Client Success Stories

Measuring success in social prescribing is complex. In our service, we use client surveys for feedback (read our client feedback here). We also measure life satisfaction and anxiety levels pre and post interventions using (ONS 4). We report on who is accessing the service (this helps us identify who’s missing), in which electoral ward they live (this helps us work out if where you live is a factor in why you do, or don’t, use our service). We also report on ethnicity and gender for the same reason. You can read more about the data we collect and report here.

Another way we measure success is by exploring the impact of social prescribing interventions on client’s wellbeing. For example, by improvements in their ability to self-manage their long-term conditions or via improvements in their knowledge of, and access to, local services. We think the best way to illustrate these changes is by creating short client stories describing how social prescribing made people’s lives better. In the stories that follow, we don’t use people’s real names or photos. If you think you would benefit from a referral to social prescribing, complete the self-referral form and a member of the team will contact you.


Jane is in her mid-40s with a teenage son diagnosed with autism. Jane home-schools her son and is also looking after her father who is in poor health. Jane is concerned that her son is not as socially active as he should be due to not being in a mainstream school. Jane also has concerns over her son’s behaviour at times. Jane says she is also constantly worried about her father not getting the care he needs at the supported living accommodation. Jane says her concerns were contributing to her feeling low in mood. Moreover, she didn’t know where to turn to for help. Jane felt that she had been let down by services.

I met with Jane in a private room at her local Community Centre as she did not want to meet at her GP Surgery. Together we discussed her concerns about her son and father. I asked Jane to also think about what she would like to do for her own mental health and how this may be achieved.

To support Jane, I provided information on how EHC plans are formulated and the places to contact for help (school and Education Dept at the Council offices). Jane agreed that she would contact both. We talked about the support CAMHS could offer Jane and her son. Jane had been in contact with the service previously but agreed that contacting them again may be beneficial. We talked about potential activities/interests and how exercise can improve mental health. We also talked about Jane contacting the assisted living accommodation manager to discuss concerns over her father’s care.

At her review appointment, Jane said she was feeling more positive about everything. She confided that she had felt dejected (due to her previous experiences of services) prior to the initial assessment with me and had almost not turned up for the appointment. Jane said that having the time to talk through her concerns had made her leave the appointment with ‘a new spark’ and the feeling of being empowered to get the help she needed.

Jane told me that she had completed her goals and spoken to all relevant parties, and had attended meetings with them. She told me that she is currently involved in formulating an EHC plan for her son and feels a little better about the care provided for her father. Jane also told me that she had joined a gym, this is something where she can focus on herself, and her son can engage in it if he wishes. Jane felt she had made so much progress that she discharged herself from the service after just three weeks, thanking me for the time spent with her and the support provided.



Jane contacted the volunteer and befriending project as she wanted to become a volunteer. Jane has a mild form of muscular dystrophy and a mild learning disability. The long-term impact of Jane’s muscular dystrophy is muscle weakness, resulting in decreased mobility. Mild learning disabilities can impact Jane’s mental wellbeing in terms of causing anxieties. 

I contacted Jane and we talked through the volunteer application process, checking regularly to ensure she understood her responsibilities as a volunteer and the level of commitment required. We also talked about what she wanted to get out of volunteering. Jane said she wanted to remain physically and mentally active and thought volunteering would be a good way to achieve this.

I met Jane on several occasions which enabled me to get to know her and gain an understanding of her strengths and weaknesses. Although the recruitment process took longer to complete, Jane enjoyed the process and was happy that she would be able to achieve her goal of helping people in her community. Jane completed the application process including her safeguarding training with assistance from her support worker.

Jane requested that her client lived local due to her mobility issues but was also keen on being able to walk a short distance to remain active. Jane is looking forward to being matched with her first client.


Jane is in her late 60s. She had recently fled a domestic abuse situation and currently lives alone in a 1-bedroom ground floor flat with warden support. Jane’s mobility, sight, and memory are affected following a stroke couple of years ago. Although Jane uses a walking stick, she says she’s very prone to falling and has had about ten falls during the last 12 months. There is an emergency alarm system in place in her accommodation, but Jane doesn’t wear an emergency alarm pendant or a wristband. Due to issues with her sight, Jane struggles to manage the activities of daily living. Jane’s friends help with weekly shopping, meals, and laundry and she has a daughter and a stepdaughter, but they do not live nearby.

With Jane’s agreement, I contacted her GP to arrange further fall prevention measures and to make a referral to the fall’s clinic. I also contacted the Visual Impairment Officer to arrange lone cane training. I contacted the Adult Social Care team regarding the care package Jane had in place to ensure it met her current needs. I provided Jane with information on the Stroke Association and Lifeline emergency alarm systems, Age UK Befriending Service and Age UK activity groups.

Jane was very pleased to see me face-to-face to find out the ways I could support her to overcome her struggles, saying that she felt her concerns were properly heard. Jane appreciated my contact with relevant services to support her with activities of daily living and to prevent further falls. Jane said that the support she received, the follow-up calls, and encouragement given during the social prescribing intervention was highly appreciated.



Jane is in her late 70s. Her husband had recently passed away and her mobility levels had decreased which was affecting her confidence to travel alone. Jane’s daughters take her out regularly but as they provide support from the door to the car, she is aware that her opportunity to mobilise on her own outside has decreased. Emotionally Jane’s confidence has also diminished as her late husband dealt with all administration chores. Her family are in the process of returning to work and Jane was aware at the time of referral that she had little social interaction planned with others.

Jane’s initial assessment was carried out face-to-face at Age UK café as an opportunity for Jane to attend somewhere new but be reassured that I would be there to meet her. This also allowed her to find out more about services that are offered here i.e., Advice and information support. Generally, thereafter, reviews were carried out fortnightly via telephone.

To support Jane, I provided her with information on the Office of Public Guardians as Jane had an administration query about power of attorney. I also provided information on U3A and the Monday Movers exercise group. I referred Jane to PHD’s Health and Wellbeing Coaching service to support her to become more active and increase confidence with functional fitness. I also referred Jane to Occupational Therapy who provided her with supports for the bathroom and bedroom. After meeting for her initial review at Age UK café, Jane reflected on how she had managed this.  It increased her awareness that she will need to pre-plan journeys in terms of availability of buses and routes etc. Jane also reflected on how much she enjoyed the opportunity to go out and about on her own.



John lost his mother a couple of years ago, and his mental health deteriorated significantly following this. Following her passing away, John’s anxiety levels peaked, and he became unable to work, answer the phone, open his post, and socialise. Due to this, John also missed out on an appointment for his benefits and stopped receiving this, so began to struggle money-wise. He was extremely upset as he had been unable to fund a headstone for his mum, which affected his mental health further.

To support John, I signposted him to Citizens Advice for a benefits check and he was awarded a higher level of benefits. We also created a plan together with his close friend, for them to go through 3-5 letters a day to make sure there were no further outstanding bills or appointments missed and manage his anxiety around this. As John was struggling with grief but unable to talk on the phone for counselling, I referred him to Darlington MIND for face-to-face counselling sessions and arranged some funding for this. John also consented to a referral to his GP regarding mental health and was commenced on antidepressants which he found beneficial and reduced his intrusive thoughts. As John is an army veteran, I signposted him to Sporting Force – a free gym for veterans, which he reports to have found helps his mental health too. John was referred to a veteran’s support agency who were able to provide funding for the headstone for his mum’s grave. John attended all appointments face-to-face due to his anxiety about talking on the phone. He was seen 2-weekly but did have regular non-attendances due to his mental health which we worked on together to eventually improve his attendance.

By the end of his social prescribing intervention, John said he felt more positive and well-supported, was managing better financially, was enjoying his counselling sessions and attending the gym. He also felt like a ‘weight had been lifted off his shoulders’ with the support financially for his mum’s headstone.


Jane is in her late 70s and lives on her own. She struggles with deteriorating physical health, finding it difficult to manage the activities of daily living. To support Jane, referrals were made to Adult Social Services for a carer package, Home Instead Senior Care, Molly Maid Domestic cleaners, Lifeline Services, Adult Social Services for Lifeline assessment and Occupational Therapy for home adaptations.

Jane reported that the interventions gave her peace of mind as she knew she didn’t have to struggle anymore day-to-day. She said she felt less anxious knowing a support package was in place.



John lives with anxiety.  He struggles to attend appointments and finds telephone conversations difficult due to his tinnitus.  Previously John had lived an extremely varied life, enjoying various outdoor jobs.  His work had taken him to the other side of the world.  John said he wanted to be able to go outside and enjoy nature once more.

We co-produced a care plan that included sending a text prior to review phone calls to help John prepare for the conversation.  The main intervention focused on linking John to Community Peer Mentors who connected him to a mentor who shared John’s interests. John said he looked forward to the weekly visits with his mentor and was enjoying going for short walks with the view to lengthen these in the future.

Other support included a referral to PHD’s health and wellbeing coaches who worked with John to break down his goals into small manageable steps. John was also referred to Age UK who supported him in completing a PIP application which greatly reduced John’s anxiety around this.



John is a 5-year-old boy who lives with his mam and older sister who has severe learning disabilities. The initial assessment was completed with mam who reported that, due to the level of care her daughter required, John was missing out on opportunities that in her words “a normal 5-year-old would have”. Mam was given information on age-appropriate activities in the local area, including Messy Church, Scouts, the Move More holiday club and Future Pathways.

John’s mam was interested in the information passed on and was making plans to visit the Move More holiday club. She was also planning to speak to Future Pathways. Importantly, during this time John was allocated a Social Worker.


Jane is in her early 80s and lives with her elderly husband. She struggles with deteriorating physical health, mobility problems and recently had a fall. Her husband helps with activities of daily living, but she is finding it difficult to manage, especially with her husband’s deteriorating memory. She uses a walker to support her mobility and is under the care of MSK.

Referrals were made to her GP to arrange further fall prevention measures and Age UK Information and Advice Service for a benefits review.  Information was provided regarding available local services including Home Instead Senior Care, local cleaning services, Age UK Hot Meal Delivery Service, Friends of Darlington Memorial Hospital Transport Service, Darlington Carers Support, and local support groups and services that support people with dementia to get relevant support for her husband. She was also supported and encouraged to continue her hobbies by providing art materials, word searches, and crossword books.

Jane stated that the interventions helped her to manage her day-to-day activities without a struggle and gave her peace of mind as she knew the ways to support her husband as well. The RIACT team has contacted her following our task to the GP to start regular exercise sessions to improve her mobility. She reported that she was also very pleased that she could continue the hobbies that made her relaxed and improved her well-being.


Jane’s daughter contacted the PCN/Age UK Volunteering and Befriending project as she was concerned about her mum’s mental wellbeing.

Jane lives alone since losing her husband 5 years ago. Jane has little cognitive stimulation and spends much of her day sitting, staring out of the window. Jane’s family tried to encourage and motivate her, but Jane had no interest in engaging. Loneliness was having a negative impact on Jane’s mental wellbeing, long term health conditions, mobility, and appetite.

On receiving the referral, I contacted Jane’s daughter who highlighted her concerns. I visited Jane at home later that week and carried out her befriending assessment, utilising the older persons outcome star assessment tool. This enabled me to gain a clear understanding of the support Jane needed. As a result, I recruited a volunteer to visit Jane and arranged for hot meals to be delivered daily.

Jane and her volunteer enjoy trips out to a local café and going for short walks. Being able to get out of the house, seeing people and experiencing different scenery helps to take Jane’s mind off her long-term health conditions, and it is helping with her low mood and mobility. Jane said that her mental and physical wellbeing has improved, particularly since receiving a daily nutritious hot meal from Age UK.


South Asian women are disproportionately affected by chronic diseases and large cross-national surveys of many western nations such as the UK, Australia and the US have consistently reported that South Asian women report lower levels of physical activity than their white counterparts REF.  To support Asian women in Darlington, social prescribers partnered with Tees Valley Sport to create a programme of physical activity in Northgate Ward. Corporation Road Primary School (which is based in the heart of Northgate Ward) allowed us to use their sports hall free of charge. Sessions were delivered in a female only environment and designed to be as comfortable and inclusive as possible.

The group spoke Bengali, and all had very little to no English. I stepped in and interpreted where I could, which broke the ice and made the ladies feel more comfortable. From the first session it was clear a ‘show and copy’ activity would be the most appropriate.

Attendees wore a mix of traditional and casual dress. Some group members wore trainers, while others wore sandals. By the fourth session most people were wearing trainers. A colleague donated two pairs of trainers which was very much appreciated. We covered doors and windows and ensured no male staff could enter the hall during the exercise session.

Group members gave me their mobile numbers so that we could keep in touch via a WhatsApp group and are already making plans for future groups. We are excited to see how everyone progress in their wellness journey.


Jane is a 12-year old  girl who is currently with CAMHS being assessed for possible ADHD and Autism. Jane said she is being severely bullied at school, verbally, physically and mentally. Jane said she is also bullied online which has led her to self-harm and becoming increasingly withdrawn.

The initial assessment was completed with Jane and her mam who reported that their main concern was the bullying and its detrimental effect on Jane’s behaviour. To help Jane have more control over her emotions, she was provided with information on understanding emotions, feelings and her mental health from Darlington Mind. Jane was also provided with information on the importance of telling an adult if she felt she wanted to self-harm and different strategies she could to use to avoid harming herself.

Jane and her mam were very interested in the information  they received.  Jane was particularly  interested in the self-help guide. Both Jane and her mam are happy that interventions are being put in place to help improve Jane’s mental health and wellbeing.