A Holistic Approach to Leaving Hospital:

The Case for Social Prescribing at the Point of Discharge

Leaving hospital can be a vulnerable and uncertain time. While medical treatment may be complete, many people continue to face challenges that can affect their recovery and long-term wellbeing whether that’s loneliness, housing stress, or the need for additional community-based support. This is where social prescribing can play a vital role.

By linking individuals to local supports, activities, and non-medical services, social prescribing provides a crucial bridge between hospital care and everyday life. In Ireland, there is growing recognition that embedding social prescribing into personalised care plans at the point of discharge could transform patient outcomes and strengthen community care.

The HSE’s Social Prescribing Framework (2021) positions social prescribing as a cornerstone of integrated care and community support. It complements Sláintecare’s vision of shifting more care into the community, ensuring that people receive person-centred, coordinated, and responsive support at key transition point particularly when leaving hospital.

Evidence from the Health and Wellbeing Community Referral (HWBCR) Pilot shows that social prescribing empowers people to take greater control of their health by connecting them with local, non-clinical supports. This reflects the ambitions of Healthy Ireland, which places strong emphasis on tackling the wider social, economic, and community factors that shape health outcomes.

In practice, including social prescribing in discharge planning means ensuring patients are connected to existing supports such as Family Resource Centres, Local Development Companies, and community health initiatives. These connections address the social determinants of health, reduce isolation, and strengthen continuity of care once patients return home.

The research base in Ireland is also growing. The LinkMM trial, led by the Royal College of Surgeons in Ireland (RCSI), is exploring the impact of social prescribing link workers in primary care for patients living with multimorbidity. Early evaluations of HSE demonstrator projects (2018–2021) further highlight improvements in mental wellbeing, social connection, and reduced reliance on clinical services all of which are highly relevant to ensuring safe, effective, and supportive hospital discharge.

Hospital discharge is not just the conclusion of treatment it is the beginning of recovery in the community. By embedding social prescribing into personalised care plans, Ireland has a real opportunity to create more joined-up, compassionate, and effective pathways of care that support people not only to recover, but to thrive.

Sources

HSE Social Prescribing Framework (2021)  The official framework outlining the HSE’s approach to integrating social prescribing into community-based health and wellbeing services:https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/mental-health-and-wellbeing/hse-social-prescribing-framework.pdfHSE.ie

HSE Social Prescribing Overview Page  Offers a concise summary of how social prescribing services work in Ireland, including link worker interventions and programme goals:https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/mental-health-and-wellbeing/social-prescribing/HSE.ie

LinkMM Trial Protocol (BMJ Open, 2021)  Details the pragmatic RCT exploring the impact of link workers in general practice settings for patients with multimorbidity in deprived areas:https://pubmed.ncbi.nlm.nih.gov/33526499/PubMedBMJ Open

Exploratory RCT Findings (BMC Primary Care, 2024)  Reports on the feasibility and potential impact of primary-care-based link worker interventions, relevant to multimorbidity and community health outcomes:https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-024-02482-6BioMed Central

Mental Health Reform Briefing Document (2023)  Highlights policy mandates positioning social prescribing centrally within Irish health reform (Sláintecare, Healthy Ireland, mental health strategies):https://mentalhealthreform.ie/wpcontent/uploads/2023/06/MHR23_SP_SCREEN.pdf