Introduction

The evolving ambition for neighbourhood working seeks to bring services closer to home and within communities, foster collaboration, and promote wider health and wellbeing. These interventions support key health ambitions; prevention not sickness, increase self-management and therefore reduce hospital admissions and support access through referring people to digital skills support.

Social prescribing roles exist within local authorities and the voluntary sector as well as PCNs. Although funded separately is the adoption of multi-disciplinary team models across a neighbourhood footprint the ideal time to draw these services together under a single service with collective ambitions and a wider reach to serving our population?

Let’s look at the PCN Social Prescribing model.

Understanding Social Prescribing within PCNs

Social Prescribing has often been referred to as a movement; this is no understatement. As a referring service the reach across a range of local, non-clinical services extends beyond health. Passionate advocates of improving Children and Young Peoples (CYP) mental health, At Scale has worked with Yorkshire Health Partners to develop a Children and Young People (CYP) Social Prescribing model, Enabling Flourishing Futures | At Scale Ltd . We know there are CYP SPs across the country working with CYP community and voluntary sector, schools and other educational establishments providing early intervention and impacting already overstretched CAMH services.

PCNs have embedded Social Prescribers in their teams, connecting individuals with community groups, voluntary organisations, and practical support. This model bridges the gap between medical and social care, recognising that health is shaped by a complex interplay of social, economic, and environmental factors. The integration across multiple sectors really is Neighbourhood working in action.

The opportunity to draw together the social prescribing workforce within local authorities, community and voluntary sector as well as PCNs provides an opportunity to create an MDT across a Neighbourhood based on combined workforce with collective aims and outcomes, but that’s a discussion for another day.

So why explore the Social Prescribing model?

Key Elements of the Blueprint

Community-Centred Approach

PCN Social Prescribing is rooted in local knowledge and relationships. Social Prescribers work closely within neighbourhoods, mapping assets, understanding local needs, and building trusted partnerships with community organisations. This approach ensures that interventions are tailored, relevant, and effective.

Collaboration and Partnership

The service exemplifies multi-agency working. Social Prescribers act as connectors, facilitating collaboration between health services, local authorities, voluntary sector organisations, and residents themselves. This partnership working is vital for the new neighbourhood working ambition, which relies on breaking down silos and sharing responsibility for community wellbeing.

Personalised Care

Social Prescribing prioritises personalised support, co-producing care plans with individuals based on their unique circumstances and aspirations. This person-centred approach aligns with the neighbourhood working ambition’s focus on empowering residents and respecting their lived experience.

Asset-Based Community Development

Rather than focusing solely on deficits, Social Prescribing builds on the strengths and assets within neighbourhoods—be it community groups, peer networks, or skills. This strengths-based perspective is essential to sustainable neighbourhood working.

Data-Informed Practice

PCNs collect and analyse data on social prescribing outcomes, enabling continuous improvement and evidence-based decision making. This data-driven approach helps identify what works, supports resource allocation, and demonstrates impact at a neighbourhood level.

Implementing the Blueprint in New Neighbourhood Working

For example, to realise the ambitions of new neighbourhood working, stakeholders can adopt the following strategies inspired by PCN Social Prescribing:

·       Embed link workers or Social Prescribers within neighbourhood teams to act as connectors and advocates for residents.

·       Invest in mapping and strengthening local assets, ensuring services are co-designed with communities.

·       Foster a culture of partnership across sectors, including regular communication and shared goals.

·       Prioritise personalised, holistic care that addresses the wider determinants of health.

·       Utilise data to monitor progress, share learning, and adapt interventions responsively.

The Primary Care Network Social Prescribing service offers a practical, tested model for neighbourhood working. Its focus on collaboration, personalisation, and community assets can guide the development of integrated, locally driven support systems. By adopting these principles, the new neighbourhood working ambition can move from vision to reality.

Looking to develop your Neighbourhood Plan, refine existing models or just fancy a chat about where to start contact rachel.edwards@atscale.co.uk 07771608773