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How to embed Social Prescribing in individual and organisational professional practice

Social Prescribing Model

Why do it?

(Information abridged from the Social Prescribing and Community-Based Support Summary Guide NHS England.)

  • There is emerging evidence that social prescribing can lead to a range of positive health and wellbeing outcomes for people, such as improved quality of life and emotional wellbeing. Social prescribing schemes may lead to a reduction in the use of NHS services, including GP attendance.
  • The economic benefits of social prescribing are becoming well established. An evaluation of a national social prescribing scheme which served 2,250 people at risk of loneliness reported a Social Return on Investment (SROI) of £3.42 for every £1 invested. The PrAISED (Promoting Activity, Independence, and Stability in Early Dementia) feasibility study generated SROI ratios ranging from £3.46 to £5.94 for every £1 invested, using a control group to accurately attribute this finding. The evaluation of City and Hackney’s social prescribing scheme conservatively generated an SROI of £3.51 for every £1 invested. Researchers estimated a potential SROI of £8.56 for the overall population of 2,000 service users. (Full report and findings here.)
  • When social prescribing works well, people can be easily referred to local social prescribing link workers from a wide range of local agencies, including general practice, local authorities, pharmacies, multi-disciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations. Self-referral is also encouraged. 
  • Link workers give people time, and focus on what matters to the person as identified through shared decision making or personalised care and support planning. They connect people to community groups and agencies for practical and emotional support. 

Who is it for?

Social prescribing works particularly well for a wide range of people including those:

  • with one or more long-term conditions 
  • who need support with their mental health
  • who are lonely or isolated
  • who have complex social needs which affect their wellbeing. 


What good social prescribing looks like – for people

  • People, their families and carers know about social prescribing and can easily be referred to social prescribing link workers from a wide range of local agencies.
  • People are involved in the co-production of their care. (There is a useful guide here on How to get started with Co-Production in Social Prescribing.)
  • People, their families and carers can refer themselves to social prescribing link workers. 
  • Building on ‘what matters to me’, people can work with a link worker to co-produce a simple plan or a summary personalised care and support plan, based on the person’s assets, needs and preferences, as well as making the most of community and informal support. 
  • People, their families and carers may be physically introduced to community groups, so that they don’t have to make that first step to join a group and to meet new people on their own. 
  • People, their families and carers are encouraged to develop their knowledge, skills and confidence by being involved in local community groups and giving their time back to others. 
  • Being connected to community groups through social prescribing enables people to be more physically active and improves mental health, helping them to stay well for longer and lessen the impact of long-term conditions. 

Social prescribing for children and young people

Whilst the principles of delivering social prescribing to children and young people are the same as for adults, the methods of working with them are often very different. To effectively work with children and young people it is important to understand that they may face a range of complex challenges including in their family setting, or as a result of their wider health, educational, work or social context.

To help you provide support for children and young people, here is a very useful toolkit.

What good social prescribing looks like – for communities

  • Communities understand the power of social prescribing in reducing health inequalities.
  • Communities work with social prescribing to ensure that services are fully accessible to all communities, including those in greatest need, who may be hardest for agencies to reach.
  • Communities recognise that the NHS, local authorities and statutory services alone cannot meet all people’s support needs. 
  • Communities are actively involved in developing and delivering social prescribing. 
  • Communities are able to support people who participate in social prescribing, improving their confidence and ability to manage their own wellbeing.


How to do it

What needs to be in place locally  

1) Collaborative commissioning and partnership working

Social prescribing works best when all local partners work together to build on existing assets and services. Successful schemes generally have collaborative commissioning and creative partnership working, with the following common characteristics: 

  • All partners build it together. 
  • Local relationships matter. 
  • The VCSE sector is involved from the start.


2) Easy referral from all local agencies 

It is important that a wide range of agencies, including all general practices, are able to refer people to social prescribing and that this process should be as easy as possible. To be effective, the following are needed: 

  • A wide range of local agencies are able to refer to social prescribing. 
  • Informed decision-making. 
  • National social prescribing codes in GP IT systems to capture social prescribing referrals: NHS England has worked with NHS Digital to establish national SNOMED CT7 codes for social prescribing: 871711000000103 | Social prescribing declined (situation) 871731000000106 | Referral to social prescribing service (procedure). 
  • Easy referral within general practice.


3) Workforce development

For social prescribing to work successfully, link workers need suitable support and training. It is also vital that the wider workforce have an understanding of social prescribing to enable appropriate referrals. 

  • All referrers need support to understand link worker roles and how local systems can make the best of them. 
  • Social prescribing link workers need regular access to ‘clinical supervision’. 
  • Accredited learning and link worker qualifications.
  • There are lots of resources on this site to support workforce development. Have a look, too, at the variety of training options available for individuals, teams and organisations through the Personalisation team.


4) Link workers employed to give time 

Paid link workers are a fundamental feature of good social prescribing. They play a pivotal role by developing trusting relationships and providing personalised support. As a result, their work: 

  • strengthens community resilience 
  • reduces health inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity 
  • increases people’s active involvement with their local communities.


5) What matters to you? Co-produced simple plans or summary personalised care and support plans 

An important element of social prescribing support is for the person and their link worker to co-produce a simple plan or a summary personalised care and support plan, which outlines: 

  • what matters to the person – their priorities, interests, values and motivations
  • community groups and services the person will be connected to 
  • what the person can expect of community support and services 
  • what the person can do for themselves, in order to keep well and active 
  • what assets people already have that they can draw on – family, friends, hobbies, skills and passions.
  • Here is useful guidance on how to get started with co-production in social prescribing.


6) Support for community groups 

It is essential to ensure that local voluntary organisations, community groups and social enterprises are locally sustainable and can plan ahead, if social prescribing is to be embedded across all local areas. Support should include: 

  • Funding. There are different ways that local commissioners can provide funding.
  • Safe referrals. It is necessary to ensure that community groups have support with all relevant aspects to ensure both people and link workers are safe.


7) Common Outcomes Framework 

Social prescribing is locally driven. To encourage consistent data gathering and reporting of outcomes, NHS England has worked with a wide range of stakeholders to develop a Social Prescribing Common Outcomes Framework (see Annex D in the document) for measuring the impact of social prescribing on the following outcomes: 

  • Impact on the person. 
  • Impact on the health and care system. 
  • Impact on community groups. 


Training, documents and best practice resources: