1.1. Social Prescribing Link Working in English and Scottish Primary Care

Primary care policies in England and Scotland have promoted the use of social prescribing schemes and to enable this have funded the recruitment—at scale—of social prescribing link workers (SPLWs) [16, 17] to support GP practices to deliver social prescribing, supporting efforts to address social determinants of health. SPLWs work collaboratively across the health and care system and particularly with voluntary, community, and social enterprise (VCSE) organizations, to support service users referred to them.

In both countries, GPs and other primary care staff make referrals to SPLWs who, using a “good conversation” approach, meet service users and discuss what matters to them and what they need help with, and then make appropriate plans [18, 19]. Various methods of connecting service users to community social prescribing groups and activities are then used.

In England and Scotland, primary care health policy developments have been followed through into practice, with comprehensive SPLW schemes introduced and SPLW networks established in both countries.

1.2. The Development of SPLWs in England

Whilst both social prescribing services and link worker roles existed prior to the 2019 NHS Long-Term Plan [17], this policy delivered a significant development in social prescribing provision. Social prescribing was included as one of six programs in the comprehensive model of personalized care to promote enablement. NHS England recommended that social prescribing be targeted toward patients with chronic illness and multimorbidity, mild-moderate mental health conditions, patients with loneliness, and those with complex needs [17]. The 2019 Long-Term Plan provided funding for 1000 additional SPLWs to connect people to VCSEs, with a target that every GP practice in England would have access to SPLWs with a target of 900,000 people being referred into social prescribing schemes by 2023/24 [17].

In 2019, Primary Care Networks (PCNs) were introduced in England, groups of GP practices encouraged to work together, covering patient population groups of around 30–50,000. PCNs may directly employ SPLWs or subcontract provision of the service to another provider in accordance with the Network Contract Directed Enhanced Service (DES) contract specification. SPLWs are funded in PCNs as part of the England GP contract agreement to bring additional capacity to primary care [20–22]. In December 2023, there were over 3500 SPLWs in England [23] achieving the 2019 Long-Term Plan mandate for universal PCN coverage [24]. The 2023 NHS England long-term workforce plan reports intentions to increase this number to 9000 by 2036/37 ([25], p. 98).

In January 2023, NHS England produced the workforce development framework for social prescribing SPLWs [26], developed to support SPLWs and their employers to maximize impact of the role. Organizations employing SPLWs, including PCNs, can use this framework to support recruitment and retention. The framework also includes specific information for PCN SPLWs that are funded through the Additional Roles Reimbursement Scheme (ARRS), a program that provides funding to PCNs in England to recruit additional staff [26].

Alongside funding for SPLWs, in 2019, the English Department of Health and Social care provided £5 million [27] for the National Academy of Social Prescribing (NASP), a national charity to enhance social prescribing infrastructure [28]. England also has the National Association of Link Workers (NALW) [29], with over 1000 members who, whilst not a regulator, spearhead standards and advocate for social prescribing SPLWs in healthcare [30]. In 2019, NALW held its first SPLW conference [31].

1.3. The Development of SPLWs in Scotland

Following the introduction of devolution in 1999, health and social care policy was devolved in Scotland. In 2016, the Scottish Government (SG) produced a manifesto commitment to recruit up to 250 SPLWs to work in Scotland’s most deprived GP practices by 2021-2022 [32]. This followed a SG funded pilot study of SPLWs in socially deprived Glasgow GP practices in 2014 [33]; however, before the independent evaluation findings were published in 2017, the SG funded “early adopter” primary care–based SPLW schemes in five different areas of Scotland, across four separate health boards [34].

SPLWs were later formalized as one of six priority areas in the 2018 Memorandum of Understanding (MoU) of the first ever Scottish GP contract which aimed to transform primary care in Scotland [35]. Following the new GP contract, funding and governance arrangements for SPLWs shifted centrally from the SG, to Scotland’s 31 Health and Social Care Partnerships (HSCPs) [34]. HSCPs are organizations formed to integrate health and social care services provided by Scotland’s 14 Health Boards and 32 local authorities and came into effect following SG legislation in 2014 [36]. The SPLW programs were delivered as part of the SG’s Primary Care Improvement Plans (PCIPs) and mainly funded through the Primary Care Improvement Fund (PCIF) [34].

The 2018 Scottish GP contract MoU was later revised in July 2021 (MoU 2) [37] and whilst all six priorities of the original 2018 MoU remained areas of focus, HSCPs were encouraged to prioritize action on three of the six MoU areas, which did not include SPLWs (our emphasis) [37].

As of March 2024, there were 325 SPLWs in Scottish primary care [38]. Voluntary Health Scotland (VHS) is the national intermediary and network for voluntary health organizations in Scotland [39]. VHS advocates for the voluntary health sector in Scotland, collaborating with HSCPs, SG, universities, research bodies, and Royal Colleges to drive sustainable improvements in health and social care. Since 2021, the SG Primary Care Directorate has funded VHS to develop the Scottish Community Link Worker Network (SCLWN) to support Scottish SPLW infrastructure [40] and in 2023 the SCLWN held its first annual conference in Glasgow [41]. In 2020, the Scottish Social Prescribing Network (SSPN) was established to develop the strategic direction of social prescribing in Scotland [42] and in 2023 received funding from the SG. It works closely with the SCLWN and SG to develop social prescribing initiatives in Scotland.

In November 2023, Essential Connections, the first ever national scoping report of SPLW schemes in Scottish primary care, was published by VHS [43]. In relation to the changes in the GP contract MoU 2 (not prioritizing SPLWs) their report noted “This apparent diminution of community link working within the primary care improvement agenda was a significant worry among participants” [43, p37]. Similar concerns were also raised in a 2023 report by the SG’s Primary Care Health Inequalities Short-Life Working Group ([44], p5).

1.4. The Need for Reflection and Evaluation of Primary Care SPLW Schemes

The activities and outcomes of SPLWs at scale are a relatively new phenomenon in the English and Scottish primary care landscape and whilst having established SPLW networks in both countries, compared with other NHS primary care professional groups, the SPLW workforce is still in the early stages of development. However, systematic reviews on the impact of SPLW schemes both generally, and particularly in primary care, have suggested that the evidence base in this field is suboptimal and subject to bias [45, 46] and that high-quality evaluations are now required [47, 48].

Additionally, while one of the goals of SPLWs is to help address health inequalities by helping mitigate the effects of the social determinants of health, their actual long-term impact remains uncertain with some arguing that focusing on individual service user change without tackling systemic/structural factors could, inadvertently, widen health inequalities [49–52]. Furthermore, whilst it is recognized that more research is needed on SPLWs impact on health inequalities, research challenges include limited healthcare utilization data [53] and inconsistent data collection in general, but particularly on wider health determinants and ethnicity, which can result in an inability to fully explore SPLWs’ impact on health inequalities [54]. Questions remain about how SPLW outcomes are achieved within complex health systems [55], and the role of SPLWs in preventive healthcare has been underexplored [56]. Knowledge gaps persist regarding SPLW interventions on specific clinical conditions. A systematic review on social prescribing for mental health [57] found inconclusive results and recommended future research focus on theory-driven interventions, long-term outcomes, treatment fidelity, and person-centered care. Systematic reviews of social prescribing for long-term conditions [58] and on psychosocial referrals in primary care [59] highlight heterogeneous interventions, poor evidence quality, inadequate blinding, and high attrition, emphasizing the need for rigorous controlled trials to assess clinical relevance and sustainability.

Thus, to summarize, there are significant gaps in the evidence base for SPLWs in terms of effectiveness (both on service user outcomes and GP workload) and cost-effectiveness. In addition, there is a growing recognition that robust research and evaluation are required to better understand the key features of, and variations in, and efficiency of different SPLW delivery models, how they operate on the ground, and how effectively their impact on service users is being recorded and measured.

3.1. Mapping and Description of SPLW Schemes

To explore the background, development, and operational models of SPLW schemes in primary care, we gathered data through one-on-one discussions with key NHS primary care leads with responsibilities for SPLW activity and key VCSE stakeholders, as well as primary and secondary online sources across five research regions.

In each study region, we contacted the designated regional lead for person and community centered approaches (at Integrated Care Systems in England and HSCPs in Scotland) to help identify candidate services. We then contacted the designated lead for each identified candidate service to request insights and documentation relating to the development, organization, and delivery of the service.

We engaged 98 key SPLW stakeholders, including SPLW leads from PCNs, GP federations (England), and HSCPs, initially via email and then through follow-up meetings (in-person or online), to discuss the rollout and nature of SPLW services across each region. VCSE leads hosting/employing SPLWs in the five regions were similarly consulted. Using the Template for Intervention Description and Replication (TIDieR) [61] (described in Section 3.2) as a question guide, we conducted one-to-one discussions covering service background, development, funding, target groups, referral processes, and available community assets. Stakeholders provided reports, evaluations, and case studies to support our understanding and mapping of SPLW services.

In addition to these one-to-one meetings, we conducted online searches to gather detailed information on SPLW activities within PCNs, HSCPs, and VCSEs hosting/employing SPLWs. Google was the primary search tool used due to its extensive indexing, supplemented by VCSE network lists, charity directories, and health-focused VCSE organizational networks. Targeted phrases and keywords, such as “VCSE hosting/employing primary care link workers” and “voluntary sector link workers,” refined results. We reviewed official VCSE websites for evidence of link worker programs and community initiatives, and where direct evidence was scarce, job advertisements and press releases were analyzed for relevant insights.

Online searches faced challenges due to regional variations in link worker terminology (e.g., “community link workers,” “SPLWs,” and “community link practitioners”), requiring flexible search terms. Information gaps were common, especially for smaller VCSEs with limited or outdated online presence. To address this, search terms were refined iteratively, and supplementary sources like newsletters and reports were used to triangulate information.

Our systematic approach provided a structured framework to identify key SPLW leads across PCNs, GP federations (England), HSCPs, and VCSEs hosting/employing link workers. By engaging these leads, utilizing online resources, reviewing written materials, and applying the TIDieR template, we effectively mapped the development, funding, organization, and rollout of SPLW schemes in NHS primary care and VCSEs across five regions.

3.2. Mapping SPLW Activity Across 5 Regions Using TIDieR

Data gathering for the mapping exercise took place between April 2022 and May 2023.

The TIDieR [61] was used (see Supporting file 1: for our TIDieR template) to record the description of each local SPLW service across the five regions. The TIDieR is widely used in health research in a range of applied health research contexts and settings [62]. Detailed intervention description is important across many fields of health research, and TIDieR provides a standardized template to facilitate a detailed specification of the necessary components of any intervention or service, making it easier to delineate two or more similar interventions from one another.

The TIDieR template enabled us systematically describe SPLW services across the five regions, focusing on routine data availability, target groups, referral sources, scope of SPLW activities, service types (from “light” signposting to more “hands-on” therapeutic support), and appointment limits. The accuracy of the TIDieR descriptions was then sense-checked with the representatives from each identified service and the designated regional leads.

Using the completed TIDieR descriptions, we then developed a typology of service delivery models. Our core focus was on classification according to the type of service delivered, the populations targeted, and how the service was organized. The emergent typology of delivery models was then shared with stakeholders in order to check its overall representativeness. Stakeholders included local designated regional, our Patient and Public Involvement and Engagement Group and Research Advisory Groups, the NHSE national delivery team, and Public Health Scotland.

3.3. Data Analysis

Between September 2023 and July 2024, the researchers who conducted the mapping exercise across all five regions, authors ED, HC, CP, MB, ME, and HB, held regular formal meetings to agree on our methodological approach to analyzing the data, discuss ongoing analyses, discuss any differing opinions in interpreting the data, and refine our findings.

An inductive content analysis approach was used to examine the data collected in the TIDieR framework. The process was structured and descriptive. Initially, data were reviewed through each individual variable in the TIDieR framework, e.g., type of service provided, target population, and who refers to service, generating open codes. These codes were then grouped into categories, e.g., service user issues and supports offered to service users. Through constant comparison, the categories were synthesized into broader themes, e.g., collection of routine referral data, SPLW encounters, and service user outcomes, that identified common patterns and differences in how SPLW services were delivered on the ground. The analysis was iterative, ensuring findings remained grounded in the data and accounted for local and regional variations.

The TIDieR framework data were then organized manually in Microsoft Word using tidy data principles [63]. Although developed for quantitative data, this structured approach suited multiple qualitative data descriptions of SPLW interventions collected across five regions. Each variable (e.g., referral processes, target populations, and outcome data) was placed in a column, each observational description in a row, and additional detail in a separate cell. This format supported inductive content analysis, enabled systematic comparison, and once data were categorized allowed for broader thematic summations. Analyzing these structured data was manageable without software, and the use of a consistent tool like the TIDieR template proved effective for this structured and descriptive exercise (see Supporting File 1 for a copy of our TIDieR template).

We conducted separate in-depth analyses in each of the five regions to identify key features of SPLW services, producing regional summaries of how schemes were centrally organized and delivered in practice. These were then aggregated for cross-regional comparisons, allowing us to identify commonalities and differences in delivery models. Regular analysis discussions helped refine findings and informed the development of a visual model of SPLW service typologies, which, together with the regional summaries, captured key areas of variation and convergence at scale, including SPLW service types, target populations, referral processes, scope of support, service monitoring, and outcome data collection.

4.1. SPLW Service Model Typology

The SPLW schemes examined in the five regions covered 143 PCNs (in three English regions) and 10 HSCPs (in two Scottish regions). We identified four different model types regarding service delivery of SPLW services in primary care.

The models of service arrangement in use across the five regions are summarized and illustrated in Figure 1.

The following sections also provide a description of the model types; the different models in operation; variation in model usage; priority groups for whom the SPLW schemes were targeted; referral sources to SPLW schemes; and the scope of SPLW services provided and describe the collection of routine referral data, SPLW encounters, and service user outcomes across the five research regions.

4.2. Variation in Model Usage Across the Five Regions

For greater detail regarding the extent of variation within the models across the regions, see Supporting Table 1: Use, and variation of use, of each service model in and across five regions.

4.3. Priority Groups for Whom the SPLW Schemes Were Targeted

Across the five regions priority groups covered included a very broad range of service user types and needs, covering all population types. In some of the regions, North East and North Cumbria, West of England, and Greater Glasgow and Clyde, PCNs and HSCPs offered services to all age groups, catering for children and young people. In other regions, Greater Manchester and Lothian, PCNs and HSCPs focused on adults only.

In some regions, as well as offering generic SPLW services some PCNs and HSCPs offered more specialist SPLW service support. In North East and North Cumbria, some PCNs operating Model 3 services could choose target population groups if they wished and other SPLW services designed specifically for a target population or need such as mental health support, learning disabilities, or children services. In the West of England, some SPLW services began as focused, i.e., over 50s, those leaving hospital, those with mental support needs, those at risk of frailty, and those who have complicated health needs related to the challenges they face living in a deprived area. However, most reports indicate that those currently being referred have a broader range of needs. In Greater Glasgow and Clyde, some HSCPs, whilst offering generic SPLW services, also had two thematic SPLWs that focused on asylum seekers and refugees and homeless people.

In Greater Manchester and Lothian, the SPLW services across PCNS and HSCPs did not offer such specialist supports, and instead offered a broad generic service to all types of service users (although in Greater Manchester one SPLW service targets those aged over 50 years and in one Lothian HSCP a SPLW was based in a service to support people experiencing homelessness).

In some regions, such as Lothian, for example, services were adapted over time with one HSCP, which was an early adopter of SPLW services in Scotland in 2017, and the target population was initially weighted to address populations experiencing social deprivation and experiencing/at risk of health inequalities but since the introduction of the 2018 Scottish GP contract, there are now almost equal numbers of mainstream and health inequalities focused SPLWs.

A brief summary of each region’s target groups is provided below (Algorithm 2).

4.4. Referral Sources to SPLW Schemes

Across all the five regions, most referral sources came from staff employed in GP practices which SPLWs were allocated to. In all the regions, all GP practice staff, including receptionists, could make referrals to SPLWs. In four out of the five regions, self-referrals were also accepted, with only Lothian certifying that referrals had to come from GP practice staff.

In two English regions, additional referral sources to self and GP practice staff referrals included referrals from a range of nonprimary care services. These included, in Greater Manchester, in small numbers, referrals from the Department of Work and Pensions (DWP) and the Ambulance service and in South West England, referrals from a range of health/social/community care services. In Scotland, of the HSCPs mapped, all referrals were either by GP practice staff only (Lothian) or self-referral and GP practice staff (Greater Glasgow and Clyde).

A brief summary of each region’s referral sources is included below (Algorithm 3).

4.5. The Scope of SPLW Services Provided

The scope and nature of SPLW services provided across the five regions were numerous and wide-ranging but there was a commonality across the regions regarding key issues service users needed support with, and supports offered to service users, as outlined in Table 2.

Some SPLW schemes in the five regions had exclusion criteria, e.g., service users currently receiving support from psychiatric services, or with known behavioral issues, suicidal ideation, acute psychoses or those in current or very recent crisis, or housebound. However, in some regions, SPLWs did make home visits to housebound service users.

The heterogeneity of SPLW schemes offered reflected the enormous diversity of service user needs, and also the different levels of engagement service users needed with SPLWs. Some service users required only one session with a SPLW to address a single immediate issue (e.g., signposting to weight management support or a grant to purchase a much-needed domestic appliance). Other service users, particularly those with complex psychosocial needs, required longer-term, more therapeutic support for numerous and/or more complex issues over a number of sessions (e.g., someone living with a number of life-limiting chronic illnesses including depression, very socially isolated, and wishing to make lifestyle changes).

Across all the regions and models, SPLW services offered signposting to appropriate VCSE community services and help in managing issues that require support from statutory services such as housing and benefits through local authorities and the DWP. Across all five regions, SPLW services also offered support to service users in accessing support for core social determinants of health, for example, support in addressing food and fuel poverty, help in purchasing much needed household goods, and help with debt. For many service users with complex psychosocial needs, the therapeutic support provided by SPLWs was very important.

4.6. Collection of Routine Referral Data, SPLW Encounters, and Service User Outcomes

As highlighted in Table 3, there was significant variation in link worker data collection both across and within regions, as well as among individual PCNs and HSCPs, in terms of systems used, data collected, and outcome measures used and how consistently.

Data systems include widely used platforms such as EMIS, SystmOne, Elemental, and bespoke databases, with some regions using additional tools like NEBULA, CharityLog, or Salesforce. Data collected commonly cover referrals (numbers, demographics, and reasons), appointment details, signposting, and service user statuses. In some regions, PCNs and HSCPs also gathered general outcomes data, financial gains, or patient feedback. Outcome measures varied, with ONS4 and (S)WEMWBS being the most frequently used tools, supplemented by others like Well-Being Star, PAM, Recovery Outcomes Web, and bespoke assessments. Regions differed in consistency and quality of data collection, with some HSCPs producing detailed annual reports while other PCNs and HSCPs collected data more sporadically.

For additional information, including routine data collected, see Supporting Table 2: Additional information about SPLW schemes in the five regions.

Feedback from some key stakeholders involved in the mapping exercise highlighted some SPLWs concerns over using validated well-being tools to measure service user outcomes with some feeling that well-being tools such as ONS4 and WEMWEBS did not appropriately capture social prescribing interventions, especially the frequently reported “softer” impact SPLW interventions can have on service users.

7.1. Limitations

In some of the regions, the number of PCNs examined in the mapping exercise was fewer than the exact number of PCNs in operation.

Some reporting may have been inaccurate if researchers’ summaries of the SPLW interventions varied from the actual implementation and adaptations led by practitioners.

Because SPLW schemes are developed and implemented differently in various regions across different UK countries, the results of this mapping exercise may be relevant only to regions with similar SPLW models.

7.2. Strengths

The five regions are diverse, covering multiple SPLW schemes and varying in population demographics, socioeconomic factors, geography, and access to services, offering insight into different organizational and funding approaches to primary care SPLW services.

In-depth consultations (n = 98) were organized with key stakeholders representing appropriate NHS, local authority, and VCSEs involved in the management and delivery of primary care SPLW schemes.

We used the TIDieR to provide a full description of SPLW services in the five regions, including the additional item of “voice”, i.e., who was involved in preparing the description. The accuracy of the TIDieR descriptions was sense-checked with key stakeholders.