Knowledge exchange event in the southwest of England

As we approach the end of the study exploring the implementation of link workers in primary care, we are holding a series of knowledge exchange events across England. The first was held in Birmingham in September. The second was held in Exeter in October 2023. The event was arranged to disseminate findings from our study and to get feedback on what we have learnt from it. It also gave those present the opportunity to think about the implications of our findings to their own practice or work situation.

Preparing for the meeting

 “Will anyone come? Will attendees speak to each other? Will our findings and analysis resonate with practitioners? Will the projector work?”

These are questions that many researchers might ask themselves as they prepare for an in-person dissemination meeting involving a wide audience of practitioners and researchers; they certainly crossed my mind as we set up our event. From the other perspective, delegates might have their own concerns: “Where is this place? Have I got time to attend? Will I know anyone? Will there be cake?"

Exeter Community Centre provided a reassuring and warm venue for the event, and many concerns quickly dispelled as delegates arrived, had tea, ate delicious cakes and networked at their tables with colleagues and people they had not previously met. We were impressed at the broad spread of delegates that included academics from Plymouth and Exeter universities, analysts working in the health sector, health care professionals and representatives from the voluntary sector – both social prescribing link workers and providers of services that link workers might refer patients into. Delegates, who came from Devon and Cornwall, commented that they made good links across organisations and geographies.

Starting off

The two-hour session began with Stephanie Tierney presenting some background to the link worker study. This included a description of how we selected link workers to follow and observe in the study and the interview process for professionals and patients. She went on to outline the key concepts and ideas that came from our analysis. These included continuum concepts - ‘discretion’ and ‘boundaries’, ‘belonging’ versus ‘fitting in’ - and also patient ‘readiness’ and ‘holding’. For this session, we presented in more detail the two ideas of discretion and holding, followed by round table activities and larger group discussion of these concepts.  

Holding as a concept in social prescribing

We defined holding as an active process carried out by link workers which involves more than just listening and connecting people to activities. It is a process that allows patients to feel contained, reassured and emotionally supported. It can also help to prevent overwhelm by aiding people to gain perspective when they are facing multiple difficulties and may not be able to make changes in their lives straight away. 

Debra Westlake presenting on the concept of holding

 The activity we designed to explore holding involved each table of delegates discussing the consequences (both positive and negative) of holding for a different stakeholder in social prescribing: patients, GPs and health care professionals, the wider NHS system, link workers. This yielded rich discussion and interesting perspectives from each table, including:

• The importance of sensitivity to different patients who might need different things at different times – patients may ‘dip in and out’ of holding.
• The need to give some more reluctant patients permission to take their time to fully explore their concerns and then to set realistic expectations with patients about what the link worker can (and cannot) do.
• The difference between secure attachment to and dependence on the link worker and other services – confidence developed in a relationship with a link worker may transfer to more confident and balanced relationships with other practitioners in health and voluntary sector organisations. 

Discretion

We explored the ideas of discretion and boundaries and the consequences of link workers having flexibility or limits on different elements of their role, such as the length of time spent with patients and number of sessions with them. Discretion allows link workers to feel trusted and respected and able to use their judgment about how best to support patients, whereas boundaries can protect link workers from being overwhelmed, ensure some common features of social prescribing delivery, and allow for structure, support and security in the role.

We invited delegates at each table to select elements of the link worker role (e.g. time spent with patients, training undertaken, outcome measures used). They discussed where to place them on a continuum according to how much discretion they felt link workers should have over these elements – from complete discretionary practice to no discretion at all (i.e. a firm boundary). Key points raised in this activity were: 

• Discretion in a number of areas could be linked to the local population’s needs, as identified in such tools as public health measures of deprivation or levels of ill health.
• Some elements of training for link workers should be non-discretionary (e.g. safeguarding), whereas others are about personal development of the individual and can be flexible.
• Time to work in the community and create groups or research what is available should be protected so link workers do not only work with individuals.
• Measures of outcomes should be functional to the conversation that link workers have with patients, rather than a bolt on that may feel as though it doesn’t measure things that are important to either the link worker or patient.
• Discretionary practice may build over time as a link worker settles into their role and develops knowledge and confidence, whereas guidance or boundaries may be useful initially.
• Discretionary practice is negotiated over time with key actors such as managers and health care professionals; where link workers have different ‘bosses’ – for example in the voluntary sector and the health sector – this can be complicated. 

Final reflections

The concepts we have highlighted in the study seemed to have meaning for delegates, based on feedback they provided at the meeting. They described these concepts as useful areas to consider when developing recommendations about the implementation of link workers in primary care.

We were pleased that people stayed after the event to share practice ideas and contact information so they could keep in touch and learn from each other. 

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.