Transformation Partners in Health and Care > Using Social Prescribing, Health Coaching and Care Coordination to tackle health inequalities

Using Social Prescribing, Health Coaching and Care Coordination to tackle health inequalities

This toolkit is aimed at Primary Care Network (PCN) managers, GPs, Training Hubs, practice managers and network managers in London who oversee and manage the three personalised care Additional Roles Reimbursement Scheme (ARRS) roles as part of the personalised care transformation in London. It aims to support efforts to embed social prescribing link workers, health and wellbeing coaches and care coordinators in Primary Care Networks (PCNs) to reduce health inequalities.

The toolkit has been co-produced with partners across personalised care and primary care teams in London to understand and develop practical support needed to effectively embed, sustain, and scale the three personalised care ARRS roles in London and ensure health inequalities is a core part of their strategy. One-to-one drop-in support sessions, monthly webinars and workshops, case study interviews and feedback sessions were undertaken between November 2021- June 2022 as part of co-production efforts.

This work is set in a complex and constantly evolving health and care policy landscape, especially in the context of the statutory legislation of Integrated Care Systems and the development of national and regional strategies around integration, population health, and health inequalities. The guide will be reviewed in 6 months from the publication date.

This toolkit has been created to practically support PCNs in two main areas:

  • Using the three Personalised Care ARRS to tackle health inequalities
  • Embedding the three Personalised Care ARRS roles in systems working with complexity and deprivation


Across London PCNs, the personalised care ARRS workforce is used in varied and innovative ways that are responsive and tailored to local needs and priorities.  In producing this guide, we have consulted PCN Clinical Directors and managers, GPs, SPLW, CC and HWBC network managers and frontline staff, training hubs and workforce development leads and the VSCE sector to understand the challenges and co-create practical support and resources. The guide includes a blend of informative content with references to relevant policy and national guidance, checklists, top tips and examples of best practice and case studies drawing on insights and recommendations from our stakeholders.


Our approach has included: 

  • Bottom-up approach to collecting challenges and questions through one-to-one meetings, webinars and workshops 
  • Close working with those championing best practice in London through case study interviews and regional support to help areas showcase and scale their work 
  • Feedback sessions on the toolkit with PCN managers, training hubs, social prescribing managers and more as well as collaboration with other regions to collate information

Principles and context of personalised care

Health Inequalities, Population Health & Proactive Social Prescribing

Embedding and supporting your personalised care workforce to tackle health inequalities

Working in the wider system

APPENDIX 1: Policy Context

APPENDIX 2: You said, we did