When people hear the words 'GP', 'practice nurse' or 'dentist', they have a broad idea of what these healthcare professionals do. As the NHS workforce expands, users of primary care are gaining greater access to support from 'physician associates', 'paramedics' and 'advanced practitioners'. Not everyone will have interactions with these professionals. However, it will probably be expected that these individuals will have undergone specific training and have a remit in terms of the problems they address. Other new roles within the NHS may be less familiar to people, as this blog outlines.
The advancement of social prescribing
Part of the NHS workforce expansion reflects a recognition that people's health is influenced by a variety of factors, some of which can be classed as ‘non-medical’ (e.g. they may be social, environmental or economic). As a result, the NHS has made a commitment to providing personalised care. Social prescribing forms part of this commitment and refers to the use of community assets (groups, organisations, charities, events) to address the 'non-medical' difficulties (e.g. isolation, financial worries, housing problems) that can affect how someone feels physically and psychologically. It is an umbrella term, incorporating a broad range of activities, including (but not limited to) luncheon clubs, befriending services, debt counselling or volunteering. To optimise social prescribing, roles have been developed within the NHS and voluntary sector to support people in using community assets. These roles enable patients to identify local services/groups that may help with their ‘non-medical’ needs. A variety of titles are used for these roles, including ‘care navigator’, ‘social prescriber’ and ‘link worker’. How they are implemented in practice varies across England. Faced with such diversity, patients may be confused about the purpose of these roles, who they are for, and how they work.
Link workers in primary care networks
The NHS Long Term Plan has formalised and broadened the reach of social prescribing; within primary care networks (PCNs), specific funding is provided for the introduction of social prescribing link workers. By 2023, NHS England aims to have 4,500 link workers across PCNs to support 900,000 patients. This new role will be integral to multidisciplinary community-based teams, that will also include clinical pharmacists, physician associates, community paramedics, and physiotherapists.
Link workers perform a range of tasks. They are paid to give time to people, develop a rapport, discuss what matters to individuals and help them produce an action plan. They can then identify ways of meeting personal well-being goals by drawing on community assets. In this sense, link workers act as change agents, who have the skills and capacity to motivate and empower patients. Link workers are also expected to establish relationships with and between primary care and voluntary/community sector staff and volunteers, to support local groups, and to help form new groups/activities when a gap in their area is identified. Furthermore, they should engage in training and skills development. Their contribution to patient care will be supported by the National Academy for Social Prescribing. Its stated objectives are to:
- Raise awareness of social prescribing
- Explore resources from non-statutory and statutory funding
- Broker relationships between sectors
- Develop and promote a strong evidence base for social prescribing
- Promote training for and best practice among those involved in its delivery
During the current COVID-19 pandemic assistance from link workers may be more important than ever, in trying to temper the negative impact of social isolation on people’s physical and mental well-being. Guidance on their role in continuing to support those in need during this time has been published as part of NHS England’s GP preparedness updates. It states that practices should identify those most at risk during the current pandemic, who might encounter significant social emotional difficulties. They should be connected to a link worker, if this is not the case already, who will make initial contact by video or telephone.
Differentiating link workers from care navigation
Distinct but complementary to social prescribing link workers are ‘care navigators’. They tend to be existing members of staff in a GP practice (e.g. receptionists) who are trained, as part of their work, to have conversations with patients about their ‘non-medical’ needs. Care navigators tend to offer active signposting, which NHS England states "works best for people who are confident and skilled enough to find their own way to services after a brief intervention." Staff delivering this support may receive training in identifying available community resources, communication skills and risk management. They act as guides, directing patients towards appropriate local resources.
NHS England delineates between care navigators and social prescribing link workers in terms of the intensity with which they support a person. Link workers will often see someone on several occasions, may visit people in their own homes and even accompany them to groups or organisations if they lack the confidence to do so alone. This is not usually the case for primary care staff in situ acting as care navigators, who tend to have more limited interaction with patients. Moreover, link workers form part of PCN multidisciplinary teams and will receive medical and emotional supervision within their post; again, this is not necessarily the case for care navigators.
A further set of titles to comprehend
There is a coda to the above in the form of the updated GP contract, published in February. This document announces further new roles to become commonplace within general practice over the coming years – including health and wellbeing coaches and care coordinators. Like link workers, these roles are concerned with facilitating personalised care. The document suggests they can be distinct from link workers, but they may be combined. This will be up to PCNs to decide, although they are expected to have a social prescribing service with at least one link worker. Introducing potentially overlapping roles could cause confusion and undermine efforts to ensure that patients know in what ways link workers can support them. Helping patients and healthcare professionals to appreciate how these employees can assist primary care delivery was identified as a priority in a survey run for the National Academy for Social Prescribing, to inform its business plan, completed by members of the National Association of Link Workers.
The importance of augmenting comprehension of the link worker role fits with our own work in the area. We have held several public engagement events where the notion of link workers was unfamiliar to most of those attending. Furthermore, our realist review highlighted how essential it is to fix these roles in the minds of patients, and to clarify the terminology, so people 'buy-in' to the idea of receiving assistance from a link worker with their 'non-medical' difficulties. Patients need to be clear about the potential differences in the degree of support they might expect to receive from those with differing job titles. Variance in understanding could have implications for uptake of services, how social prescribing is marketed and public backing of this type of work. A better understanding of what is offered by link workers, care navigators and other roles to be introduced into primary care will ensure that misunderstandings are reduced, and patients maximise the benefits they can offer.
Stephanie Tierney is a Departmental Lecturer and Senior Researcher at the University of Oxford. She co-leads a network of academics, clinicians, providers, policy makers and members of the public with an interest in social prescribing.
Kamal R. Mahtani is a GP and Associate Professor at the University of Oxford. He co-leads a programme of work to build the evidence base to support the redesign of primary care services including building the evidence base for social prescribing.
Amadea Turk is a researcher at the University of Oxford. She works on a project exploring patient-centred approaches to medication management and has a strong interest in social prescribing.
All authors are part of the part of the SPCR Evidence Synthesis Working Group.
Disclaimer: The views expressed in this commentary are those of the authors and not necessarily those of the host institution or the NIHR.