Structuring a PCN Social Prescribing Service for the post COVID ‘New Normal’

Planning for the Future


The impact of the COVID-19 pandemic has fundamentally changed the way Primary Care and the voluntary sector operates in support of the community. Self-isolation, shielding and social distancing have created a challenge in supporting the most vulnerable and elderly members of the community, with Social Prescribers at the forefront of the response.

The uncertainty over an end date and the possibility of a second more serious wave of infection are both challenges – as is the potential for a fourth wave, shown in the diagram below  –  a long lasting legacy of patients suffering from mental health problems, anxiety, depression and loneliness.  Such enduring challenges suggest the need to refocus on the role and structure of Social Prescribing services to ensure they can meet the new demands that will be placed on them.

The following Insight article is intended to provoke thought and kickstart the debate as to an appropriate way to employ and deploy Social Prescribing teams within the Primary Care setting. No two PCNs have exactly the same circumstances and challenges, so models will inevitably vary, but the model we discuss below seeks to be responsive to the current COVID-19 environment, whilst being flexible enough to meet the challenges of the fourth wave.

Key Takeouts

  • The impact and long-term implications for mental health of the coronavirus pandemic has highlighted the value and flexibility of social prescribing roles in Primary Care.
  • There is a widespread view that a fourth wave of mental illness, anxiety, depression and loneliness affecting significant parts of the population will follow the acute phase of the pandemic.
  • The need to cope with the community impact of this fourth wave is likely to lead to full recruitment of the additional SP roles (Care Coordinator and Health Coach), alongside more creative use of the ARRS to recruit more staff to SP roles, possibly at the expense of other roles within the DES permitted list.
  • With a larger team, and a move to telephone-based consultations rather than Practice based ones, the default model of sharing the Social Prescriber around Practices based on list size is no longer efficient (if it ever was). Social Prescribing teams should now work for the PCN, triaging patients from Practices to support priority referrals from across the PCN.
  • If the team is employed by the PCN, there is scope to adjust the optimum number of staff in each of the three SP roles to meet the needs of the wider patient community in each PCN.
  • With an expected 5 SP roles operating within a PCN by 2023/24 (NHS illustration) (possibly upwards of 20-25 in an average size CCG) there is a compelling argument for CCGs to provide a comprehensive Social Prescribing Referral Platform to ensure most efficient use is made of the additional SP resources.

Workforce Planning for the Social Prescribing Team

The increased flexibility under the new Network Contract DES of March 2020  allows PCNs to recruit two additional roles to the Social Prescribing team in 2020/21 (Care Coordinator and Health & Wellbeing Coach). It also allows PCNs to determine for themselves how many of each of the available AHP roles they recruit to meet the needs of their patient community, within the overall financial ceiling of the Additional Roles Reimbursement Scheme (ARRS). With a ‘use it or lose it’ approach to funding, there has never been a better time to plan ahead to ensure that the Social Prescribing team staffing and structure meets the needs of the PCN going forward.

The structural diagram below suggests one way in which the Social Prescribing team might be structured to support the PCN and shows the relationships between the Social Prescribing team and other stakeholders within the wider PCN community.

Changing Reporting Responsibilities

Where solo Social Prescribers are employed by the PCN, the default deployment model, whilst not universal, is one in which the SPLW divides their time amongst the PCN’s practices, in rough proportion to the list size of the Practice. This takes no account of the relative needs of the patient community in each Practice and is inefficient in terms of travel time and administrative load. With a minimum team of 3 SPLWs, this model becomes logistically complex and even more inefficient.

By working for the PCN as an entity, the SP team can take referrals from each Practice, triage the referrals for PCN priority/urgency and then allocate each patient to the appropriate member of the team.

Recruitment of New Roles

The DES states that the Care Coordinator is a Band 4, whilst the Social Prescribing Link Worker and Health Coach are both Band 5. This presents something of a dilemma. Do you avoid recruiting a Care Coordinator all together and avoid the potential conflict when the whole team, with minor variations, are doing essentially the same job? Or do you seize the opportunity to create a sensible organisational structure within the SP team – one that allows for different roles and responsibilities, succession planning and the potential for promotion for Care Coordinators into one of the other roles?

The key to maintaining harmony within a team where people are on different salaries, yet carrying out broadly similar roles, is to have clearly defined roles and responsibilities, aligned to the salary level for that role. The DES has tried to provide detailed job descriptions for each role, but they are very similar, and it is difficult to identify any major differences that would justify different salaries.

So here are our thoughts on how you might structure a Social Prescribing team for 2020 and beyond, looking at each role in turn and ending with an ‘at a glance’ table to show the differences: 

The Social Prescribing Link Worker (SPLW)

The SPLW is likely to be the longest serving member of the team, potentially with up to 10 months in post if their PCN moved quickly in 2019. As such, they will be experienced in the ways of the PCN, will have built the key relationships needed and will almost certainly have a referral, evaluation and management system up and running. By default therefore, they are likely to become the Lead within the team, helping new members with induction and familiarisation. They will already have built up a sizeable case load, so it makes sense that they continue with that and become the main Link Worker in the PCN with the largest caseload. They will also use their experience to allocate referred patients to members of the team based on the mix of skill sets available.

The Health & Wellbeing Coach

Those recruited into the Health Coach role may or may not already be qualified as Health Coaches. As there are probably not around 1,200 Health Coaches around the country waiting to be recruited, they may well be recruited from complementary roles or express a desire to move into that role.

Regardless of coaching experience, the new Health Coach recruit should undertake the foundation training and induction for a Social Prescriber – getting them up to a baseline knowledge of how Primary Care works and how the Social Prescribing team operates within the PCN.

Then, at some later stage, the non-accredited Health Coach can undertake one of the 5–day Health Coach online courses run by DNA Insight or one of the other organisations accredited by the Personalised Care Institute. This will equip them to start using Health Coaching with the more challenging cases referred to the SP team.

Health Coaches will focus their skills on helping those patients with low initial PAM scores or with complex or multiple issues. There will be a need therefore for initial triaging of referred patients by the Team Lead to assess the patient’s complexity and likely initial PAM score, prior to allocation to one of the SP team. It is crucial to take a view at the triage stage, as changing responsibility for a patient from Social Prescriber to Health Coach after the Patient’s initial PAM score has identified their level, is clearly not Best Practice.

The Care Coordinator

Given that the Care Coordinator is a Band 4, whilst the rest of the team are Band 5, it is essential to identify a distinct role from the rest of team to avoid valid comparison of what may be perceived as very similar roles and responsibilities.

This can be achieved by focusing on the Coordinator role of the job title. The Care Coordinator should still be trained as a Social Prescriber and will take on a caseload (albeit a smaller one). They will however become the default stand-in to pick up new referrals for all colleagues when on holiday and will become the main coordinator and point of contact with the VCS organisations and groups to which the team refers patients. The Coordination part of the role can also include:

  • Coordination across the PCN, team cohesion and support.
  • Team lead for evaluation efficiency and reporting.
  • Management of the Social Prescribing IT platform and integration/alignment with Practice’s EMIS/SystmOne.
  • Team lead in building out and supporting voluntary groups/organisations.
  • Team lead in building a Social Prescribing Champion and volunteer structure within PCN Practices, including working with those who had volunteered during COVID and who still wish to volunteer their time.
  • Liaison with the Patient Participation Group.
  • Team Lead in developing content and maintaining the accuracy of the Directory of Services.
  • Setting up and managing a group for patients where the demand is not met by CVS or local groups (e.g. a walking group or coffee morning for the lonely).

Social Prescribing Referral Platforms

With potentially five members of the Social Prescribing team delivering support in a PCN by 2023/24, and maybe around 20-25 or more doing so across a typical CCG, there is an increasing justification for the deployment by the CCG of a comprehensive social prescribing IT or Referral platform. It is no longer a ’nice to have’ when there is sufficient budget left over. Instead, with wider understanding of the value provided by social prescribing and increasing numbers of Link Workers across health and social care, the Referral Platform should be considered an essential component in the management of any comprehensive social prescribing programme.

Social Prescribing Referral platforms can help organisations to make community based and on-line support more accessible for patients/residents and carers. They can include community directories (Directories of Services) and provide a process to ensure they are maintained and therefore remain relevant. The best platforms also provide secure video consultation functionality for when social distancing is in force and offer self-referral to community groups by making the directory available to their communities via an App linked to the platform.

Such platforms can also offer case management software, which enables a Social Prescribing service and its stakeholders to understand the impact of referrals on their service users, and on the local voluntary and community sector. The platform can in addition offer commissioners the opportunity to track the movement of service users through the system, and identify capacity, demand, and utilisation rates through analytical dashboards. The resulting data identifies the value provided to the CCG/PCNs by the voluntary groups and services to which they refer their patients – providing an evidence base that enables future service planning and the allocation of future funding to service providers according to the value they deliver.

Furthermore. from a VCS perspective, such technology could allow groups and services to showcase and connect more people to the services they offer, helping with efficiencies in data collection and administration and demonstrating the impact and outcomes achieved for the populations they serve.


Nick Sharples is Managing Partner of DNA Insight, a Primary Care training consultancy providing consultancy and training programmes in Social Prescribing, Health Coaching, Care Navigation and Workflow Optimisation. nick@dnainsight.co.uk dnainsight.co.uk

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