Transformation Partners in Health and Care > Addressing health inequity in London through personalised care and community-led prevention

Addressing health inequity in London through personalised care and community-led prevention

Five years on from the launch of the NHS Long Term plan, almost half a million Londoners have experienced personalised care and support following referral to a social prescribing link worker.

Link workers, and other personalised care roles including health and wellbeing coaches and care coordinators, take a more wholistic approach to supporting people most impacted by health inequalities – a key priority in supporting London’s vision to be the healthiest global city.

Since 2019, TPHC’s Community-led Prevention team has supported London’s health and care systems to develop and embed these roles as part of the national ambition to ensure 2.5 million people experience more choice and control in the way their care is delivered.

As a result of this work, more people are actively involved and connected to activities, groups and services in their communities that meet the practical, social and emotional needs that affect their health and wellbeing.

This is important because one in five GP appointments focus on wider social needs, rather than acute medical issues. Stress, unemployment, debt, loneliness, lack of education or support in early childhood, insecure housing and discrimination can impact up to 80% of the health outcomes people experience. People living with multiple long-term conditions, disability, frailty or who live in ethnic minority communities are bearing the brunt of the widening gap in health inequalities.

London now employs 1,600 of these personalised care roles through the NHS, providing support that addresses these wider issues that affect health and wellbeing – That’s almost 500 link workers, 150 health and wellbeing coaches and over 900 care coordinators in London’s primary care networks, with many more funded in the voluntary and community sector.

As the NHS looks back on what it has achieved in the first five years of the Long Term Plan, TPHC is pleased that together with our partners, including those from regional government and the voluntary and community sector, we have played a key role in influencing policy, supporting local strategy, developing evidence, supporting the workforce, and driving innovation in personalised care and social prescribing.

Looking ahead, TPHC’s support to the system will be even more important, following the NHS Long Term Workforce Plan setting out an ambition to increase this local workforce to around 4,300 by 2037. That would mean an increase of up to 650,000 referrals per year, up from the 225,000 referrals made in 2023.

In 2024 and beyond, we will continue our work with local health systems so the personalised care workforce is thriving, and expanded into other settings including secondary and community-based care, so Londoners living with long term health conditions are more effectively supported, and pressures on NHS services are reduced. 

We’ll also continue developing more proactive, preventative and community centred approaches to improve the health and wellbeing of those most impacted by health inequity and ensure communities have a say in the services that are commissioned for them, through innovations like Community Chests, where local funding is pooled to create an accessible funding pot for the voluntary and community sector to support local activities.