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Social Prescribing/community navigation

Community Social Prescribing is a National NHS Programme with a ‘light touch’ approach to supporting the health and wellbeing of individuals and communities. The programme is implemented by different organisations across the country.


Imagine If has delivered the Social Prescribing Service for the Coastal Cluster and Truro Primary Care Networks (PCNs) in Cornwall for four years. We work closely with the multi-disciplinary teams in each PCN to ensure patients receive support that is holistic, personalised, and empowering.


Imagine If has a unique approach to social prescribing, which we call “Community Navigation”. Helping people navigate life’s challenges with the support of the community. Community Navigation has three key elements:


  • Signposting: strive to understand the patient holistically to assess need; signpost patients to suitable community support and make appropriate medical referrals.  

  • Coaching: support patients to develop the confidence and resilience to access services and utilise the support on offer fully, motivating them to set goals and break down barriers.

  • Community Development: spotting the gaps between services; collaborate with local people and groups to fill these gaps and respond to the needs of the local community, with a ‘by the community, for the community’ approach.


We believe it’s important to understand what matters to the patient to support them properly. We also know telling someone to exercise more, for example, isn’t enough. We work with patients improve their awareness, recognise, and celebrate their Assets, and motivate them to engage with their community.


We work with a wide range of people of all ages, who are often facing more than one of the following:


  • Long-term health condition​

  • Bereavement and loss​

  • Depressed, low mood, anxiety and other difficulties with their mental health​

  • Loneliness and isolation​

  • Chronic pain​

  • Unpaid carers

  • Complex social needs​

  • Financial / benefit difficulties


Though our work with the Coastal Cluster PCN has come to an end, we continue to support patients in the Truro PCN. We also adopt a Community Navigation approach in our HUB Network, which enables us to reach a greater number of people as well as those who are harder to reach, without the need for a GP appointment. We promise to develop the support available, ensure support is accessible, and make positive change sustainable.

"Social prescribing has worked wonders for me... Since attending the Truro Museum Creative Wellbeing and The Nook Art Sessions, my confidence has been increasing and I have been sleeping better - feeling connected to other people with similar interests and a day to aim for each week has made me feel more energised. Doing something that I love and feeling useful to other people has given me a purpose."

"You cannot know just how much having this conversation together today has meant to me. I feel you’re the first person who's really listened and I feel better in myself than I have done for many months."

"Thank you for checking up on me and thank you so much for this morning, I really appreciate you being there for me, and the care and support gives me so much... because they'd [the physio] received your email, they asked me to stay to have an appt with the Dr who was really lovely. [They] are going to chase things up and see me again tomorrow."

Cardiac Rehab

Our Cardiac Rehab Coaching Project receives patients from across Cornwall who are recovering from recent myocardial infarction (heart attack). The project aims to support patients and their families through what is often an incredibly traumatic process, with emphasis on the wider determinants of health and wellbeing to improve clinical outcomes.


The project is in its infancy, starting in February 2023 and led and delivered by Development Coach, Anna. Anna uses a combination of social prescribing, coaching and Asset development to guide and support patients, working with multi-disciplinary teams to ensure patients receive the care they need.


Patients referred often present with unaddressed mental health illnesses and complex social circumstances. In many cases, poor coping mechanisms for these may have contributed to a myocardial infarction.


Flexibility and an open-mind enables Anna to take a holistic approach. Meeting with patients weekly, time is taken to understand where the patient is at and what’s important to them. Patients are supported to set meaningful goals, develop strategies to manage emotions, and consider challenges from a solution focused perspective. Together, they work to break down barriers and limiting beliefs, increase motivation and make use of existing support networks.


Self-referral has shown to dramatically increase engagement and the adoption of new habits long-term. Over time, patients build the confidence, self-esteem and resilience needed to take control of their own health and develop better, healthier coping mechanisms. When ready, patients are encouraged to self-refer to community support groups and appropriate professional services.


Working with Cornwall’s Cardiac team, gaps in services are being identified, current practice informed, and early intervention strategies developed.

"I can’t stress enough how vital imagine if and Anna have been in helping me realise what the life I want to live looks like and helping me build the foundations to reach it."

"I'm really happy that this help has been available to me because without it, I'd be repeating old behaviours which caused me incessant mental pain and anxiety. I think the cycle is being broken and that gives me great joy."

Tottenham Hotspur Foundation 

Nando's: Employability and Recruitment

Longmeadow Primary School 

Exeter University 

Newham Youth Offending Service 

Roman Fields Provision


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