Approaches to delivering social prescribing link workers in primary care: What can we learn from Normalisation Process Theory (NPT)?
Stephanie Tierney, Debra Westlake, Geoff Wong, Kamal R. Mahtani
30 September 2022
We are engaged in a programme of research on the link worker role in primary care. Link workers (known by other titles such as social prescribers, community navigators or well-being advisors) are employed to support GP practices to deliver social prescribing. Social prescribing seeks to assist patients with their non-medical problems (e.g., loneliness, debt, housing issues) that can affect their health and overall well-being.
One of the key things link workers do is to listen carefully to people. They should have time to talk to someone referred to them (usually by a GP or other health professional) about their life circumstances. Sometimes they will develop an action plan with the patient and other times they signpost people to services. Their work often involves connecting people to ‘assets’ in the community (e.g., groups, organisations, charities, activities) that can help with specific non-medical problems.
We are currently undertaking a realist evaluation of the link worker role. This involves spending time with link workers in different parts of England and conducting interviews with healthcare professionals and patients. In this research, we are interested in identifying mechanisms that might bring about changes. Mechanisms are described as “real but invisible forces that make...programmes work (or not). A mechanism is not a particular component of the programme but rather, they are the reactions the participants have to the resources the programme offers…”. Mechanisms that may be at work when seeing a link worker include feeling listened to, contemplating options, or being encouraged to try new things. Mechanisms can bring about change, but only if the context or conditions are right; otherwise, mechanisms are not ‘triggered’ and the change or outcome expected from an intervention or programme (e.g., introduction of link workers into primary care) does not transpire. Realist evaluations express these causal explanations in the form of context-mechanism-outcome-configurations (CMOCs).
Our early analysis of data is trying to understand how the context in which link workers are situated can shape or trigger mechanisms, and to identify and explain the range of outcomes that these mechanisms produce. As part of this study, we are exploring the various ways in which link workers are being delivered in primary care. Despite this variation, we feel there are core issues that are emerging from the data. These issues can be related to an existing theory called Normalisation Process Theory (NPT).
Normalisation Process Theory (NPT)
NPT was developed by Carl May and Tracey Finch with other colleagues to understand and evaluate the adoption, implementation and continuation of innovations to become routine practice. It acknowledges that healthcare delivery is shaped by a range of actors, their beliefs and behaviours, and resources they have at their disposal. NPT is said to focus on “factors that promote and inhibit the routine incorporation of complex interventions into everyday practice.” Complex interventions are those in which several interacting components or activities work together to produce a varied set of outcomes. Social prescribing is an example of a new intervention that can be carried out in a variety of ways to produce a wide range of outcomes. In this blog, we consider whether the mechanisms outlined in NPT may help us to better understand how social prescribing is set up and/or provided. We reflect on how these mechanisms might apply to the link worker role in primary care.
Mechanisms within NPT
There are four components within NPT that could be thought of as potentially important mechanisms. They centre on the work that actors undertake to implement and embed a change to practice. These four components are:
- Coherence-building – relates to sense-making and how people differentiate a new intervention from what currently happens; how they agree on what the intervention entails and who it is for; how practitioners identify their role in the intervention.
- Cognitive participation – relates to engagement and how key actors push an intervention forwards; how they join in with the intervention components; how far they see a change to practice as the right thing to do; how they support the intervention and its delivery.
- Collective action – relates to actions taken to make an intervention happen and the work people do together to produce intended results; how engaging with the intervention enhances trust and confidence people have in each other; the appropriate allocation of tasks to people with the right skills and knowledge; how far the intervention is integrated and supported by an organisation.
- Reflective monitoring – relates to the costs and benefits of an intervention and how people hear about its effects; how people collaborate to assess if an intervention is of value or working in the way they expected, but also how individuals themselves judge if it is worthwhile, and whether people modify what is delivered in response to feedback.
NPT and social prescribing
Other researchers have thought that NPT might be a useful ‘lens’ through which to understand the role of link workers in primary care. A study carried out in an area of high socioeconomic deprivation in Glasgow used NPT to explore the process of introducing and embedding community link practitioners (CLPs) in primary care (they served a similar role to link workers in England). The researchers found there were two types of GP practices – those where the intervention (CLPs) was fully integrated and those where it was partially integrated. The mechanisms relating to coherence, cognitive participation and collective action were more apparent in the fully integrated practices. These practices had better shared understanding of the intervention among staff, higher staff engagement with the intervention, and were implementing all aspects of it at patient, practice, and community levels. Neither type of GP practice, however, had developed any formal monitoring processes. Our study can add to this research by not only looking at the healthcare and link worker processes of introducing social prescribing into GP practices in England, but by also examining the role of patients in understanding their health and how social prescribing might assist them. We believe that to understand the normalisation of the link worker role in primary care, the input of both professionals and patients must be considered. We are not aware of other research in which NPT has been applied to the role patients play.
NPT and data from our link worker study
Our early data collection and analysis have highlighted that NPT, and the four potential mechanisms listed above, could be a useful lens for thinking about the role of link workers in primary care. We present below some tentative CMOCs from our initial data collection and analysis. It should be noted that these represent our early (and not our final) thinking on this topic.
|Potential mechanism||Early CMOCs from our data|
|Coherence building||When link workers have clear boundaries around what they do and who they see (C), it helps others to understand the role (O), because it demarcates their contribution from that of other staff (M).|
|Cognitive participation||When primary care staff accept that health can be affected by a range of factors (e.g. social/emotional) (C), they appreciate the contribution social prescribing can make to people’s well-being (M) so refer, to a link worker, patients who might benefit from seeing this person (O).|
|Collective action||When healthcare staff understand the contributions that link workers may make to patient care (C), they will be more likely to refer patients to them (O) because they value them (M).|
|Reflexive monitoring||Having time and an agreed system to gather feedback on patients’ progress (C) helps link workers to show they are making a difference (O), which prompts them (and referring practitioners) to feel they are carrying out valuable work (M).|
We are in the process of collecting and analysing data on the implementation of link workers in primary care. Our early thinking about the data suggests that NPT might be a useful lens to underpin some of this research. We are considering whether there are activities or delivery approaches associated with link workers that are becoming 'normalised' or embedded into practice that are helpful, and also those that might not be in the best interests of these employees or patients they support. We will provide further updates on this work in due course.
The study mentioned in this blog is funded by a grant from the National Institute for Health and Care Research (NIHR130247). The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or the authors’ host institution.
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