A woman in her 60s was referred to Jenna, a Social Prescribing Link Worker (SPLW), in February 2025 after a long period of struggling with day-to-day living and growing social and financial pressures. At the time of referral, she was overwhelmed by debt and unable to cope with even basic tasks such as opening her post. The sight of letters caused significant anxiety, as she feared further financial consequences and the impact this was having on her health and wellbeing.
Her situation was complex. Alongside financial difficulties, she had a history of trauma, bereavement, and difficult family relationships, all of which had contributed to poor coping strategies over time. Anxiety had become a major barrier, and previous attempts to engage with services had not been sustained. As a result, she had been discharged from support on more than one occasion, which left her feeling increasingly isolated and without trust in services.
From the outset, Jenna focused on building a consistent, trusting relationship with her. This was not a quick process. Regular home visits and supportive telephone calls were used to gradually reduce anxiety and create a sense of safety and continuity. Over time, this consistent presence helped the patient begin to feel able to talk openly about her situation and identify what mattered most to her.
Once trust had started to develop, a coordinated, multi-agency approach was put in place. The SPLW acted as a central point of contact, carefully linking the patient into a range of services while ensuring she was not overwhelmed. This included support from a Community Matron for case management and hospital avoidance, the Fire Service for a home safety assessment, P3 for housing, tenancy and financial support, and Citizens Advice Bureau for structured debt advice. Occupational Therapy became involved to support mobility and daily living needs, while the Respiratory Team reviewed her COPD. Her GP provided ongoing medical and mental health input.
A key part of the work was ensuring that introductions to new services were done gradually and often jointly, so the patient did not feel abandoned or left to navigate systems alone. This steady, coordinated approach helped her remain engaged where previously she had disengaged.
Over the course of a year, from February 2025 to February 2026, significant changes began to take place. As her support network grew, so did her confidence. She began opening her post again, attending appointments, and engaging with professionals without the same level of fear and avoidance. Financially, her situation improved dramatically—she moved out of debt and successfully secured Personal Independence Payment (PIP), which brought a major sense of relief and stability. With support from P3, she also began working towards finding more suitable housing and started to save for her future move.
Perhaps most importantly, her relationship with services transformed. Where there had once been fear and avoidance, there was now trust and collaboration. She began to feel able to ask for help when needed, rather than withdrawing.
This change was reflected clearly in her wellbeing scores. At the start of support, her ONS4 measures indicated extremely low wellbeing and high anxiety. By the end of the intervention, her scores had improved significantly: life satisfaction increased from 0/10 to 10/10, feeling worthwhile from 2/10 to 8/10, happiness from 0/10 to 9/10, and anxiety reduced from 10/10 to 0/10. Her Patient Activation Measure also improved from level 0 (feeling overwhelmed) to level 4 (feeling able to manage her own health and wellbeing).
The patient described the change in her life in very simple but powerful terms. She explained that she no longer felt trapped by debt or fear, and that the support she had received had given her both practical solutions and emotional reassurance. She said she was now able to engage with services confidently and take steps to manage her own future.
Looking back, she summed it up clearly:
“I don’t know where I’d be without the help. It’s made such a big difference and has been a lifesaver for me. I’m no longer in debt, and now I’m getting PIP, I have started saving up for when I move house. Nothing could have been done better. I’ve had excellent help and care from all involved. Thank you so much.”
This case demonstrates the impact of consistent, trauma-informed social prescribing support, and the value of coordinated, multi-agency working in helping someone move from isolation and distress to stability, confidence, and independence.
Thank you to Jenna McAdam, PGPA Social Prescribing Link Worker in Central Halifax PCN for sharing this work.