Embedding a physical activity-centric social prescribing post within a Primary Care Network

Evaluation of a newly introduced activity and wellbeing coach role, jointly developed by Rise and Oxford Terrace/Rawling Road Medical Group to strengthen the Primary Care Network’s social prescribing offer. 

Designed to deliver proactive, cohort-specific wellbeing and activity programs, coaches work alongside primary care teams, including frailty nurses and link workers, to support patients through tailored interventions

How to sustainably embed the role of new activity and wellbeing coaches within Primary Care Networks and in a way that supports preventative care, reduces reliance on clinical staff, and delivers measurable value to the health system.

Successful co-design and development of new activity and wellbeing coach role within Primary Care Networks, integrated in a way that supports proactive and preventative care, reduces reliance on clinical staff, and delivers measurable value to the health system.

The activity and wellbeing coach is a non-clinical role embedded within primary care teams to provide an innovative, activity-based approach to social prescribing. Designed to move beyond traditional referral models, the role focuses on proactively prescribing ‘movement’ as a central component of health improvement and prevention. Coaches, often with physical activity expertise, deliver tailored programs that support long-term lifestyle changes, enhance patient confidence, and promote independence. By integrating into primary care, the role strengthens collaboration between clinical teams and the voluntary sector, reduces reliance on clinical staff, and enables practices to offer enhanced personalised care aligned with Universal Personalised Care and Population Health Management principles.

Key actions taken:

Role development and expansion:

• coaches were embedded within primary care teams and included in multi-disciplinary team meetings
• local flexibility was maintained, allowing adaptation to community needs
• patient experience measurement: 
  • outcome tracking tools were implemented (e.g. frailty metrics, weight management)
• patient feedback mechanisms were established to inform program improvements
• peer-led support networks and community-building activities were piloted
• referral pathway standardization:
  • clear referral processes were developed and shared across practices
• staff engagement/consultation undertaken to improve identification of suitable patient cohorts
• health system data was used to target referrals effectively.

Cross-sector collaboration:

• role remit was clarified across stakeholders
• partnerships with local authorities and Voluntary, Community and Social Enterprise (VCSE) organisations were strengthened:
  • co-design principles were applied to refine program delivery.

Data and evaluation frameworks

• systems for collecting patient outcomes and cost-effectiveness data were introduced
• research collaborations were initiated to identify best practices
• evaluation frameworks were developed to assess impact on patient health and service demand.

Funding models

• discussions with ICBs and local health authorities began to secure long-term funding
• business case to be prepared to demonstrate economic value and sustainability.

The introduction of Activity and Wellbeing Coaches has delivered significant benefits across patient, practice, and system levels.

Patients reported improved physical health, confidence, and overall wellbeing through tailored, activity-based programs that foster long-term lifestyle changes. Practices suggested enhanced capacity and efficiency, as coaches potentially reduced reliance on clinical staff and strengthened multidisciplinary collaboration.

At a system level, the approach demonstrated the potential to address health inequalities by targeting cohorts most likely to benefit from preventative interventions, while promoting partnership working between primary care and the voluntary sector. Feedback also highlighted increased patient satisfaction and engagement, reinforcing the value of integrating non-clinical roles into the wider social prescribing offer. 

While these benefits are promising, a systematic evaluation using patient health management data and cost analysis is required to quantify the financial impact and demonstrate return on investment/ cost efficiency savings for Primary Care Networks and Integrated Care Systems. We hope this will be undertaken in the coming months.

Primary care financial resource (additional roles reimbursement scheme allocation) currently being used to sustain role. This is an unsecured provision at present.
 

Main learning points:

• alternative approach to social prescribing
• Activity and wellbeing coaches provide a proactive, activity-based model that moves beyond traditional signposting, focusing on physical activity as a key intervention for health improvement
• positive impact across Levels
• the role improves patient confidence, physical health, and wellbeing; likely reduces pressure on clinical staff; and supports system-level goals of prevention and health inequality reduction
• importance of co-design and collaboration
• successful implementation relies on partnership working between primary care, voluntary sector, and community groups, ensuring clarity of remit and shared resources
• integration requires structural support
• embedding the role in primary care teams, multi-disciplinary team meetings, and referral pathways is essential for sustainability and effectiveness
• data and evaluation are critical
• consistent outcome measurement and access to population health management data are necessary to demonstrate impact and cost-effectiveness
• funding certainty is key
• long-term sustainability depends on clear funding models, ideally supported at system level (Integrated Care Boards) rather than individual practices.

Michael Ali, Health Integration Strategic Lead 

Email: [email protected]