Social & Wellbeing

Supporting health beyond medicine

At Durham Dales Health Federation (DDHF), we recognise that health and wellbeing are shaped by far more than medical treatment alone.

Our Social & Wellbeing Services provide personalised, holistic support that helps people improve their health, independence, confidence, and quality of life by addressing the wider social, emotional, and practical factors that impact wellbeing.

Working closely with GP practices, community organisations, and healthcare partners, our teams empower patients to access the right support, strengthen resilience, and take greater control of their own health and wellbeing.

A Personalised and Holistic Approach.

Our services are built around the principles of personalised care – understanding what matters most to each individual and supporting them to achieve healthier, more independent lives.

Using a holistic model that combines:

Social assessment
Lifestyle coaching
Care coordination
Social prescribing
Community signposting and referrals

Our teams help patients access support for a wide range of non-medical needs that can significantly affect health outcomes.

Supporting Thousands of Patients Across Durham Dales

During 2024/25, DDHF’s Social & Wellbeing Services supported over 61,253 patient interactions across our communities.

supported by Social Prescribing Link Workers

supported by Health & Wellbeing Coaches

supported by Care Coordinators

These services continue to play a vital role in reducing health inequalities, improving patient wellbeing, and supporting more joined-up care across primary care services.

Our Multidisciplinary Team

Our Social & Wellbeing workforce includes a team of 20 dedicated professionals comprising:

Social Prescribing Link Workers (SPLWs)
Health & Wellbeing Coaches
Care Coordinators

The service also includes two specialist county-wide roles:

Cancer Early Diagnosis Facilitator
Armed Forces Community Social Prescribing Link Worker

Together, these teams provide personalised support for patients across all three Primary Care Networks (PCNs).

Social Prescribing Link Workers (SPLWs)

Our Social Prescribing Link Workers help connect patients with community-based services and support networks that improve practical, emotional, and social wellbeing.

Each PCN has dedicated SPLW support, led locally to ensure strong community relationships and tailored support for patients.

SPLWs support people experiencing challenges such as:

Social isolation and loneliness
Housing difficulties
Financial concerns and debt
Employment and education issues
Emotional wellbeing difficulties
Substance or alcohol misuse
Low confidence and anxiety

By focusing on what matters most to the individual, our SPLWs empower patients to access meaningful support that improves long-term wellbeing and independence.

Health & Wellbeing Coaching

Our Health & Wellbeing Coaches provide practical support and lifestyle coaching to help patients make sustainable changes to improve their health.

Working across Wear Valley and Bishop Auckland PCNs, the coaching service supports patients through:

One-to-one coaching sessions
Group education programmes
Lifestyle and behaviour change support

The team supports patients living with or at risk of:

Pre-diabetes
Type 2 Diabetes
Weight management challenges
Long-term health conditions

Our coaches bring specialist expertise in areas including health coaching, nutrition, and chronic disease education to help patients build healthier habits and improve overall wellbeing.

Care Coordinators

Our Care Coordinators work closely within GP practices across Bishop Auckland and Teesdale PCNs to help patients navigate healthcare services and receive coordinated support.

They play a vital role in improving continuity of care by supporting:

Follow-up appointments
Healthcare screenings
Annual reviews
Vaccination coordination
Two-week wait cancer pathways
Ward rounds
Referrals into wider support services

By working collaboratively with clinical teams and patients, Care Coordinators help improve patient experience and ensure care is organised efficiently and effectively.

Cancer Early Diagnosis Facilitator

DDHF hosts a county-wide Cancer Early Diagnosis Facilitator role on behalf of the Integrated Care Board (ICB), supporting Primary Care Networks and GP practices across County Durham.

The role focuses on improving earlier cancer diagnosis and increasing screening uptake through:

Practice-level data analysis and insight
Supporting improvement initiatives
Sharing best practice across primary care
Delivering cancer awareness training
Strengthening system-wide collaboration

This proactive work helps improve early diagnosis rates and supports better outcomes for patients across County Durham.

Armed Forces Community Support

DDHF is proud to host a unique county-wide Armed Forces Community Social Prescribing Link Worker service dedicated to supporting veterans and their families across County Durham.

Led by Chris Cowley, the service supports County Durham’s Armed Forces Community of more than 22,000 veterans.

Specialist Support for Complex Needs

Patients are referred through GP practices for personalised support relating to a wide range of challenges including:

Financial difficulties

Social isolation

Employment support

Housing and accommodation concerns

Emotional wellbeing and mental health support

The service works closely alongside veterans to help them navigate services, access support, and improve overall wellbeing outcomes.

Strong Partnership Working Across Services

The Armed Forces Community service works collaboratively with a wide network of organisations including:

County Durham and Darlington NHS Foundation Trust
Durham County Council
Tees, Esk and Wear Valleys NHS Foundation Trust
Police services
GP Practices
Department for Work and Pensions
Veterans’ charities and specialist support organisations
Veterans hubs and community networks

Partnerships include collaboration with services such as:

Delivering Impact for the Armed Forces Community

Since August 2024, the service has:

Supported over 200 veterans and family members
Improved social and wellbeing outcomes for veterans across County Durham
Delivered Armed Forces Community awareness training to healthcare professionals
Developed pathways and training packages to improve support for veterans
Shared best practice regionally to strengthen veteran support services

The work has also contributed to County Durham achieving 100% GP Veteran Accreditation Scheme status, helping ensure veterans are recognised and supported appropriately within primary care services.

Empowering
Healthier Communities

Through personalised care, strong partnerships, and compassionate support, DDHF’s Social & Wellbeing Services are helping people across Durham Dales and County Durham live healthier, more connected, and more independent lives.