Getting feedback on our early findings at a knowledge exchange meeting with link workers

As a research team, we are currently completing follow-up interviews at the seven sites involved in our study on the implementation of link workers in primary care. These follow-up interviews are happening 9-12 months after initial data collection at each study site. Interviews are being conducted with patients, but also with the link workers we shadowed. I was delighted to be able to go back and see the team at one of the sites involved in our study. I presented some early findings from data collected across the seven sites. I also ran some knowledge exchange activities with those at the meeting about the concepts of discretion and holding, which have developed as part of our analysis.

Holding

We talked about how hard it is to define ‘holding’. It can be perceived negatively, as creating dependency with patients, or positively as being supportive of people who are experiencing emotional strain and distress and may prevent them needing to go back to their GP. We discussed how it does not necessarily mean ‘holding onto’ patients over long periods of time. Link workers at the meeting thought the reassurance of talking to a professional person was key, as well as building a trusting relationship with them. They felt it was difficult to quantify or measure what link workers do with a patient that gets them to the point of taking up a suggestion, but that holding can be part of the active process of building patients’ emotional resilience and confidence to undertake activities in their community or make changes in their lives.

Link workers emphasized that patients do not usually know anything about social prescribing when they are first referred. Therefore, they aren’t ‘ready’ at the first appointment as they do not know what to expect. Link workers noted it was rare for patients to “just go off and do an activity” after a single meeting. They added that initial sessions with a link worker are often spent finding out about the person and building trust; there is a sense of peeling back the layers of what is needed.

At this site, there is a delivery model of undertaking 6-9 sessions with a person and working on the issues that present in that time and then allowing patients to come back into the service if there are more layers to address. Holding might be needed until people are ready to do more work. The high volume of referrals they are receiving means these link workers are not currently able to offer long term holding and it may be important to set patient expectations from the outset. However, longer term examples of ‘shared holding’ were described – where GPs are concerned about particular patients and ask link workers to keep them on and support the primary care team in caring for these individuals over a more sustained period.

Discretion

I explained we are looking at the theory of street level bureaucracy. This is a term used in the literature for public servants or workers who develop policy and practice at the front line. It is based on the idea of these workers having discretion around how to cope with high demands and limited resources as well as limited clarity about how to implement any guidance about a role.

While link workers at this meeting agreed that discretion in how they implement their role is important, they felt the term ‘bureaucracy’ has a negative connotation in current narratives and that this was not a positive way to describe themselves. They preferred the terms ‘flexibility’ and ‘autonomy’ in practice. We will continue to discuss the term with our research participants and patient-public involvement group to find a better way of describing it.

Link workers worked in pairs with post-it notes to describe various aspects of their role. They placed these aspects on a spectrum to indicate their views about how discretionary they might be in an ideal social prescribing service. They were asked to think freely about what would work best and to consider the potential outcomes – both intended and unintended – of having freedom to make their own decisions about such issues as how many appointments patients can have and whether or not link workers spend time in the community developing activities for patients. There were varying views across the team about how flexible each aspect should be.

• In general, link workers appreciate flexibility to respond to patient needs in the way they feel is most appropriate to their role. They are keen to have as high a degree of discretion as is possible with regard to holding and other aspects of patient care.
• In an ideal world, they would not exclude anyone, whatever their needs, from their service. They would have flexibility about where and for how long people were seen, although the issue of maintaining a balanced caseload and link worker wellbeing was mentioned.
• Ideally there would be capacity to spend time in the community and perhaps set up groups, but the issue of not treading on the toes of other community services and duplicating their work was raised as important.

Discretion to hold family members

Link workers at the meeting emphasised they are often not working with a person in isolation – so what they do with an individual has a ‘knock on’ impact with others. They frequently support carers (which might include spouses, parents, siblings, offspring) who then in turn can better care for the patient who has been referred. This might involve listening to the carer and holding their emotions about their responsibilities to the patient. This might enable carers to continue supporting their relative or friend.

Conclusion

It was very useful to hear from link workers in regard to our thinking about the data. We would like to thank them for their insights and reflections, which will help to ensure that the findings we produce are relevant to end users.

The link worker 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 author and not necessarily those of the NIHR, the Department of Health and Social Care, or the author’s host institution.