Understanding social prescribing in socially and economically disadvantaged settings: Emerging findings and future research priorities

In April 2023, we held an online workshop with key social prescribing stakeholders. The purpose of the workshop was to share emerging findings from our study that explores how social prescribing is working in socially and economically disadvantaged settings. A further aim of the workshop was to promote knowledge exchange between different stakeholders and identify priorities for future research.

The workshop was attended by fifteen social prescribing stakeholders including social prescribing link workers, social prescribing managers, members of the National Academy for Social Prescribing, and academic researchers. During the workshop the research team presented emerging findings from the NIHR SPCR funded study which consisted of two work-streams:

• A qualitative systematic literature review
• Interviews with link workers working across different socio-economic areas in England

Workshop participants discussed the emerging findings. They were asked to consider them in light of their own experiences working in social prescribing, as well as to reflect on what these findings may suggest for policy, practice and future research.

The discussions were visually summarised by an artist from Scriberia.

Emerging findings for the research

Work-package 1: A systematic literature review of link workers’ experiences of undertaking social prescribing

The approach to the review (meta-ethnography) sought to translate meaning across studies and develop a new theory, or line of argument, that goes beyond what is described in the individual studies included in the review. Our protocol was registered on PROSPERO. The review included 18 papers published between 2017 and 2022.

The review identified two key themes that seem to shape link workers’ experiences of their role: 

• The challenge of the wider system
• A poorly defined role

A thread running across the papers highlights that link workers are operating within an overstretched and underfunded health and social care system; this is compounded by the effects that years of austerity have had on local community infrastructure and people’s livelihoods. This influenced the ways in which link workers network with community services, which themselves are overstretched and underfunded, and shapes the support they were able to offer service users due to what activities/support were available in the local community. Across the papers, the remit of the link worker role or social prescribing was often poorly defined and/or poorly understood by others. This could result in inappropriate referrals and the feeling that social prescribing was being used as a “dumping ground for difficult patients” (Frostick and Bertotti, 2019).

Work-package 2: Social network interviews with link workers from areas with different levels of social and economic disadvantage

We conducted social network interviews with 21 social prescribing link workers. In our sample, 18 link workers were female, 3 male; ages ranged between 24-61; time employed as a link worker ranged between 4 months and 10 years; 14 link workers were employed by a Primary Care Network, 5 by a Voluntary and Community Organisation, and 2 by another avenue. In terms of area deprivation (defined by the Indices of Multiple Deprivation) – 14 link workers worked in areas with high deprivation, 5 in areas with a mixture, 2 in areas with low levels of disadvantage. 

Each interview involved a mixture of qualitative semi-structured questions about general experiences of working as a link worker in their local areas, and more structured network interview questions where each link worker was asked to systematically name individuals and organisations they worked with as part of their job. They were asked to nominate what they considered “core contacts”, as well as people and organisations that they referred service users to in the last 2 months. Interviews were conducted online via Microsoft Teams and with the use of social network analysis interviewing software called Network Canvas.

Early analysis of some of the network data in our sample suggests the following:

• Link worker caseload in our sample is correlated with area deprivation; average case load in disadvantaged areas was 56.2 patients per link worker, and 24.5 in areas with low levels of disadvantage.
• The average number of contacts (links with other organisations/people) per patient was lower in areas with high levels of disadvantage in our sample
• Working with other link workers correlated with having more contacts overall in their network.

Initial analysis of the qualitative interview data highlights the impact of deprivation on link working and social prescribing in general – with data supporting the fact that link workers seem to be supporting an overstretched system. Data also highlight that there may be differences in patient needs across different areas of deprivation; patients in areas with high levels of disadvantage were described as struggling to meet basic needs such as food, housing, and gas and electricity, making it difficult to expect them to engage in typical social prescribing activities. Role autonomy seemed to be key in allowing link workers to set up the service as they saw necessary – including building in enough time to go out into the community and network with organisations. Many interviewees felt it was important to have a presence in the community to help develop trust and to catch patients who did not attend a GP practice. Working in a team was described positively; as helpful for establishing links in the community, knowing where to refer patients to, keeping lists of community assets up to date, and for sharing advice and support.

Workshop discussions with social prescribing stakeholders

Participants likened the link worker role to sorting through a messy kitchen drawer with miscellaneous items that were not organised. Some noted that link workers often go above and beyond, which may contribute to misconceptions and misunderstandings around the remit of their role. They noted that link workers often had to engage in “firefighting” (addressing basic needs/emergencies such as housing, food, heating, and finances) which sometimes may make it difficult to engage in a fully holistic approach. They also highlighted current evaluation measures such as number of referrals to social prescribing or number of onward referrals into the community as inappropriate for measuring the success of social prescribing due to the high number of inappropriate referrals that link workers receive.

Priorities for future research included the need for rigorous mapping of social prescribing provision against area level deprivation and population level health outcomes; research that reflects and is flexible to what is happening in practice; the need for better evaluation measures as current ones may not be demonstrating the full value of social prescribing given the different ways in which it is being implemented.

what might this mean for social prescribing and health equity?

The link between social prescribing and health inequities is a complex one. On the one hand, social prescribing has gained policy attention and support as a way of mitigating the impact of austerity on healthcare, by linking service users with community resources, therefore filling the gaps left by reduced funding for public services.

However, the success of social prescribing also depends on the availability of community infrastructure to which service users can be referred and signposted. The very reductions in funding for community and public services that social prescribing is trying to mitigate may also have limited the availability and accessibility of the community assets that social prescribing relies on to succeed. It is therefore vital that consideration is given to the investment that may be needed to support local communities to ensure that social prescribing does not disproportionately benefit better-served areas, and thus work to widen inequities. As other authors have also highlighted (Gibson et al. 2021; Mackenzie et al. 2020), attention should also be given to the fact social prescribing programmes which place and emphasis on behaviour change and individual agency, may be difficult for service users experiencing disadvantaged socioeconomic circumstances to fully engage with. 

Social prescribing is without a doubt a source of vital support for individuals and communities across the UK. However, thought needs to be given to the way in which it is implemented – with provisions in place to ensure that community infrastructure is able to support social prescribing. It otherwise risks becoming an overflow or holding service for other specialist health and statutory services.

References: 

Frostick C, Bertotti M. The frontline of social prescribing – How do we ensure Link Workers can work safely and effectively within primary care? Chronic Illness. 2021;17(4):404-415. doi:10.1177/1742395319882068

Gibson, K., Pollard, T. M., & Moffatt, S. (2021). Social prescribing and classed inequality: A journey of upward health mobility?. Social Science & Medicine, 280, 114037

Mackenzie, M., Skivington, K., & Fergie, G. (2020). “The state They're in”: Unpicking fantasy paradigms of health improvement interventions as tools for addressing health inequalities. Social science & medicine, 256, 113047.

Acknowledgements

Many thanks to Stephanie Tierney, Bernie Hogan, Michelle Yeung, Steven Markham, Elizabeth Thomas, Kamal R. Mahtani, and Catherine Pope who helped facilitate the stakeholder workshop and who provided comments on this post.

funding

This study has been funded by the NIHR School of Primary Care Research (Project no: 529) and the NIHR Doctoral Research Fellowship Programme (NIHR302325)