Street-level bureaucrats: Ideas from Lipsky applied to the role of social prescribing link workers
11 March 2022
In this blog, Stephanie Tierney, Senior Researcher and Departmental Lecturer, Centre for Evidence-Based Medicine, University of Oxford, shares details of the latest study that aims to explore and explain the link worker role in primary care, and highlights the concept of 'Street-Level Bureaucracy', proposed by Michael Lipsky to better understand this role.
Social prescribing is a component of personalised care. It strives to support people with non-medical difficulties they face that can affect their well-being. For example, feeling lonely or having financial worries can influence people’s health behaviours (e.g. smoking, eating, drinking) and emotional state. Connecting people to what are sometimes described as ‘community assets’ – local groups or activities, voluntary organisations, charities – to help address their non-medical issues is a cornerstone of social prescribing, which is facilitated through link workers.
Link workers (also known by other titles – e.g. community navigators or social prescribers) are employed to talk to people about their non-medical difficulties and to connect them to relevant community assets. People are often referred to a link worker by their GP; it is now common for these employees to be attached to a doctor’s surgery.
We are currently conducting a study, funded by the National Institute for Health Research, which aims to explore and explain the link worker role in primary care. It involves in-depth data collection, taking a case study approach, around several link workers in different parts of England. We are interviewing people but also observing their interactions, and we are collecting documents that relate to the link worker role in an area (e.g. information given to patients about social prescribing, job descriptions).
Our current data suggest a number of existing theories that may be useful in understanding the link worker role. One of these is the concept of ‘Street-Level Bureaucracy’ proposed by Michael Lipsky. It centres on real-world experiences of implementing policy and guidelines into practice, which can be curtailed or shaped by a lack of resources (time, equipment, space, personnel, knowledge, skills). A tension arises between the content of policy or guidelines and the structural realities faced by those charged with implementing such information – so-called ‘street-level bureaucrats’ (e.g. teachers, police officers, social workers and health professionals).
Street-level bureaucrats (SLB)
For Lipsky, SLBs have to efficiently deal with their workload. They have some degree of independence in their workplace interactions, yet they face pressures due to inadequate resources and over-demand for their service, alongside having multiple and sometimes unclear objectives in their role. There may be ambiguity around how their performance will be managed as expectations from different actors (e.g. clients, peers, managers, policy-makers, funders) can diverge. SLBs are active agents, who have to respond to varying circumstances (due to changes in policy, organisational structures or the people they are supporting) in order to bring meaning to their role and to normalise what they do in a pressurised, under-resourced work setting. SLBs look to manage such pressure and uncertainty by engendering various coping strategies.
SLBs are said to employ coping mechanisms as they encounter a gap between workplace demands and limited resources, as they feel unable to meet the expectations of those they support or serve. Lipsky described how they engage in “routines and simplifications” to manage such pressures. These strategies can include:
- Rationalising – attempting to manage caseloads by limiting dissemination of information about services, employing waiting lists and offering shorter and fewer appointments.
- Stereotyping – prejudging certain groups to retain some energy, which can contribute to inequitable rationalising and become a defence mechanism whereby some individuals are assumed to be difficult to help.
- Creaming – focusing on selected clients and solutions, handpicking more straightforward cases that look likely to succeed.
- Measuring – creating monitoring systems that capture information easily, and measuring areas that are likely to be positive.
- Redefining – SLBs may develop private goal definitions, shifting how they perceive the job to compensate for a psychological gap between what they experience and what they expect. To make their job manageable, SLBs may opt to favour and focus on particular aspects so they can continue to feel a sense of achievement when faced with multiple and sometimes competing expectations.
Coping strategies listed above can be seen as “micro choices” that “ultimately become the de facto policy of the organisation, which may contrast starkly with its official stated aims.”
Policy enactment through interaction
SLBs are not operationalising policy in isolation but, in part, through their interactions with clients/students/patients – individuals who will have their own strategic agenda. As noted by Lipsky, SLBs’ workload “consists of people, who in turn are reactive to the bureaucratic process.” SLBs need a good insight into individuals and their situation. Holding such an understanding means they often have greater experiential and local knowledge than those making policy, an asymmetry that can facilitate or legitimise the coping strategies mentioned above.
Link workers as SLBs
Our research on the link worker role, to date, suggests that these employees face pressures and demands that would make them SLBs. They come into a role that is still evolving in primary care, which can be implemented in a range of ways. Discretion enjoyed by link workers varies depending on where they are located and can be affected by expectations of their employer (and the perceptions they hold about the nature and scope of the role and how it fits within primary care). It can also be affected by how their performance is measured and monitored. Link workers have some degree of independence in how they work with patients, although this is curtailed or shaped by context (e.g. how the service has been set up, available community assets that they can refer on to – or of which they are aware). Their discretion has been affected by the pandemic, when some link workers’ role became more structured as assisted with efforts to deal with the immediate impact of COVID-19 (e.g. organising medication for patients, helping with vaccination programmes).
Our research suggests that link workers may engage in coping strategies to manage workplace stresses, which means their actions and activities can diverge from local and national policy. This is not a criticism, as link workers strive to support people experiencing challenging psychosocial circumstances; rather it can be a state of being that enables them to continue working in their post despite the stress they can encounter from it. Examples of strategies that may be used, which we have identified from our reading of the literature, include:
- Rationalising – having shorter more focused appointments, conducting telephone rather than in-person meetings with patients.
- Stereotyping – identifying some individuals as hard to help or not willing to change their situation.
- Creaming – dealing with patient problems that are low level and easily addressed rather than ‘unpeeling’ the layers and getting to the key psychosocial issues affecting a patient’s overall well-being.
- Measuring – prioritising patient contact (if this is something they are assessed on) rather than investing some of their time into developing community assets, which can be considered a ‘back-stage’ activity that goes unrecognised in terms of how their work is assessed (yet is essential to the success of their role).
- Redefining – focusing on aspects of their role that they feel most comfortable with, which may differ from link worker to link worker (e.g. listening and showing empathy, developing relationships, making community connections). When unable to hold on to a sense of achievement in their job, link workers may feel alienated from it, if they experience a disjuncture between their expectations (in terms of helping people) and the reality of the post (limitations in what can be achieved with the resources available).
Lipsky’s work highlights how SLBs are not just implementing but shaping policy through their decision making and employment of coping strategies as they interact with clients/people in need and other actors. This means there can be a difference between policy as a written artefact and how it is implemented as an activity. Link workers can be seen as SLBs, who have some discretion over how they work, who can feel stretched due to a discrepancy between need and resources. Demand for social prescribing is likely to increase following the COVID-19 pandemic, as its consequences hit and people encounter non-medical issues (e.g. social, economic). This may make it more likely that the coping strategies described above will be employed by link workers.
The study mentioned at the start of this blog is funded by a grant from the National Institute for Health 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.
What to read next
Understanding the implementation of link workers in primary care: A realist evaluation to inform current and future policy
8 November 2021
A new study, led by CEBM members, Dr Stephanie Tierney and Associate Professor Kamal Mahtani, aims to understand the link worker role in primary care as part of social prescribing (in particular, to identify what works, for whom, why and in what circumstances). In this blog, the team shares details about this research, which has been funded by the National Institute for Health Research (NIHR).
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