Background

Addressing Health Inequalities has been a policy priority for London and the UK for over 20 years. 84% of factors contributing to total health are socioeconomic factors, health behaviors and physical environment with only 16% of factors attributable to the health system (Hood et al., 2016). 

In 2019, The NHS Long Term Plan (LTP) specified that Personalised Care needs to become Business-As-Usual (BAU) and should be delivered via Universal Personalised Care (UPC). The LTP social prescribing targets were part of this drive to provide UPC, giving people more control over their health and how their care is planned and delivered:  

• Increase the number of Social Prescribing Link Workers (SPLW): Recruit 1,000 SPLWs by 2020/21, and more by 2023/24  
• Increase the number of people referred to social prescribing: Refer at least 900,000 people to social prescribing by 2023/24  
• Set safe caseloads: Set a maximum safe caseload of 200-250 people per year for SPLWs  
• Support SPLWs’ professional development: Provide dedicated time and funding for training and professional development (CPD)  
• Regularly supervise SPLWs: Use regular supervision sessions, appraisals, and personal development planning to help SPLWs progress  

The Mayor’s Health Inequalities Strategy set out the ambition for all Londoners to have access to Social Prescribing (SP). 

The Community Led Prevention (CLP) (previously Personalised Care) programme was a London regional partnership programme supporting health services to embed more upstream, preventative, community led models of care, through interventions which focus on addressing the wider social determinants of health, such as social prescribing and broader community connector type models.  

Alongside system partners, the team have delivered a range of regional improvement and transformation initiatives to embed social prescribing, achieving outstanding impacts for Personalised Care and health equity in London. 

By building strong partnerships across London, the programme has had a key role in influencing the shift towards a more integrated, preventative, and biopsychosocial model of healthcare across London health and care systems.  

The partnership programme was closed in March 2025 following a decision by the London Regional Exec Team (LRET) as personalised care policy has been embedded through local strategic delivery across ICBs, Places and Neighborhoods.  

All the projects and activities within this programme have either ended or transitioned to other areas of the London health system. 

Governance

The programme has historically reported into London’s Personalised Care Advisory Group (PCAG), chaired by NHSE London Personalised Care SRO and NHSE London Personalised Care Clinical Director. The PCAG currently reports into NHSE LCEG, however, as of March 2024 this governance is under review.  

Programme activity was also steered by: 

• A Personalised Care London Clinical Leadership Group, chaired by NHSE London clinical director for Personalised Care and had clinical leadership representation from across all 5 London ICBs
• A Personalised Care Senior Management Team for London, including the NHSE London head of personalised care expansion, the clinical director for personalised care and the NHSE London personalised Care SRO 
• A Knowledge Sharing Forum, which had representation from all personalised care operational leads across London’s 5 ICBs
• A Social Prescribing Advisory Group which had cross-partnership representation from NHSE London, GLA, ICBs, VCFSE, OHID, and London Councils

As well as reporting into the PCAG, some elements of the programme have had dotted lines into other governance structures as outlined below: 

Projects	Governance Board
Community Chest	London Leaders Group
Social Welfare and Legal Advice	London Health Equity Group / London Health Board
Health Equity Group Support	London Health Equity Group

Methodology of the work  

The activity of the programme centres around enablers where there is benefit in a once-for-London approach: 

• Training, developing, and connecting the personalised care workforce and supporting professional advocacy
• Improving access to specific support in the community to address wider determinants
• Improving access to health and care services by increasing health literacy, patient activation levels and by developing culturally competent approaches for specific London populations

The programme has delivered a range of regional improvement and transformation initiatives to embed and scale social prescribing, and wider community-led preventative approaches and is structured around the following capabilities: 

• Strategy and System Support: Work with cross-sector partners to support strategy, service design and implementation of whole systems approaches to social prescribing and wider community-based support using population health management approaches
• Workforce Support: Provide support to London’s personalised care workforce (Social Prescribing Link Workers, Health Coaches and Care Coordinators) to embed, develop, retain, and maximise their impact on health inequalities
• VCSE Partnerships: Scale innovation and initiatives to strengthen partnership working between NHS, Social Care, VCFSE organisations to enable integrated neighborhoods and build capacity in VCSEs
• Co-production: Support services to embed lived experience into service design
• Programme Development and Delivery: Deliver ‘once for London’ programmes and projects which support our strategic objectives
• London Health Equity Capacity: Lead on the Health Equity Collaborative (HEC). Forming part of the London Region’s Health Equity Ecosystem, the HEC is a pan-London partnership, with representatives from across the health and care system who have a shared ambition to support health equity and champion community-centred preventative models of care. The HEC provides resources to support specific projects proposed through the Health Equity Ecosystem that are identified as requiring partnership leadership

Across the programme activities, we coproduce case studies, toolkits, newsletters, strategy, and implementation guides and hold London-wide webinars to highlight good practice. 

The programme has ensured partnership working is an integral key thread underpinning all projects and programme activity. The team coproduces all priorities with ICBs and codesigns all projects with local services and people to ensure that they are responding to the shared challenges on the ground. The activities delivered have been initiated using a theory of change model, which is developed and tested with a range of stakeholders. 

A core function of the programme has been to convene and foster collaboration between cross-sector stakeholders and system partners, in support of INTs. Across programmes, the team have created platforms to amplify stakeholder and lived experience voices. This includes but is not limited to an SP Managers’ Network, SP Evaluation CoP, Secondary Care CoP, Patient Voices programme and a Partnerships Group. The team has been committed to using all platforms and relationships to shape and codesign programme activity. 

All activities the team delivered were geared towards sharing best practice and scaling innovation across London. Where projects were delivered in local areas, the team developed shared resources and held learning events across London to enable scale. The team provided London’s ICSs and Boroughs with a single point of contact and facilitated connections and networking across boundaries. As well as providing a communication channel to disseminate any information, guidance, and resources to all social prescribing services across London. And advocating for the workforce and services at a London and national level to ensure they are thriving and continue to deliver impact.