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In this blog, researcher, Debra Westlake, reflects on a previous evaluation she conducted between 2020 and 2021 with a team at the University of Plymouth, investigated the impact of COVID-19 on social prescribing in the southwest of England.

Older couple holding hands at a table, both wearing masks © Shutterstock

This blog centres on a recent paper authored by Debra Westlake. She is a researcher involved in our current study - Understanding the implementation of link workers in primary care.

Background to the evaluation

The onset of COVID-19 presented huge challenges for frontline staff in the NHS, including newly appointed social prescribing link workers located within GP surgeries. Many of these link workers came into post just a few months before the lockdown in March 2020. Those recruited subsequently never experienced ‘business as usual’ or social prescribing without pandemic conditions. In addition, the organisations within which they were employed – Primary Care Networks – were fledgling collaborations of surgeries that suddenly faced unprecedented demands to adapt services, such as developing remote consultation methods.

The social prescribing pathway

In the Plymouth study we found it helpful to think of social prescribing as a pathway with three interconnecting elements. These elements were identified from our data and in conversation with study participants. The pathway is shown in Figure 1.

 linkworkergraphic.png

 

Access is about how patients are connected with social prescribing – how referrals are made to link workers and what sorts of people might be given access: for example, people with a certain type of health condition, who have mental health needs or who have social needs such as housing, debt or isolation. People who tend to have many appointments with primary care professionals are also sometimes referred.

Engagement is about the interaction that happens between the link worker and patient: the form it takes (perhaps on the phone or in person) and the content of the conversation (e.g. the issues link workers and patients talk about). Our evaluation suggested that outcomes of the conversation could be primarily signposting people onto another organisation or activity (transactional social prescribing) or building a relationship with a patient, finding out about their wider concerns, that might be social or health related, and setting some goals with them (therapeutic or holistic social prescribing).

Activities is about experiences and services the link worker refers a patient onto or connects them with; this could be a connection into statutory services or community organisations in their local area.

Our evaluation showed that the pathway was not linear: patients may start activities and then come back to the link worker. It was also true that patients may be referred in again after their allotted sessions with a link worker had been completed. In the evaluation, the number of sessions was based on the NHS recommended six sessions, but varied widely in practice.

COVID and its impact on the pathway

  1. Access

In the evaluation, we identified initial lags in link workers being given the tools needed to work remotely, such as computers, phones and access to IT systems. It was hard to do their job or to feel part of the primary care team, especially when told to work from home. In the early stages of the pandemic, neither link workers nor health care professionals, like GPs and nurses, were entirely clear what the social prescribing role might entail. The evaluation highlighted uncertainty about who were the priority patients to be referred into social prescribing, so it was hard for link workers to draw any boundaries. Some link workers were enlisted by their surgeries to help with welfare checks for people classed as ‘shielding’ during the pandemic. Others supported vaccination recruitment and clinics.

  1. Engagement

Engagement with patients switched primarily to telephone consultations, which suited some individuals and was necessary given social distancing measures. There were advantages to this; more patients could be offered appointments in a day, as phone calls tended to be shorter than face-to-face appointments. However, some link workers found themselves spending half their week on vaccine work. This meant reducing their usual client-caseload, introducing waiting lists for referrals or shortening frequency of contacts. It could be difficult to build relationships with some patients, and contacts were often more transactional, rather than fully exploring people’s holistic needs.

  1. Activities

Activities and services to refer patients on to were curtailed by the pandemic. This was because people were not allowed to meet or travel during early lockdowns, and organisations stopped holding face-to-face meetings and appointments. In addition, voluntary sector organisations experienced challenges with funding and staffing and had to adapt their ways of working. This meant some link workers found themselves engaging in emotional ‘holding’ phone calls with patients until organisations offering mental health or social support were open again.

Unmet expectations

The evaluation found variation in the needs of people referred into social prescribing. Where there were no explicit criteria agreed between the link worker and referrers (e.g. GPs) about who could be referred into the service, link workers often found themselves seeing people who had many different types of needs, including people with severe mental health problems. Some felt seeing people with complex needs was not part of their job and they had not expected to work with this type of person. Whether link workers were asked to 

perform work related to COVID also varied, as did link workers’ attitudes about whether this was part of their role. This connects to whether any agreed boundaries had been drawn around their role from the outset. Some felt that flexibility in working with the demands on primary care was key to their role, and encouraged a sense of being part of the team. Others believed that performing vaccination clinic duties, instead of seeing referred patients, was not part of their expected role. One link worker said:  ‘the role has become something that I didn’t sign up for and I’m feeling burned out’ (SP49).  

Role support and satisfaction

Feeling their expectations were not being met or feeling overwhelmed led to some link workers experiencing stress and dissatisfaction, and thinking about leaving their post. The evaluation found that peer support for link workers played an important role and may have prevented link worker turnover. Several peer support groups adapted to online meetings during the study period. Link workers commented that they found the groups useful in suggesting links to resources for patients, and in providing vital professional support. Link workers also stressed the importance of adequate line management and clinical supervision. Where this was present, they were more likely to feel supported and satisfied.

Parallels with early reflections from our current study - understanding the implementation of link workers in primacy care

We are in the process of collecting data for our current study. As we collect data, we also engage in ongoing analysis and reflection of what we are learning. There are parallels from this new work with the previous evaluation described above:

  • Adaptations in practice coming out of the pandemic: Our current research suggests that many voluntary and statutory sector organisations and services are now opening up for face-to-face work. Link workers in the sites for our current study are tending to now offer a hybrid model of face-to-face and phone appointments.
  • Role satisfaction: Fieldwork for our current study suggests that responsiveness to primary care requirements and ways of working (including COVID adaptations) might help the link worker to be seen as a team member. However, this can require significant flexibility and emotional work from link workers. We think this might be important for how satisfied and comfortable a link worker feels about their role in primary care, but also might take a toll on their wellbeing.  
  • Expectations: What link workers expect from the role seems to be important and related to something called cognitive dissonance – when ideas about something do not meet with what happens in practice. We think how much discretion link workers feel they have in their role and how much communication they have with primary care professionals, like the GPs who refer patients to them, is also important for their job satisfaction.

Moving forward…

Link workers have shown themselves to be creative and adaptable to pandemic conditions and to working in primary care. We are exploring the benefits and disadvantages of some of these changes for both link workers and patients as we move forward with the study.

 

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.