I have the pleasure and privilege of knowing Dr Marie-Anne Essam for almost as long as I have been working in the world of social prescribing and been very lucky to have worked and presented with Marie-Anne now on many occasions. Her energy and passion for her belief in the power of social prescribing is palpable and infectious, so you can only imagine the two of us in a room together! Marie-Anne brings with her though the compelling practical and professional evidence as to why social prescribing can be a game changer for primary care.
Marie-Anne is a Hertfordshire GP whose vision, compassion, and unwavering belief in community-centred care have made her one of the most respected clinical leaders in the social prescribing movement. A founding clinical champion for NHS England's national social prescribing programme, she has been instrumental in shaping both the narrative and the practical implementation of social prescribing across primary care. As one of the earliest GPs to embed social prescribing into everyday practice, she helped shape national understanding of how relational, non-medical support can transform health outcomes and strengthen communities.
Throughout her career, Marie-Anne has combined frontline general practice with strategic leadership, training, and mentorship. She has supported hundreds of clinicians to embed social prescribing into everyday practice, translating the principles of personalised, relational care into tangible improvements for patients and communities. Her contributions have been widely acknowledged across the NHS, voluntary sector, and academic partners, who frequently cite her as a trusted voice and a generous collaborator. She has also supported other countries, such as Canada, to develop their own authentic models of social prescribing.
Marie-Anne continues to inspire the movement with her clarity, humility, and deep commitment to what matters to people. Her leadership has helped establish social prescribing as a cornerstone of modern primary care and a catalyst for healthier, more connected communities.
I hope you enjoy reading!
Guarding the Treasure: Essential Advice for clinicians in Primary Care
by Dr Marie-Anne Essam1. Support and affirmation of the team
Your Social Prescribers are doing an incredible job, working with people and people situations which are beyond your own reach as a clinician. It is important that, personally, you acknowledge and appreciate the wider social determinants of health, the reality that most of their clients will have been repeatedly misunderstood, let down and side-lined where they sought help within clinical settings. Frankly, given people have unique and multifaceted lives, facing challenges which extend far beyond our medical textbooks, Social Prescribing is essential to whole person healthcare. Once the personal tangled mess is sufficiently unravelled and understood, our "complex" patients have an opportunity to experience long overdue hopefulness, motivation to engage with help, and the resilience to sustain them as they progress despite long term difficulty or disability.
Make sure you appreciate and acknowledge their contribution: reflect openly to them the incredible skills you notice as they discuss cases with you. As a profession, their ability to broker trust and to truly start at the "what matters to you" point, is mission-critical to personalised care, and we have a lot to learn from them.
2. Early recognition of points of stress
Compassion is a costly commodity to pour out in multiple connections and conversations during a working day. Your Social Prescribers, who are in their role as they do care deeply, are likely to "take their work home with them" and may lose sleep trying to puzzle-solve, ensure safeguards for vulnerable clients. A poor interface with other professionals, including the referring clinicians, can leave them feeling that the responsibility of so far insoluble problems has been left with them. Find out where there are points of heaviness, frustration, worry. Give them space to feedback where they have not received the due support from the Practice, or they have had pushback from outside agencies whose help is essential to achieving progress for their clients.
3. Practical oversight of the case load numbers and waiting list
The team will tell you if the balance of complexity on their case load, or the number on the waiting list is worrisome.
The NHS specification for case load is essentially no more than 1 client per the hours you work in the week. The team lead should have slightly fewer clients than this to ensure adequate time to liaise with colleagues etc. The mix of complex/not so complex cases is important. The team need a share of those who will likely take a lot of time and effort, as those whose situations improve relatively quickly after that initial "what matters to you" connection, and some skilled advice, signposting etc, involving the right other agencies.
As the practice add in other work streams and projects for the team, a reduction of the case load numbers, or an increase in the workforce will be necessary.
Social Prescribing takes time. Rush it or dilute it, you will quite simply lose the potentially transformative impact on the lives of those referred who need it most.
The length of time a patient needs to be on a caseload varies – typically between 3 and 9 months, occasionally more. If the help needed was delivered in one short encounter, it was arguably "signposting", rather than Social Prescribing, which entails the coaching, goal setting and resilience building not required in a simple information exchange. Signposting is, of course, essential, and it is a good idea to ensure that information is readily available via organisational websites, waiting room screens etc. This may helpfully reduce the flow of referrals to the team.
4. Adjustments factored in for leave/sick leave
Your team lead may well be able to handle this. With sight of each other's diaries and caseloads, the team can support each other during short absences. However, there may be special considerations, if a member is off for a long period of time. It is important that adjustments to work expectations of returning colleagues are reasonable, and how they are coping is properly checked by team and by clinical supervisor. Facing illness, treatment, or personal bereavements are likely to have a direct impact on how much personal psychological resilience a Social Prescriber has available for their clients' problems.
Ensure the referring practice is aware when you are one or more men down: careful consideration of the timing of referrals is helpful.
5. Case Discussions
This is extremely valuable, and you will find the team contribute to one another often far more than you can add in as a clinician. The dynamic of shared insight and resourcefulness amidst a group of Social Prescribers is a wonder. It is essential that they are also supported to connect with colleagues beyond their immediate team, as the bouncing of ideas off one another produces avenues of possibility.
There will be some aspects which the clinician can assist with readily. Referrals, support letters (- noting organisational protocol -), communication with colleagues (- for instance in the case of an inappropriate referral -), advising re a clinical appointment which may address some emerging issues (- for example, medication reviews, incontinence, mobility or memory issues)
Aim to get a case study written up by the team at least once a month, which you can keep as a portfolio to showcase the practice and any visitors. Ensure that either consent has been obtained, or the story is anonymised beyond any recognition.
6. Case notes, Read coding and Outcomes Measurement
Support your team to contribute appropriately to the patient's record, cognoscente of where issues are sensitive and should be "invisible" noting that FOI may also include their notes later.
Read codes are available for some social determinants, including housing, financial, isolation issues. Ensuring that carer or veteran status, for instance is read coded is important. Your Social Prescribers will find out things their doctors did not know.
Outcomes measurement is an area which needs to be considered within the practice leadership, and data collection facilitated meaningfully in a way which is not burdensome to clients or Social Prescribers. Questionnaires re:wellbeing and loneliness are used before and after Social Prescribing intervention, but not exhaustively, as there are some setting the team have not felt it fitted. Other outcomes including longer term resolution of housing problems, unemployment, antidepressant use, inappropriate GP contacts etc would be usefully collected – potentially by an administrator assisting the team – and would showcase to the practice the invaluable contribution the team makes.
7. Integration of Social Prescribing within the organisation
Keep as an open "agenda" item the opportunities emerging for joining the dots around patients and professionals. Care Coordinators, Primary Care Mental Health workers, Registration Teams, Receptionists, and every clinical subset within the team needs a clear understanding of the role of Social Prescribers, how to reach them, and an appreciation of how their own role and observations may permit them to identify an aspect of psychosocial challenge with which the Social Prescriber may be able to help.
A strong link with the Patient Participation Group is recommended. This group are aware of some of the access concerns, and act as the voice for some of the more vulnerable patients.
Include a Social Prescribing case study at any opportune moment, to share the learning with different colleagues. Care Study meetings, Gold Standards Framework Meetings, Target Days, Newsletters.
8. Encourage the growth of social capital in the community
Part of the NHS specification for Social Prescribers is as community development agents. Simply, as they form a bridge between their clients and outside agencies (charities, advice bureaus, healthy hubs, local government etc) they have an opportunity to get to know these agencies, to ensure that, broadly, their governance and client approach is sound, and to envision possible developments of services through collaboration, application for funding streams, and publicity of the work accomplished with their clients. Voluntary groups, particularly, need all the support, publicity and connection they can get.
As we build the Neighbourhood Model around the practice, the Social Prescribers and their own local knowledge and relationships will prove vital to ensuring the resource is used creatively and that any incoming funds are used in a manner intuitive to local population need.
Enable participation of the team in local forums and groups which work together on behalf of the communities. Their voices there, and the knowledge they will pick up, are of paramount importance.
9. Look ahead, and support training and development of your team
Level 3 Social Prescribing training was stated by the government as a mandatory requirement for ARRS role Social Prescribing. It has since slipped, via "aspirational" to somewhere apparently beyond reach. Keep it on the table for discussion, and work with the team to identify any helpful training and qualifications.
Social Prescribers are entitled to training and must be supported to do it. Their profession is emerging as a creative "can-do" workforce, desperately needed for patients and their carers who cannot navigate the siloed systems to access what they need to live their best lives. We must support and protect their growing expertise, in the hopes of meeting the rising tide of need for it. Specialist training, with its due recognition, is only fair. We would not cut short any of the requirements for any of our other colleagues to be both qualified and kept updated.
It has been my privilege to be closely involved with Social Prescribing over the last 15 years. Design, recruitment, delivery, education, specification, supervision, evaluation, and advocacy for an exceptional workforce bringing community around those who need it most.
This document was written initially for the PCN I left September 2025 to support my clinical colleagues. I hope it will catalyse wider respect and reflection. If we can ensure good standards on our part as caretaker clinicians, this creative, powerful workforce will flourish.
I am now in post at a new practice, working part-time, and still available to help Social Prescribing flourish at home and abroad. Amidst political and economic flux, healthcare and governments need to appreciate this experienced, resourceful workforce is an undeniable essential.
This is far from an exhaustive guide for the clinical supervision of Social Prescribing. As a medical practitioner myself for 40 years, the closer I have worked with these colleagues the greater the possibilities I have seen for my own patients who have spent time on their caseloads. It is a personal learning experience to spend time reflecting with the team on their work, and humbling to realise that, for many patients, the contribution that purely clinical medicine could make to their transformed lives was proportionately small. However, enabling patients to constructively engage with clinicians, make good and informed use of the resources available to them for their physical health needs, is also of huge benefit to efficient and effective healthcare.
Carrying the baton for Social Prescribing within a clinical team may take some courage and determination, for many of our very clever clinical colleagues have their entire focus on the details in our textbooks. Population Health is, though, improved one unique, precious individual at a time, and I sincerely believe our Social Prescriber are our greatest allies and assets in any healthcare organisation.
To all clinical supervisors, I wish you all the very, very best, in the interests of the best lives possible for patients everywhere.
About Marie-Anne:
I've been a GP 35 years, in Hertfordshire, England. Social Prescribing is without doubt the most potentially whole-person-life-changing-treatment I have had to offer my patients. It's been an enormous privilege being involved in its design, specification, delivery, recruitment, education, supervision and promotion for over 15 years, here and abroad.
I'm keenly aware Social Prescribing is dependent upon community resources, and I provide pro Bono support where opportunities arise to support vision, funding and governance.
Very happily married over 42 years, mum to 2 daughters, grandma to 10, and blessed to say I have some excellent friends, some of whom will be reading this blog!
It's taken me most of my adult life to realise my body is not designed for carbohydrates, and thrives lifting heavy weights. You'll find me with the eggs and ribeye! I've also learned there is no "one size fits all", so please enjoy yours!!!
Favourite holiday ever was Algonquin Park, Ontario, in a mini Winnebago. Walked, kayaked (fell out) and rode horseback through the most spectacular landscapes. And that was on the back of a SP trip!
Play piano, by ear for preference, dance around the lounge to jazz music with my man, and love creative antics, all gloriously amateur.
There, enough about me! What's above is very close to my heart, because I sincerely believe that it is our duty and honour as clinicians to guard the jewels our non-clinical colleagues bring. Social Prescribing is, after all, Population Health Medicine one precious, uniquely individual at a time.