The value of social prescribing within a pulmonary rehabilitation service, North West London
Project overview, including who was involved in the project
Social prescribing has been shown to enhance health outcomes and reduce health inequalities by addressing patients' social, emotional, and physical needs.Following a comprehensive service review, including internal evaluations and feedback from external stakeholders (patient and public involvement (PPI),we identified that wider determinants of health significantly impact patient engagement, adherence, and completion rates within our pulmonary rehabilitation (PR) service. In particular, we observed a rise in health inequities and an increasing need to support our patient population with issues such as fuel poverty, inadequate housing, social isolation, and psycho-social wellbeing.
Social prescribing is a fundamental element of personalised care, and NHS England (NHSE) continues to champion its expansion, primarily through link workers embedded within Primary Care Networks (PCNs). However, these link workers are often overwhelmed by high referral volumes and may lack specific knowledge around the long-term management of respiratory conditions.
After engaging with social prescribing leads across North West London, we recognised that integrating a dedicated link worker within our PR service could bridge this gap, enhancing both understanding of respiratory care and improving patient outcomes.
With this in mind, we launched a pilot programme using NHSE Pulmonary Rehabilitation Transformational Funding to evaluate the impact of embedding a dedicated social prescriber within our PR service.
Who was involved in this work/project?
Pulmonary Rehabilitation (PR) Clinical Team (AHP’s, Exercise Specialists, Respiratory Practitioners)
Dedicated PR Social Prescriber
Senior Leadership and Clinical Team within the organisation
Integrated Care Board (ICB) Social Prescribing Network
Primary and Community Care
Social Care
Voluntary Sector
Patient and Public involvement, targeted at hard-to-reach areas
Quality Improvement Team
Project outcomes/impact
Following initial focus and review, integrating a social prescriber within the PR team has demonstrated several positive outcomes:• Strengthened connections with community and voluntary sector organisations, including the social prescribing network.
• Enhanced holistic patient management through collaborative working and timely, appropriate referrals.
• Greater awareness and understanding within the service of the root causes of health inequities, particularly among hard-to-reach populations and patients who frequently do not attend (DNA) or are unable to attend (UTA). This has enabled the use of a tailored, patient-centred "menu of choice" approach to care.
• A shift toward a whole-population approach, supporting individuals who may benefit from social prescribing, such as those experiencing loneliness, complex social challenges, low-level mental health needs, and long-term conditions.
• Improved multidisciplinary team (MDT) knowledge of social prescribing and the wider determinants of health, leading to better patient engagement in respiratory care.
• Stronger integration and collaboration between primary care, community services, and the voluntary sector, enabling more coordinated and localised patient support within neighbourhoods.
In addition, the PR service has prioritised the development of a pre-rehabilitation (pre-PR) home service to better engage hard-to-reach patients. This service aims to address barriers to participation, whether physical (exercise readiness), psychological, or social, and facilitate smoother entry into PR programmes.
The role has also supported the creation of comprehensive self-management plans for patients upon discharge, with the goal of improving long-term health outcomes, fostering patient empowerment, and reducing overall healthcare utilisation.
If you were to run the project again, what would you do differently?
• Establish a dedicated pathway and service team from the outset.Although this developed over time, it was not in place at the beginning because the structure and scope of the service were still evolving. With no previous studies or comparable roles to learn from, much of the development was iterative. In hindsight, setting up a defined pathway and dedicated team earlier would have strengthened implementation and consistency.
• Put robust administrative and data collection processes in place early on.
Effective systems to support data collection, project evaluation, and shared learning evolved gradually. This required clinicians to build strong relationships with quality improvement and project management teams to assess the role’s feasibility and to develop evidence for future business cases and service expansion. Earlier alignment and infrastructure would have supported evaluation and scalability sooner.
• Introduce social prescribing educators and peer champions earlier.
Over time, we established social prescribing teachers and peer champions within the service to promote awareness, embed the approach into routine care, and extend the reach of the social prescriber. Implementing this structure earlier would have accelerated engagement and increased patient access.
Advice you would have for others undertaking the same type of project.
• Define a clear vision for the role before recruitment.
Having a well-developed understanding of how you expect the role to evolve will help you attract the most suitable candidates and set clear expectations from the outset.
• Recruit individuals who are comfortable working autonomously.
Social prescribing roles often require a high degree of independence. The post-holder should be self-motivated, proactive, and willing to develop knowledge in specialist areas (such as respiratory care), while building strong relationships both within the organisation and across external sectors.
• Plan for flexibility and growth.
The role is likely to evolve over time. In our experience, it expanded significantly after implementation, highlighting the importance of addressing social, emotional, and physical barriers to care. Building adaptability into the role from the beginning will support its long-term success and impact.