Care Coordinators play an important role within a PCN to proactively identify and work with people, including the frail/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 patients 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.

Click Here For The Recruitment Pack

Click HERE for the Minimum Training Standards & Recommended Additional Training

Care Coordinators require a strong foundation in enabling and communication skills as set out in the core Curriculum for Personalised Care. These can be achieved via a two day health coaching skills course and additional training as guided by Health Education England. Care coordinators should also access statuary and mandatory training, including but not limited to:

  • Principles of information governance, accountability and clinical governance
  • Maintenance of accurate and relevant records of agreed care and support needs
  • Identify when it is appropriate to share information with carers and do so
  • The professional and legal aspects of consent, capacity, and safeguarding

Care Coordinators should be familiar with the six components of the universal model for personalised care with a specific focus on:

  • Support for self-management
  • Personalised care and support planning
  • Shared decision making
  • Social prescribing
  • Personal Health Budgets

Benefits to patients

  • The patient’s go-to person if their needs change or if something goes wrong with service delivery – The care coordinator ensures that there are no gaps in the patient’s service provision – Many elderly and disabled people with highly complex needs struggle to coordinate with all the relevant services directly on their own – Improved patient education and understanding – Better health outcomes – Patients can eliminate unnecessary appointments, procedures and tests – Patients feel more empowered and actively engaged in their treatment

Benefits to PCN’s

  • Ensuring seamless service provision significantly decreases the risk of the patient deteriorating and thereby reduces the overall cost of care and the likelihood that additional interventions will be needed in future. By identifying high-risk patient populations before they incur costlier medical intervention, employers can begin to reduce both practice expenses and total NHS costs – Employers can gain access to additional data that can reveal practice population health levels and risks – Care coordinators glean information about patients’ treatment histories, medication adherence, new symptoms and management of chronic conditions.

Benefits to the wider NHS

  • Ensuring seamless service provision significantly decreases the risk of the patient deteriorating and thereby reduces the overall cost of care and the likelihood that additional interventions will be needed in future – By identifying high-risk patient populations before they incur costlier medical intervention, employers can begin to reduce both practice expenses and total NHS costs – Employers can gain access to additional data that can reveal practice population health levels and risks – Care coordinators glean information about patients’ treatment histories, medication adherence, new symptoms and management of chronic condition.
London Care Coordinator monthly email
Please see the support available and most recent resources for care coordinators below.
JAN PEER SUPPORT: Using EMIS in your Care Coordinator role: population searches, tips and hints
We had Nadine, a GP in Barnet run an interactive session on using EMIS for population searches. The slides are attached. Please get in touch if you have any questions!
DEC PEER SUPPORT: Reflection back on the year
We discussed Reflection, development, and the importance of goal setting, you may find the following pages helpful when considering goal setting for the new year:
NOV PEER SUPPORT: Mental health
The slide packs are attached and recording is here.
Resources from the session:
  1. Hub of Hope  – search to find local mental health support
  2. Samaritans
  3. Mind
  4. Good thinking– mental health online platform for Londoners
  5. Free course – Level 2 mental health first aid training
Please join this session for all care coordinators in London. This is on the 27thFebruary at 3pm, please email us if you do not have the calendar invite. The session will include:
  • What are health inequalities and why are they important?
  • What are the wider NHS agendas around health inequalities and why is it important for care coordinators?
  • Sharing work and examples
  • Thinking around how you can get started – what inequalities are in your area, what data is available to you
INFLUENCING WIHTOUT AUTHORITY- Thursday 23rd February 2023     10.00 – 12.00 – For Care Coordinators and Health & Wellbeing Coaches
We’ve been working with the NHS Leadership Academy to offer this to people in the personalised care roles who want to become leaders and influence across the NHS and beyond.
The session provides participants with an understanding of how to influence and lead when they lack formal authority or the feeling of power, to build participants confidence to understand the power and influence they have and arm them with practical tools to take back to their teams. Watch a 2 minute video of our facilitator, Jeanne, sharing what the training involves. Dr Jeanne Hardacre is the Founding Director of Impact4Health, which is a specialist leadership, OD and culture change consultancy.

Sign up to the session here by 6th Feb, when the booking link will close!

A wealth of E-learnings to support your leadership, including coaching, managing people, stress management, unconscious bias, by the NHS leadership academy.
Access One-Off Coaching Sessions (Express Coaching)
45 minute online coaching for NHS staff, please see here.
Do you know any patients, colleagues or friends who may be interested in volunteering in a social prescribing and care Navigation service in Camden?
  1. Five new massive free open online courses (MOOCs) are now available to help health and care staff improve their knowledge skills and understanding of public health research. Find out more here.
  2. Cancer awareness training programme by Cancer Research UK– it will equip people working or volunteering in communities with the skills and confidence to have conversations about cancer and health with the people they support. Part of the training will focus on helping people to understand the importance of spotting cancer early and the screening programmes available
  3. Mental health first aid training – free
  4. Free courses England
  5. Free shared decision making eLearning refresher to respond to changing patient expectations. (30 min) – For all roles in Primary Care
  6. All Our Health e-learning sessions have been developed to provide a bite-sized introduction to the wide range of topics including homelessness, inclusion health and NHS health checks. Within these sessions, you’ll find signposting to trusted sources of helpful evidence, guidance and support.
  7. There is a wealth of free training available related to health inequalities by fair health. It covers:
  1. What inclusion health groups are – some groups that you may focus on as a Care Coordinator
  2. Practical guide to health inequalities in primary care
  3. Performing a health needs assessment for your population
  4. Trauma informed care


You are warmly invited to join us for this interactive networking event on 27th January 2023, designed to bring together individuals across public health, local authority, voluntary and community sectors with the shared goal of improving health inequalities in London. (detail attached)
Brought to you by the London Community of Practice Network for Health Inequalities, in partnership with Volunteering Matters and the Greater London Authority, we are coming together to network, share insights, learning and practical examples of work in community development with a particular focus on the cost of living.
What to expect:
  • Expert speakers from across sectors.
  • Members from the London Community Practice Network for Health Inequalities will welcome us and guide us through the session.
  • Innovations in practice: You will have chance to hear directly from colleagues about leading examples of work taking place in London.
  • Stimulating conversation: We want to hear your insights, experiences and challenges in community development and create space for you to connect with colleagues across sectors.
Ahead of the event:
Please share with us the community development work you are doing by completing this form so we can showcase this on the day. Alternatively, email your work
Venue Details:
160 Tooley Street, SE1 2QH If you have any specific access, dietary or other requirements please get in touch with RSVP by 26th January 2023
  1. Carnal Farrar have developed a mapping tool allowing users to explore potential inequalities in population and health metrics across each Integrated Care System (ICS).Try out the tool via this link.
  2. NHS England has developed a homelessness and rough sleeping (HRS) pathway, checklist and toolkit.
  3. NHSE five strategic priorities for tackling health inequalities
  4. Core20PLUS5 approach has been adapted for use in children and young people’s services.
  5. National share and learn recordings
  6. Social Prescribing newsletters (events, resources, SP news)
  7. Example of a personalised care support plan
7. Tackling Health Inequalities through the personalised care ARRS roles Case Studies:
New Care Coordinators 
  1. Please see this recording of the session for new Care Coordinators and share with your colleagues. It explains what the Care Coordinator role is, the value of it in primary care, what support there is as well as work examples from two care coordinators in Lewisham.
  2. We have adesignated webpage for those that are newer in the role, where the video is hosted.
  3. There is also a drop in session in soon for care coordinators to ask us any questions they like – we will share this shortly.
Useful Future NHS platforms you may not have joined yet
  1. Personalised care collaborative: wealth of resources about personalised care, co-production, PHBs, shared decision making, choice and events.
  2. Primary care workforce: find out about the training hubs, wider primary care team, MDT guidance
  3. PCN development support: find out about ARRS, PCN development,delivery support(flu vaccines, early cancer diag, enhanced health in care homes, NHS digital weight management prog)
  4. Social prescribing platform: resources for social prescribing, community engagement, guides and tools to working with patients
Many thanks,
Rafif Mansour
London Care Coordinator Network Manager
Salaried GP in Barnet, SPIN fellow for Barnet Training Hub
Jenny Brooks
Health Inequalities Project Manager
Personalised Care and Social Prescribing
Transformation Partners in Health and Care
Royal Free London NHS Foundation Trust
Follow us on Twitter @SP_LDN
Differences between Care Coordinator and Social Prescriber roles
These are general guidelines regarding the roles and differences between them. There may be local variations developed due to service provision and local PCN needs.
Care Coordinators
Care Coordination is a long term, integrated, evidence based programme centred around supporting people with disabilities, mental health needs, older people and their families/carers, by working together with people to help them:
  • build and pursue their personal vision for a good life,
  • stay strong, safe and connected as contributing citizens,
  • find practical, non-service solutions to problems wherever possible,
  • build more welcoming, inclusive and supportive communities.
Where local area coordination already exists in an area, it can complement social prescribing by supporting particular cohorts of people for the longer term and building community capacity and connections.
Social Prescriber Link Worker
Social prescribing links patients with non-medical support to improve their physical and mental wellbeing. Link workers 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.
Social prescribing works for a wide range of people, including those:
  • with one or more long-term conditions
  • who need support with their mental health
  • who are lonely or isolated
  • who have complex social needs which affect their wellbeing.
SPLW have an important role to play in the community too. Working closely with local partners, they can identify and address gaps in voluntary and community sector as well as helping to make groups sustainable. The roles refer back to each other to improve patient resilience and build the wider team around the patient.