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A friendly brew: how we care for our more isolated patients

The problem

We had patients who were feeling lonely and isolated, and we wanted to empower them to self-care and voice any concerns earlier. Because we’re part of the All Together Better Sunderland Vanguard programme we have a multidisciplinary team in our practice, engaging healthcare professionals across the community and third sector partners to identify patients who could benefit from their care. These patients are ‘risk stratified’ by the practice through a range of criteria including professional discretion. This identifies those who need the most combined care and support from a range of community-based services. In Sunderland, a tiny 3% of the population use half of the health resource and this is one of several measures being tested through the vanguard to tackle this effectively.

Again and again, discussions were focused on patients who were cut off from others, and as a result were left feeling lonely and isolated, which can have a massive impact on health and wellbeing. We wanted to put in place social support and companionship that would help to develop stronger social circles, and create an opportunity for people to get out of the house in a safe and welcoming environment that they would be comfortable in.

What we did

We arranged a Good Companions coffee morning at the practice every last Friday in the month starting in September 2016. What it was called, how and when it was run was in consultation with interested patients. It was introduced to patients when we did reviews of their personalised care plan, in our newsletter and on the practice website.

We simply provide the space to meet, free drinks and some staff time to benefit some of our most vulnerable patients.

The coffee mornings are giving us a chance as a surgery to speak informally to patients and identify, very early on, any health concerns. It’s been a great addition to our service and is something we know will make a big difference and is definitely worth the GP time in our practice.


This took it look a few meetings with patients and clinical staff, but time and costs have not been an issue as provision of coffee and tea is minimal compared to the benefits to both patients and clinical staff of being able to engage with each other.


This has allowed us to meet the needs of those patients who have become socially isolated in the community. It has become a safe meeting place where friendships can be made and continued. It has allowed carers a break, while the cared for person can socialise with the group. Our on call GP attends the coffee morning and can address any medical concerns.

It will help head off the problems that isolation can create. We can also speak to patients and identify health concerns very early on.

The future

Numbers are steadily increasing as word gets around, with 12 people attending our last coffee morning. We have already linked with our local carers association. We would like to develop a programme of events in association with our patients and extend this in the summer month to local walks.

If another practice wanted to do something similar, talk to your patient group, carers association and age concern. Get buy in from your practice nurses and healthcare assistants as they will know which patients would benefit.

Gillian Webster is practice manager at Dr Hegde and partners in Washington, Sunderland, Tyne and Wear