Social prescribing: Reference guide and technical annex for primary care networks

About this guide

Who is this guide for?

This guide has been created to support primary care network (PCN) employers of social prescribing link workers.

This includes practice managers, GP supervisors, other clinical supervisors and social prescribing link workers. Other staff groups may also find this guide helpful, including commissioners and local system partners, voluntary, community and social enterprise (VCSE) organisations, public health colleagues, people with lived experience and patient groups.

Aim of this guide

This guide provides additional information to help PCNs introduce the social prescribing link worker role into their multi-disciplinary teams (MDTs) as part of the expansion of the primary care workforce introduced through the Network Contract Directed Enhanced Service (DES) 22/23 Additional Roles Reimbursement Scheme. It also provides information to deliver the proactive social prescribing element of the Network Contract DES Personalised Care service specification.

This guide was first published in 2019 with the most version updated in November 2022 and should be read alongside the Network Contract DES Guidance 22/23.

Social prescribing is a key component of personalised care

Social prescribing and community-based support is part of the NHS Long Term Plan commitment to make personalised care business as usual across the health and care system. Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths and needs. This happens within a system that makes the most of the expertise, capacity and potential of people, families and communities in delivering better outcomes and experiences. Personalised care takes a whole-system approach, integrating services around the person. It is an all-age model, from maternity and childhood through to end of life, encompassing both mental and physical health support.

This represents a new relationship between people, professionals and the health and care system. It provides a positive shift in power and decision-making that enables people to feel informed, have a voice, be heard and be connected to each other and their communities.

Personalised care is implemented through the Comprehensive Model of Personalised Care. The Model was co-produced with a wide range of stakeholders and brings together six evidence-based and interlinked components, each defined by a standard, replicable delivery model. These components are:

  1. Shared decision making
  2. Personalised care and support planning
  3. Choice including the legal ‘right to choice’
  4. Social prescribing and community-based support
  5. Supported self-management
  6. Personal health budgets and integrated personal budgets

The deployment of these six components will deliver:

  • Whole-population approaches, supporting people of all ages and their carers to manage their physical and mental health and wellbeing, build community resilience, and make informed decisions and choices when their health changes.
  • A proactive and universal offer of support to people with long-term physical and mental health conditions to build knowledge, skills and confidence to live well with their health condition.
  • Intensive and integrated approaches to empower people with more complex needs, including those living with multi-morbidity, to experience co-ordinated care and support that supports them to live well, helps reduce the risk of becoming frail, and minimises the burden of treatment.

What is social prescribing?

Up to one fifth of GPs’ time is spent on issues related to wider social needs, rather than issues best solved by medical intervention. In areas of high deprivation, many GPs report that they spend significant amounts of time dealing with the consequences of poor housing, debt, relationships, and loneliness.

Social prescribing is an approach that connects people to activities, groups, and services in their community to meet these practical, social and emotional needs that affect their health and wellbeing, the wider determinants of health.

This includes connecting people to arts and culture, nature and physical activity, advice and support services, and work and volunteering.

Social prescribing is an all-age, whole population approach that works particularly well for people who:

  • Have one or more long term conditions.
  • Need support with low level mental health issues.
  • Are lonely or isolated.
  • Have complex social needs which affect their wellbeing.

Expanding the primary care workforce aims to alleviate workload pressures on existing staff, improve patient experience of access, cut waiting times and meet the government’s commitment to provide 50 million more appointments within general practice.

Boosting capacity in this way will also improve the quality of care and implement NHS Long Term plan goals, including the integration of care as set out in the January 2019 five-year GP contract deal.

Social prescribing link workers in primary care contribute to these goals, providing a service that goes further to help people with their health and wellbeing needs through non-medical, holistic support.

They are also uniquely placed to tackle growing health and wellbeing challenges, such as our ageing population, people living with complex, long term conditions, and increasing pressure on the health and care system resulting from COVID-19 and waiting list times. The roles also exist in the wider NHS and VCSE sector, so this approach also works to strengthen community resilience, working cross-sector to jointly meet the needs of diverse and multi-cultural communities and tackle health inequalities.

Alongside their core role in supporting patients, social prescribing link workers provide an opportunity to create a culture that embeds the principles of personalised care and equity and inclusion across PCN services, including supporting PCNs to meet the requirements of the Public Sector Equality Duty and health inequalities duties in relation to patients receiving services that are responsive, inclusive and tailored towards their individual needs.

Evidence for social prescribing

There is emerging evidence that social prescribing and connecting people to their community can lead to a range of positive health and wellbeing outcomes for people, such as improved quality of life and emotional wellbeing.

One example of this is that connecting people to nature and green spaces through social prescribing can reduce stress, fatigue, anxiety and depression, and boost immune systems, encourage physical activity and may reduce the risk of chronic disease.  

Whilst there is a need for more robust and systematic evidence on the effectiveness of social prescribing, social prescribing schemes may lead to a reduction in the use of NHS services, including GP attendance. Surveys have indicated that 59% of GPs think social prescribing can help reduce their workload.

The social prescribing link worker role, or the social prescribing service a PCN provides access to, should have the following common features. They should:

  • Take referrals from the PCN’s practices, from a wide range of external agencies, and through self-referrals
  • Give people time to have a person-centred conversation asking, “what matters to you?”, supporting people for an average of 6-12 sessions over a three-month period and hold a typical annual caseload up to a maximum of 200-250 people, depending on complexity.
  • Help people to identify issues that affect their health and wellbeing, and co-produce a simple personalised care and support plan (PCSP)
  • Use coaching and motivational interviewing techniques to support people to take control of their own health and wellbeing
  • Support people by connecting them to non-medical community-based activities, groups and services that meet practical, social and emotional needs, including specialist advice services and arts and culture, physical activity, and nature and green activities
  • Support accessible and sustainable community offers by working with VCSE organisations, local authorities and others to identify gaps in provision and deliver activities and groups to meet population needs
  • Offer a proactive social prescribing service to a PCN defined cohort, depending on local population health management priorities
  • Gather outcomes through use of the ONS4 wellbeing measure and/or other locally appropriate outcome measures and patient impact stories.

Working as part of the MDT

Social prescribing link workers work more closely with some MDT roles than others, including the other personalised care roles available through the Additional Roles Reimbursement Scheme (ARRS), health and wellbeing coaches and care co-ordinators. All three of these roles have expertise in personalised care approaches and working with people to understand what matters to them, but each has a unique role and skills, and some patients may work with multiple roles at the same time.

Social prescribing link workers may also work closely with allied health professionals (AHPs) such as occupational therapists and clinical and non-clinical mental health roles to create a joined-up support offer for individuals who have therapeutic needs alongside social and practical needs.

For example, health coaching is an approach based upon behaviour change theory, delivered by health and wellbeing coaches and other qualified professionals. This differs from social prescribing as the emphasis is placed on achieving changes in behaviour rather than connecting people with community groups and services. However, there are many similarities, as a motivational coaching approach is an integral part of a social prescribing link worker role. Figure 1 below outlines some of the differences between these roles.

In some PCNs, receptionists and other staff may have been trained to provide care navigation and active signposting. This is a light-touch approach, offering information to people about services, using local resource directories and local knowledge, and it works best for people who are able to find their own way to community groups and services, after this brief intervention. It complements social prescribing and is viewed in terms of ‘as well as social prescribing’ not ‘instead of social prescribing’.

Figure 1: Role differences between social prescribing link workers and health and wellbeing coaches.

Per the Network Contract DES Guidance 22/23 and Network Contract DES Personalised Care service specification, PCNs must provide access to a social prescribing service for all registered patients, and deliver a proactive social prescribing case-finding service, typically delivered through employing social prescribing link workers either directly or through contracting arrangements with a local VCSE provider. PCNs must therefore consider how social prescribing link workers will be trained, supervised, managed and supported in post. They must also plan how the service and proactive service will be delivered, for example, population health needs and priorities, referral pathways, and outcome measurements.

The PCN must provide the social prescribing link worker with access to other healthcare professionals as appropriate, to electronic ‘live’ and paper-based record systems, and administrative office support and equipment required to deliver their role.

The technical annexes within this document include a range of resources to support PCNs to get started in employing social prescribing link workers and delivering a service.

Expanded details of the PCN requirements for employing social prescribing link workers and progressing the workforce further are set out in the social prescribing link worker Workforce Development Framework.


For more information about the practicalities of providing social prescribing link worker services in PCNs, please refer to the following NHS England publications:

Additional guidance on employing, training, supervising and supporting social prescribing link workers is available in the social prescribing link worker social prescribing link worker Workforce development framework

Additional information on social prescribing and community-based approaches is available in the Social prescribing summary guide.

For a full list of all the documents relating to the GP contract and setting up of PCNs, please refer to the GP contract webpages.

View and download the implementation checklist for introducing social prescribing link workers into PCNs.

Annex B – Working with partners to create a shared local social prescribing plan

What is asked of PCNs?

The Network Contract DES 22/23 and Network Contract DES Personalised Care service specification require PCNs to work collaboratively with local partners to create a shared local social prescribing plan and, as part of a broader social prescribing service, offer a targeted programme to proactively offer and improve access to social prescribing to an identified cohort with unmet needs.

This plan may link to wider system or place-based plans and should be co-produced with ICSs, local authorities, PCNs, the VCSE sector and views of people with lived experience. To support the above, an action plan template and a self-evaluation checklist has been created. An ICS Social Prescribing Maturity Framework is also in development and will be available for systems to use in 23/24, containing further tools and information on how to collaboratively plan to design, develop and deliver social prescribing.


We know there are many areas with mature social prescribing schemes already commissioned by NHS organisations and local authorities, typically provided by the VCSE sector. Many social prescribing link workers are already working within or closely with primary care, supporting the health and wellbeing of patients by taking referrals from across the local area. It is important that all local partners work together to find the best local arrangements for embedding sustainable social prescribing services in PCNs.

This partnership will support PCNs to move towards a population health approach in working to reduce heath inequalities. It will help PCNs and partners to maximise limited resources, share learning, develop strong connections with local diverse communities and partner agencies and reduce the risk of social prescribing link workers becoming isolated.

What should the plan do?

  • Build on existing local social prescribing schemes, avoiding disinvestment in current schemes or duplication
  • Enable social prescribing link workers in a neighbourhood or place to connect for peer support and to work together as a wider team
  • Plan for recruiting additional social prescribing link workers to support expanding social prescribing services across PCNs and proactive support
  • Show how community assets will be nurtured through identifying gaps in provision and how these will be addressed
  • Demonstrate how impact on equalities and health inequalities have been assessed to ensure diverse and vulnerable population groups are considered as part of the shared local plan.

View and download the PCN shared local social prescribing plan template.

NHS England have created the following resources for employers to use as a basis for delivering a social prescribing service.

Whilst many of the principles in these resources are likely to be universally applicable, the specifics of the social prescribing service, local population health priorities, and the structure and preferences of employing organisation should be considered, and documents adapted depending on the local setup. PCNs employing a single social prescribing link worker will need to prioritise activities to ensure a manageable case load and rewarding role.

This annex contains the following resources to support recruiting that meets the requirements of the Network Contract DES 22/23 and support expansion of social prescribing into proactive case finding.

Please refer to the social prescribing link worker Workforce Development Framework for more workforce and employment information and support.

Annex D – Social prescribing data

All link workers embedded within PCN multi-disciplinary teams should have access to the GP information system used within the PCN. To successfully track the number of people benefiting from social prescribing, and in accordance with the Network Contract DES 22/23, the following SNOMED codes should be used to code activity:

  • 871711000000103 – Social prescribing declined (situation)
  • 871731000000106 – Referral to social prescribing service (procedure)

In addition to the above codes, it would be helpful for social prescribing link workers within PCNs to collect the following information. Please note that introduction of a new minimum dataset for social prescribing is expected to be published in 22/23.

Date referred to link worker

For indication of waiting times.

Who made the referral

To capture which agencies or individuals are making referrals to social prescribing.

Reasons for referral

Why the person was referred to the social prescribing link worker.

Equality monitoring

To ensure that social prescribing works inclusively to meet the needs of all communities.

Contacts with link worker

Appointments and time spent.

Where the person is being connected to

Statutory services e.g. housing, welfare rights, employment support.

Health and care services e.g. aids/adaptation assessment, mental health services.

Community activities e.g. arts, culture, physical activity, nature.

Other (please state).

Outcomes for the person

How did their wellbeing and activation levels change after 6 months?

What changes took place?

How satisfied were they with the service?

Annex E – Measuring impact

Everyone who is referred to a social prescribing link worker or service should be asked at regular intervals to give feedback about their health and wellbeing to measure the impact of social prescribing.

Social prescribing link workers in PCNs are asked to use the ONS4 Wellbeing Scale per the Network Contract DES 22/23. This tool has been chosen because it is free, easy to use and is widespread across the country.

Services can also use other impact measurement tools depending on local needs, for example, the Short Warwick Edinburgh Mental Wellbeing Scale. This guidance does not require social prescribing services to stop using existing impact measurement tools, but to consider adding the ONS4 to allow national comparison.

Systems and PCNs may wish to use the Health Systems Support Framework to engage with potential suppliers of additional outcome measures, or procure these services using the NHS England quality-assured route, providing assurance that outcome measurement tools for social prescribing meet an assessed quality standard.

Social prescribing link workers using outcome measurement tools should follow guidance produced by the publisher to measure impact in the correct way and at an appropriate frequency. They should follow PCN information storage guidelines to store information on outcomes. Broad information on the ONS4 tool is provided below:


What is it?

Why should it be used?

Who should it be used with?

How often should it be used?


Wellbeing Scale

Four short questions (ONS4) on life satisfaction, how worthwhile they feel their life is, happiness and anxiety levels.

ONS4 is a free nationally validated wellbeing scale, based on the person’s own views.

Everyone who is referred to the social prescribing service.

When the person is initially referred to social prescribing and at least every 6 months, for one year.