RIVIAM enables multi-agency working for The Active Way social prescribing
RIVIAM’s Multi-agency Referral Hub is a secure, shared digital platform that enables NHS, social care and VCSE partners to receive referrals and securely work together online to co-ordinate care and support around an individual.
RIVIAM sits alongside existing NHS and Local Authority systems, integrating seamlessly so information flows and teams can collaborate around a single shared view.
It streamlines referral and case management so services can collaborate as one Integrated Neighbourhood Team, reduce duplication and deliver a more person-centred approach.
The Active Way was a three-year active travel social prescribing pilot delivered by Bath and North East Somerset (BaNES) Council and eight partners in the Somer Valley, supporting people to become more physically active through walking, wheeling and cycling.
The Active Way three-year pilot outcomes
*Measured with KiActiv wearable data referring to physical activity data captured via a participant-worn activity tracker during the 12-week KiActiv programme, reported by KiActiv using matched pre and post measures.
Introduction
The Active Way was a three-year active travel social prescribing pilot delivered by BaNES Council in and around the Somer Valley, designed to support people to become more physically active through walking, wheeling and cycling. It was funded through the Department for Transport’s active travel and social prescribing programme, with BaNES Council awarded £1.6m.
Developed through the council’s participation in a national pilot funded by Active Travel England, it worked alongside a wide range of local partner organisations such as Sustrans and All Cycle Bath & West to provide free, inclusive and supportive opportunities that met people where they were. The programme helped people make active travel the go-to choice for everyday journeys, whether that was getting to the shops, commuting, visiting friends, travelling to appointments, or getting to a group. Through free guided activities and personalised support, The Active Way built confidence, skills and knowledge, helping people to progress at a pace that felt right. It offered flexible options for those just starting out as well as those ready to take their walking, cycling or wheeling a step further.
The Active Way sat within the Community Wellbeing Hub (CWH)* partnership model and included a network of nine organisations (including BaNES Council) contributing to referrals and support. Referrals also came via NHS Primary Care (Three Valleys PCN), GP practices (including GPs, district nurses, care coordinators and social prescribing link workers), and health practitioners including Royal United Hospitals Bath and community hospitals.
As of 26 February 2026, 6,072 people had participated in The Active Way activities since July 2023.
*The CWH is a partnership of 38 health, social care and VCSE organisations in Bath and North East Somerset, all working together using RIVIAM as their digital referral platform.
〝I live on my own and have no family. At times, the loneliness and isolation can feel overwhelming. The group rides initially provided a weekly safe space for me where I could come, ride, be with other people without the pressure of lengthy interactions. But the fresh air, the beautiful countryside and the exercise left me feeling relaxed and elated and within a couple of weeks I was lingering after the ride to enjoy a cuppa and chat with the others.〞
The Challenge
With the NHS 10-year Plan, there is a renewed ambition to improve care through more joined-up Integrated Neighbourhood Teams. The challenge is that services span multiple organisations with different systems, processes and capacity constraints.
For The Active Way, the operational challenge was to run an inclusive, multi-provider social prescribing pathway at scale without the common multi-agency pain points: duplication, unclear ownership, inconsistent updates and slow triage.
At the same time, the programme needed to embed a new pathway into busy primary care and social prescribing settings. The programme team recognised that even when the offer is strong, referrals do not happen automatically. Active engagement and seamless referral routes are essential.
RIVIAM's Solution
As the referral management digital platform for the CWH, The Active Way used RIVIAM’s Multi-agency Referral Hub to provide a consistent, shared approach to referral and co-ordination across partners. RIVIAM provided a shared referral management and multi-agency collaboration, extending secure access to partner organisations so teams could work together around a single care record.
For The Active Way, this supported three practical outcomes:
A single, shared referral pathway across different partner organisations
The Active Way managed referrals through one online form that could be accessed by both partners and individuals, with data centralised for the programme team and partner organisations.
Supported self-referral as well as multi-agency professional referrals
Both professionals and people could easily make a referral.
Audit-friendly reporting and evaluation readiness
Data from the referral platform was used to support programme monitoring. RIVIAM allows capturing data without adding admin burden for partners.
〝For us, RIVIAM was the practical choice because it was already embedded through the Community Wellbeing Hub. It gave us a simple, accessible referral route we could launch quickly, and it captured the monitoring information we needed, like demographics, location and activity tracking, without adding admin for partners.〞
Benefits
Benefits for The Active Way
- Multi-agency working in practice: shared, secure, high quality referral management and co-ordination across NHS, social care and VCSE partners.
- Reduced duplication and improved oversight: a shared view of referrals and activity for the individual across the pathway.
- One secure view with role-based access: enabled collaboration while ensuring partners only saw what they are authorised to see.
- Scalable partner delivery: a consistent pathway supported multiple activities and providers.
Outcomes for people in Somer Valley
- 6,072 people took part in The Active Way activities.
- Increased walking, wheeling and cycling in participants.
- Improved health and wellbeing.
- 81% of participants improved their physical activity*.
- +36 minutes per day average increase in physical activity*.
- Fewer GP visits reported: low GP utilisation increased by 9% at six months.
*Measured with KiActiv wearable data referring to physical activity data captured via a participant-worn activity tracker during the 12-week KiActiv programme, reported by KiActiv using matched pre and post measures.