Putting people first: How Social Prescribing Link Workers and Care Coordinators are transforming personalised care

Health and care services are increasingly recognising something simple but important: helping people improve their health and wellbeing is about much more than treating symptoms. It means understanding the person behind the patient - their life, their goals, and the strengths they already have.

When Caty from the It’s All About People team sat down with Social Prescribing Link Worker Marissa Shaw and Care Coordinator Jackie Tyson, they explored how these personalised care roles are transforming support in the community.

Their conversation highlights how listening, collaboration, and a strengths-based approach can help people regain confidence, independence, and control over their health.

Seeing the whole person, not just the condition

One of the most powerful aspects of personalised care is its focus on the person’s wider life, not just their medical condition. Social prescribing link workers in particular play a key role in connecting people with support that addresses the broader factors affecting their health.

As Marissa explained, the role is about helping people navigate a wide range of support options in their community:

“Social prescribing link workers connect people to community-based supports… activities and services that meet their practical, social and emotional needs that are going to affect their health and wellbeing.”

These supports might include housing services, financial advice, community activities, or help building social connections. For many people, these factors have a profound influence on wellbeing.

This holistic perspective recognises that health is shaped by everyday life. Isolation, financial stress, or lack of confidence can affect wellbeing just as much as physical illness. By acknowledging this, personalised care moves beyond a narrow clinical model to support people more meaningfully.

The power of listening and proper conversations

A recurring theme in the conversation is the importance of time - particularly time to listen. In busy healthcare systems, traditional appointments can be short and focused on immediate issues. Personalised care roles help fill this gap.

Marissa highlighted how vital it is to create space for deeper conversations:

“We have the time and space to really listen and pick apart what it is that someone needs to increase their health and wellbeing.”

Through these conversations, practitioners can understand what truly matters to someone. This might include personal goals, fears or barriers that would otherwise go unnoticed.

Listening carefully can reveal underlying needs that may not initially be obvious. Someone referred for one issue, such as loneliness, might also need support with confidence, employment or managing a health condition.

When people feel heard and understood, they are more likely to engage with support and feel empowered to make positive changes.

Building on people’s strengths

Personalised care is not about “fixing” people. Instead, it focuses on identifying and building on existing strengths, skills, and aspirations.

Marissa shared an example of a person who was initially referred due to social isolation. Through conversations, it became clear that the person also had concerns about living with epilepsy and how it might affect work and relationships.

By working collaboratively with other professionals, the team supported the individual to develop confidence and practical strategies:

“Now that person has that safety plan in place, and they’re developing the self-confidence to try different roles at work, which is increasing their sense of self-efficacy and self-esteem.”

This example illustrates how a strengths-based approach can help people recognise their own capabilities. Rather than focusing solely on problems, the emphasis is on enabling people to move forward with greater confidence.

Over time, this can lead to improved wellbeing, resilience, and independence.

Working together across roles and services

Another key theme is the importance of collaboration. Personalised care rarely happens in isolation. It relies on teams of professionals working together to meet people’s needs.

Within the Living Well team discussed in the podcast, practitioners from multiple disciplines collaborate to ensure the right support reaches the right person.

Jackie: "We work very closely with community pharmacy, the mental health teams, the local nursing teams, the Health and Wellbeing Coaches, and the Social Prescribers.”

Patients entering the system are discussed by the team so that support can be coordinated effectively. This approach ensures individuals are connected to the most appropriate service rather than being passed between organisations.

The result is a more joined-up experience for patients and a more efficient use of resources.

Smoothing the journey through the health system

For many people, navigating healthcare and community services can feel overwhelming. Care Coordinators play an essential role in guiding people through this complex landscape.

Jackie describes how the role often involves supporting people after hospital discharge, ensuring they have the help they need to recover safely at home:

“We can pick up with those patients and reassure them and direct them to a service that could potentially help and support them in the future.”

This support acts as a bridge between hospital care and community services. Instead of feeling abandoned after discharge, people know there is someone helping them access the right resources.

Jackie describes this as helping to smooth people’s journey through the system, reducing confusion and ensuring they receive consistent support.

Empowering people to take control

Ultimately, personalised care aims to shift the balance of power and create new and better relationships between people and health and care providers. Rather than professionals making decisions for people, the goal is to enable individuals to take greater control of their own health and wellbeing.

Jackie emphasised that reassurance and encouragement are central to this process:

“Providing reassurance and ideas and enablement so that people can actually take control of their health care journey themselves.”

This sense of ownership can make a huge difference. When people feel capable of managing their health and making informed decisions, they are more likely to stay engaged and motivated.

The role of personalised care professionals is therefore not simply to provide services, but to build confidence and independence.

Community connections as a source of wellbeing

Social Prescribing highlights the power of community in supporting health. Many people benefit from opportunities to connect with others, develop friendships, and engage in meaningful activities.

Marissa explained how link workers often help people build these connections:

“We’ll facilitate conversations… help increase people’s ability to develop friendships in the community.”

For individuals experiencing loneliness or isolation, these connections can be transformative. Activities, support groups or volunteering opportunities can provide a sense of belonging and purpose that traditional healthcare alone cannot offer.

By tapping into community assets, personalised care expands the possibilities for improving wellbeing.

Conclusion: A more human approach to health

Caty, Marissa and Jackie’s conversation demonstrates how personalised and strengths-based approaches are reshaping healthcare in meaningful ways.

By taking time to listen, focusing on people’s strengths, and working collaboratively across services, personalised care roles help individuals navigate challenges and build confidence in their own abilities.

Whether through connecting someone to community activities, coordinating care after hospital discharge or helping someone understand and manage a health condition, these roles share a common goal: putting people at the centre of their own care.

And as Marissa summarised, one of the most important elements is simple but powerful - giving people the time to talk about what matters most to them.

In a healthcare system often defined by pressure, creating that time, and building that human connection, can be the starting point for real and lasting change.

More about Social Prescribing Link Workers

Social prescribing link workers (SPLW) give people time and focus on what matters to the person as identified through shared decision-making or personalised care and support planning.

They connect people to community groups and agencies for practical and emotional support. They work within multidisciplinary teams and collaborate with local partners to support community groups to be accessible and sustainable, and help people to start new groups.

Social prescribing complements other approaches such as ‘active signposting’.

More about Care Coordinators

Care Coordinators play an important role within a Primary Care Network (PCN) to proactively identify and work with people, including the frail and elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

Care Coordinators could potentially provide extra time, capacity, and expertise to support people in preparing for, or in, following-up clinical conversations they have with primary care professionals.

They will work closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carer’s and ensuring that their changing needs are addressed.

This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.