Download Hospital Referral Form - The Bromley by Bow Centre

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Macmillan Social Prescribing Service - Referral Form
ELIGABILITY: Individual is a cancer patient or survivor (aged 18+ years, any tumour type) living in Tower Hamlets, Newham,
Waltham Forest or City and Hackney.
This form can be emailed securely to:
[email protected]
Faxed to: 020 8983 4098
(confidential/safe-haven line)
Posted via internal post to:
Bromley by Bow Health Centre, E3 3BT
Referral date:
Patient details
Date of Birth:
Referrer Details
Referrer name:
Hospital site:
Tele no:
Job role:
Fax no:
GP Practice
GP Practice:
GP Practice Tele no.
Current hospital contact
Treating consultant:
Interpreter needed?
CNS/Key worker:
CNS tele no:
Pathway point:
Having treatment
Needing help with (tick all that apply):
Cancer diagnosis details
Date of diagnosis:
Post-treatment follow up
Open access follow up
Palliative care
Why are you referring this patient?
Lifestyle (diet/exercise/smoking/alcohol):
Social isolation:
Low mood/anxiety:
Peer support/social activities:
Employment advice:
Money/debt/benefits/housing issues:
Other: …………………………………………………………………..
(e.g. general interest/support to adjust following treatment)
Unsure (to be explored during social prescriber assessment):
Are there medical conditions/considerations that restrict involvement in physical or group activities? (e.g. no heavy lifting, contact sports )
Any additional relevant medical history or support needs (co-morbidity, mental health need, learning disability)?
If your patient isn’t ready for this service but has agreed they would like us to contact them at a later date please indicate date to
Consent obtained for referral and the sharing of the patient information outlined above
Consent obtained for the service to feed back to the referrer regarding issues raised and actions taken
Consent obtained to share the patients eHNA and Care Plan – please attached e-copy with referral form
Referrer signature ………………………………………………………………………………………………………(hand-written signature only required for faxed forms)
This form can be emailed securely to:
Faxed to: 020 8983 4098
Posted via internal post to:
(confidential/safe-haven line)
[email protected]
Bromley by Bow Health Centre, E3 3BT
For further information or to query a referral please contact:
Macmillan Social Prescriber Service, 07983 290 940, 0208 709 9840, [email protected]
Macmillan Social Prescribing Service
Referrers Guide
Getting active
Meeting others
Welfare advice
Learning new skills
Improving wellbeing
Getting back to work
1-2-1 support for people living with or beyond cancer to explore their needs and identify community services to help
them meet their goals
A service for cancer patients or survivors (aged 18+ years, any tumour type) living in Tower Hamlets, Newham,
Waltham Forest or City and Hackney.
The Macmillan Social Prescribing service provides medical staff the opportunity to refer cancer patients for personalised 1-2-1
support in their community to overcome practical issues (e.g. getting back to work and accessing training) and improve their
wellbeing (e.g. getting more physically active and reducing isolation by meeting others).
This two-year pilot is being delivered by the Bromley by Bow Centre (, an innovative charity with a 30-year
track record of delivering integrated health and community services in East London, and in partnership with Macmillan Cancer
Why is this important?
Increased diagnoses and longer survival for cancer patients rates show us that long term management is becoming
more important
A Nuffield Trust evaluation (2014) showed that 15 months after diagnosis, people with cancer had 60% more A&E
attendances, 97% more emergency admissions and 50% more primary care contacts compared to a population of the
same age/gender.
64% of people living with cancer have practical or personal support needs, and 78% have emotional support needs;
the majority (75%) of which say that these needs are caused by their cancer or cancer treatment. Yet many do not get
the support they need to live as well as possible in their homes.
The Macmillan Social Prescribing service supports patients to:
Explore and define what is important to them
Identify the local activities and resources they need
Gain support to engage with these services
Local activities may include:
 health and wellbeing programmes (e.g. walking groups, meditation groups and complimentary therapies)
 work and volunteering advice (e.g. local employment support services)
 learning and social opportunities (e.g. art classes, gardening groups and faith groups)
 practical support (e.g. debt/welfare advice and money management workshops)
 support groups (e.g. parent and carer groups and cancer support groups)
What support is provided?
Telephone support – support over the telephone to identify local activities and support services
Face to face support – A series of face-to-face appointments with a member of our team. Helping patients explore their
needs/what is important to them and the services and activities in their local area, that might help them. A series of 1-2-1
sessions over a 6-month period. Appointments are available at venues in each borough within Tower Hamlets, Newham,
Waltham Forest and City and Hackney.
How do I make referral?
Complete the Macmillan Social Prescriber Referral Form on the reverse and return it via fax to 020 8983 4098 (this is a
confidential fax machine operated by the Bromley by Bow Health Centre) or email [email protected] The
service will telephone the client within two weeks to outline the support on offer/book initial appointments.
How will I gain feedback?
Referrers will gain feedback (via secure email or fax) after the initial appointment and at the end of the intervention.
How do I find out more?
Contact the team on: 07983 290 940, 0208 709 9840, [email protected]
The Macmillan Social Prescribing service is a partnership between Macmillan Cancer Support (reg. charity no. 261017) and the Bromley by Bow Centre (reg. charity no.