Social Prescribing in Primary Care


Social Prescribing in Primary Care

Background on Social Prescribing

Social prescribing aims to address social determinants of health. NHS England describes social prescribing as “a way for local agencies to refer people to a link worker. Link workers give people time, focusing on ‘what matters to me’ and taking a holistic approach to people’s health and wellbeing. They connect people to community groups and statutory services for practical and emotional support.” Social prescriptions are varied and include activities focused on health, education, skills development, sports and leisure/art activities. If utilised well, they can help to deliver several benefits to individuals and health and care systems including: giving a route for health and care systems to address social determinants of health; promoting self-care; building stronger communities; reducing healthcare service utilisation including GP appointments, secondary care referrals and accident and emergency attendances.

The NHS Long Term Plan includes a commitment to make personalised care business as usual across the health and care system. In January 2019, as part of its delivery plan Universal Personalised Care, NHS England announced a major expansion of social prescribing, as one of six components of the comprehensive model of personalised care.


To support the rollout of social prescribing, RCGP and University of Oxford have created a three Observatories:

  1. Social Prescribing Observatory
  2. Social Needs Observatory
  3. Social Prescribing Interventions Observatory

The Observatories support a Learning Health System approach by providing accurate and up to date information about social prescribing.  Healthcare professionals can currently see a breakdown based on several attributes including region, age, IMD, ethnicity, and gender.  Hovering over the line graphs with your mouse will provide information on the number of individuals with the specific attribute in the RCGP RSC, the number of total events as well as the rate per 10,000 (see figure below).

Social Prescribing Observatory

NHS England created a consensus Common Outcomes Framework (COF) for social prescribing in 2019 and recommended the use of two codes to capture social prescribing activity: “referral to social prescribing service” and “social prescribing declined”.  In collaboration with NHS England, we developed the Social Prescribing Observatory to capture social prescribing activity across England.

The Social Prescribing Observatory is updated weekly and provides information on social prescribing referrals and declines broken down by the attributes listed above as well as by ICS. The Social Prescribing Heatmaps provide an England-wide view of social prescribing activity broken down by ICS level.

Social Needs Observatory

It is well established that 80-90% of health outcomes are linked to social determinants of health. These include health-related behaviours (e.g. tobacco use, alcohol use, diet & exercise, etc.), socioeconomic factors (e.g. education, job status, family/social support, income, etc.) and environmental factors (e.g. air quality, water quality, etc.).  It is also well established that ~20% of patients go to their general practitioner for primarily social problems.

To define social need, we used several key concepts derived from the “Five Ways to Wellbeing” model proposed by the New Economics Foundation as well as Wilkinson and Marmot’s work on social determinants of health.  Our long list included several indicators which we then checked within SNOMED to determine if concepts with appropriate semantic tags were available.  This yielded eight indicators with categories and theme variables as listed in the table at the bottom of this page.

Social Prescribing Interventions Observatory

For the Social Prescribing Interventions Observatory, we built on work we have done previously exploring the use of ontologies to capture more granular information on the actual social prescription individuals have been referred to.  We have defined five social prescribing intervention indicators based on appropriate SNOMED concepts and semantic tags:

  • Health education offered
  • Referral to benefits agency
  • Referral To Physical Activity
  • Social Prescribing For Mental Health
  • Referral to Arts Therapy Services

We aim to expand this list in the future to other intervention types.

Table 1. Social Need indicators, categories and themes
Social need indicator Category Theme variable
1 . Issues related to mental health Depression MildMajorDepressionSingleEpisode
Neurotic disorders Agoraphobia
Acute stress disorder
2. Issues relating to substance misuse HarmfulUseOfOpioid (4393)
 HarmfulUseOfCannabis (4394)
 HarmfulUseOfCocaine (4397)
 HarmfulUseOfHypnotic (4396)
 HarmfulUseOfSyntheticCannabinoid (4395)
 HarmfulUseOfAlcohol (4392)
 HarmfulUseOfVolatileSolvents (4637)
 HarmfulUseOfHallucinogen (4398)
3. Issues with Employment FindingOfUnemployment
4. Issues relating to money FindingOfFinancialProblem
5. Issues relating to managing a long-term condition NCD Hypertension
Diabetes T2
Diet FindingOfPoorDiet
Sedentary lifestyle FindlingOfSedentaryLifestyle
6. Issues relating to abuse VictimOfAbuse
7. Issues relating to Homelessness FindingOfHomelessness
8. Issues related to parenting FindingOfParentingProblems

Publications & Reports