cynon based project. Funding secured through the “Warm home by prescription” scheme and Care and Repair; Further information is available from: Tess Raybould 
Care & Repair

Rhondda Docs GP Wellbeing Coordinator; Lucy Foster is the GP Wellbeing Coordinator for the Rhondda locality and is based within the 12 GP practices across the Rhondda Valleys.  Lucy supports referred individuals (18+) to address non-medical issues through identifying their interests and supporting them to access community activities, facilities and services.  This role places significant emphasis on supporting individuals and matching their interests with what is available within their community to help address issues of debt, poor housing, mental ill health and social isolation.  Further information contact Lucy Foster 07340 708385; or Anne Morris 01443 846203

Valleys Steps; Is a free, innovative programme designed to help people manage and reduce stress, anxiety levels and depression. The organisation, working in partnership with Cwm Taf UHB provides free courses addressing stress control and developing skills and awareness around personal mindfulness. Courses for people across Rhondda Cynon Taff and Merthyr Tydfil are designed to support people understand more about themselves and learn ways to boost wellbeing. Future Service Developments; As well as maintaining core courses, Valley Steps will offer community information (taster) sessions and expand its online resources. Valley Steps will continue to develop their volunteer group, including initiating a Volunteer Forum and an online chat room to support communication and sharing of ideas. From January 2018 Valley Steps will run a volunteer recruitment event. Future services could include more bespoke sessions for more specific user needs, a Social Enterprise resource for occupational groups and an adolescent service may be considered. Valley Steps  Additional information is available from the Valleys Steps Website;  Or; info@valleyssteps 01443 803048; Facebook: Valleys Steps  Twitter: @valleyssteps Main Contact; Felicity Crump

Cwm Taf Cynon Valley Organic Adventures a Link Worker Project, Weight Loss or Community Exercise Programme.  Community garden project-nature therapy, mediation classes, volunteering, health and well-being mentorship programme, self-help groups.  Project Lead; Janis Werrett
Cynon Valley Organic Adventures

Cwm Taf Hapi project - (Health, aspiring, prosperous and inclusive).  Non clinical community based project fro RCT aimed at improving general health and wellbeing.  Project Lead; Lisa Voyle. Additional information available from Hapi website
Cwm Taf Hapi project

Hywel Dda University Health Board
Growing the Future is a five-year project to champion Welsh horticulture, plants for pollinators, the protection of wildlife and the virtues of growing plants for food, fun, health and well-being.  There will be a final evaluation near the end of the project, with an Interim Project Evaluation report completed and available to view on our website - 

Healthy Lifestyle Advisers; The role of the Healthy Lifestyle Adviser is to manage a caseload of clients who require support to make changes to their lifestyle that will improve their health.  This is a South Pembrokeshire based project across five practices centred on Narberth. Cluster funding plus grant from PHW UNTIL March 2018. Reports to the cluster every 3 months and a project evaluation has been started; Further information available from: Lucie-Jane.Whelan
Healthy Lifestyle Advisers

Healthy Lifestyle Advocates; The aim of the Lifestyle Advocates: Promoting Health in Practice project is to embed a healthy lifestyle and health promotion ethos and practice within primary care clusters. This is a South Pembrokeshire based project which is being evaluated.  Further information acailable from: Lucie-Jane.Whelan Healthy Lifestyle Advocates

Generic Technician; 2Ts cluster has employed a Generic Occupational / Physiotherapy Technician who is based within the Community Rehabilitation Team, attends practice Multi-disciplinary Team meetings and receives direct GP referrals to undertake low level assessments including social referrals.  This is a 2T’s Cluster based project via their Community Resource Team which is fixed for two years concluding in November 2017; Further information available from Victoria Edwards
Well-Being Officers 2Ts

A Social Prescriber / Resilience Worker to linked to the new service the cluster hopes to introduce for Dementia. Spice Time Credit is working with the Llanelli GP Cluster on an innovative Time Credits social prescribing programme; Further information available from Laura Smith (Time Credits were developed by SPICE as a system that works on a simple hour-for-hour basis; SPICE & Time Credits in Llanelli Project is in it's fifth operational week) Further information from: Owain Williams Social Prescriber.
A Social Prescriber / Resilience Worker

Community Connectors; Working with the Local Authority and the Voluntary Sector, this Pembrokeshire bases project funds as team of four Connectors based in geographic locations across the County and is funded by LEADER, Pembrokeshire County Council, Hywel Dda Health Board, Welsh Government (ICF funding) and Volunteering Matters. Information provided by: Michelle Copeman for PAVS; Further information contact PAVS Community Connectors

Across Clusters; COPD+:  The cluster agreed to support COPD+ out of 2015/16 slippage funding for 2015/16. The EPP plus exercise project aims to combine the EPP education class with an exercise class for COPD patients with MRC <3, before they become functionally limited by their breathlessness. Its aim will be to increase their individual exercise capabilities. Project Status; A South Pembrokeshire based project. Cluster made via a “one-off” funded. Further information available from; Lucie-Jane.Whelan COPD+

The Extra Project links with obesity and will be offered to children who attend Pembroke School. It is a new initiative designed to get teenagers active and will be a 12-month pilot programme undertaken at Pembroke Leisure Centre starting in December 2015 and ending in Dec 2016; This is a South Pembrokeshire based project that was due to conclude on 1st Jan 2017. Funded via Cluster and Pembrokeshire County Council; Further information available from; Lucie-Jane.Whelan The Extra Project

Exercise Referral Scheme; National Exercise Referral Scheme (NERS): Is a Welsh Assembly Government initiative to promote physical activity in those people who are currently inactive or who have certain medical conditions. Further information available from: Rachel Pompa
Exercise Referral Scheme

Powys Teaching Health Board

Health and Wellbeing Co-ordinators; The Powys Association of Voluntary Organisations (PAVO) are currently working on placing Health and Wellbeing Co-ordinators within communities throughout Powys, whose roles are going to be focussed on accumulating information about local third sector organisations and working with Virtual Wards and Multi-Disciplinary Teams within those communities. This project is being piloted across Powys but with emphasis on the North East Cluster; Information provided by: Cherri Douglas; Powys Social Prescribing Coordinator

Community Connectors; Powys Community Health and Well-Being Coordination Service, operating in 10 Localities across Powys, linked in to Primary Care Clusters in North, Mid and South Powys (in addition to Social Service Single Point of Access and All Community Hospitals; Project Theme e.g. Connecting people with local community services and activities in local areas, using Community Connectors; Project Lead / Contacts (for further information) Freda Lacey, Senior Officer for Health and Social Care, PAVO; Clair Powell, Lead Connector, PAVO; Rationale (background and purpose/aim of the project). The Service helps people in Powys (aged 18+) and their families or carers, to access community-level services and activities which exist in their local communities. Project Details (Description of the project; who is involved; how it works; scope with regard to coverage and methodology) register on the infoengine database@

Swansea Bay University Health BoardSwansea Bay University Health BoardSSwansea Bay University Health BoardSwansea Bay Health Board

Penderi Primary Care Early Years Worker link worker has been appointed working across the Practices in the Network focusing on Parenting Skills and identification of interventions for young children. No details available re funding or evaluation; Further information is available from Debra Morgan 
Penderi Primary Care Early Years Worker

The Down To Earth Project - 'Building Our Future' project takes a practical, hands-on approach to improving mental health and well being, building confidence and increasing physical activity. The project aims to engage people in building with natural materials on a real construction site.  Project Status; No details available re funding or evaluation; Further information is available from Debra Morgan  
The Down to Earth Project

Citizens Advice (CA) will provide drop in opportunities at practices across the Network for information and guidance linked to a wide variety of issues and concerns delivering a service within the Penderi network in Swansea funded directly by the network.  The service also covers the Llwchwr network in Swansea funded by ABMU through a CVS administered Changing for the Better grant.  The service also covers the Afan Valley cluster within the Neath Port Talbot locality funded directly by ABMU.  Additional funding is received from Welsh Government delivering services in the two local authority areas in up to 4 health centres.
Further information is available from Jackie Preston visit 

Swansea Careres Service is introducing a Carers Helpdesks across the Network based in individual practices. This will allow relevant information, guidance, advice and support to be shared with Carer: Project Status; Details available re funding/evaluation; Further information is available from: Swansea Carers Centre

Infoengine  is the online directory of services covering Powys, Ceredigion, Pembrokeshire, Carmarthenshire, Pembrokeshire, Swansea, Bridgend, Neath Port-Talbot and Wrexham. The aim is to highlight the brilliant and varied services that are available to you in your community and to give you all of the relevant information about each service so that you can make an informed choice. Each organisation and group is responsible for their entry on infoengine - see our Terms & Conditions or read our Reporting Concerns section. infoengine is delivered by the following partners:
PAVO - Powys Association of Voluntary Organisations
CAVO - Ceredigion Association of Voluntary Organisations
CAVS - Carmarthenshire Association of Voluntary Services
PAVS - Pembrokeshire Association of Voluntary Services
Powys County Council
SCVS – Swansea Council for Voluntary Service. Include Swansea based information made possible through funding support from Western Bay
BAVO - Bridgend Association of Voluntary Organisations. Include Bridgend based information made possible through funding support from Western Bay
NPTCVS - Neath Port Talbot Council of Voluntary Service. Inclusion of NPT based information made possible through funding support from Western Bay
AVOW -  Association of Voluntary Organisations in Wrexham
infoengine is managed day- to- day by a team of officers in each County Voluntary Council. There is also a Project Management Board which includes key statutory partners

ABMU HB Cwmtawe Cluster Swansea Council for Voluntary Services (SCVS) is working in partnership with GP Practices within the Cwmtawe Cluster to deliver the Cwmtawe Social Prescribing Service - 'New Ways to Wellbeing', Project Lead; Cindy Hayward Cwmtawe
Social Prescribing Service

Biophilic Wales; Practical conservation and wildlife promotion on Health board sites with well-being at the heart of all we do.  Volunteers needed to help us bring biodiversity to Green Infrastructure around hospitals and clinics / health centres in Swansea and Neath Port Talbot.  There will be weekly volunteering sessions and tasks will range from cutting back scrub, planting trees and making planters to wildlife surveys.  No previous knowledge is necessary.  Project Officer Kathryn Thomas.  Timeframe: April 2019 - March 2022.
Biophilic Wales


 Sing With Us Tenovus Cancer Care Choirs

 ACTivate Your Life - Affected By Cancer

Singing for Lung Health

Warm Wales - Healthy Homes; Healthy People (HHHP)