Social prescribing and classed inequality: A journey of upward health mobility?

Equal, equitable or exacerbating inequalities: patterns and predictors of social prescribing referrals in 160 128 UK patients

BACKGROUND

Social prescribing is growing rapidly globally as a way to tackle social determinants of health. However, whom it is reaching and how effectively it is being implemented remains unclear.

AIMS

To gain a comprehensive picture of social prescribing in the UK, from referral routes, reasons, to contacts with link workers and prescribed interventions.

METHOD

This study undertook the first analyses of a large database of administrative data from over 160 000 individuals referred to social prescribing across the UK. Data were analysed using descriptive analyses and regression modelling, including logistic regression for binary outcomes and negative binomial regression for count variables.

RESULTS

Mental health was the most common referral reason and mental health interventions were the most common interventions prescribed. Between 72% and 85% of social prescribing referrals were from medical routes (primary or secondary healthcare). Although these referrals demonstrated equality in reaching across sociodemographic groups, individuals from more deprived areas, younger adults, men, and ethnic minority groups were reached more equitably via non-medical routes (e.g. self-referral, school, charity). Despite 90% of referrals leading to contact with a link worker, only 38% resulted in any intervention being received. A shortage of provision of community activities - especially ones relevant to mental health, practical support and social relationships - was evident. There was also substantial heterogeneity in how social prescribing is implemented across UK nations.

CONCLUSIONS

Mental health is the leading reason for social prescribing referrals, demonstrating its relevance to psychiatrists. But there are inequalities in referrals. Non-medical referral routes could play an important role in addressing inequality in accessing social prescribing and therefore should be prioritised. Additionally, more financial and infrastructural resource and strategic planning are needed to address low intervention rates. Further investment into large-scale data platforms and staff training are needed to continue monitoring the development and distribution of social prescribing.

Building common understanding: seeking consensus and defining social prescribing across contexts - a collective commentary on a Delphi study

Social prescribing has become a global phenomenon. A Delphi study was recently conducted with 48 social prescribing experts from 26 countries to establish global agreement on the definition of social prescribing. We reflect on the use and utility of the outputs of this work, and where we go from here.

'The book's a conversation starter': a realist exploration of the salutogenic potential of reading for pleasure

Reading for Wellbeing (RfW) is a pilot initiative, aimed at improving mental health and well-being through supporting access and increasing opportunities to read for pleasure. RfW was implemented across six North-East local authorities in England and employed Community Reading Workers to support access to books and reading for targeted populations. The current study used realist methodology to understand context, potential mechanisms of action, acceptability and reported outcomes. Data generation and analysis were conducted iteratively, using focus groups, interviews and observations.The analysis of the collated data highlighted that a positive attitude towards reading and a desire for social connections were significant motivators for engagement with RfW. This paper postulates eight programme theories relating to that context, which describe key mechanisms within RfW linked to engagement with reading, well-being, connections and practice. The paper concludes that previous notions of positivity associated with reading for pleasure enable participants to experience RfW as a positive social encounter. This positive social encounter enhances participants' multiple resistance resources such as increased sense of self-efficacy and connectedness that could impact on their sense of well-being.

Social isolation and loneliness among people living with experience of homelessness: a scoping review

Social isolation and loneliness (SIL) are public health challenges that disproportionally affect individuals who experience structural and socio-economic exclusion. The social and health outcomes of SIL for people with experiences of being unhoused have largely remained unexplored. Yet, there is limited synthesis of literature focused on SIL to appropriately inform policy and targeted social interventions for people with homelessness experience. The aim of this scoping review is to synthesize evidence on SIL among people with lived experience of homelessness and explore how it negatively impacts their wellbeing. We carried out a comprehensive literature search from Medline, Embase, Cochrane Library, PsycINFO, CINAHL, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index for peer-reviewed studies published between January 1st, 2000 to January 3rd, 2023. Studies went through title, abstract and full-text screening conducted independently by at least two reviewers. Included studies were then analyzed and synthesized to identify the conceptualizations of SIL, measurement tools and approaches, prevalence characterization, and relationship with social and health outcomes. The literature search yielded 5,294 papers after removing duplicate records. Following screening, we retained 27 qualitative studies, 23 quantitative studies and two mixed method studies. SIL was not the primary objective of most of the included articles. The prevalence of SIL among people with homelessness experience varied from 25 to 90% across studies. A range of measurement tools were used to measure SIL making it difficult to compare results across studies. Though the studies reported associations between SIL, health, wellbeing, and substance use, we found substantial gaps in the literature. Most of the quantitative studies were cross-sectional, and only one study used health administrative data to ascertain health outcomes. More studies are needed to better understand SIL among this population and to build evidence for actionable strategies and policies to address its social and health impacts.

Applying an equity lens to social prescribing

BACKGROUND

Social prescribing is often described as an intervention that can help reduce health inequalities yet there is little evidence exploring this. This study aimed to assess the feasibility of accessing and analysing social prescribing (SP) service user data to demonstrate the impact of SP on health inequalities.

METHODS

The sample size consisted of records for 276 individuals in Site 1 and 1644 in Site 2. Descriptive analyses were performed to assess the characteristics of people accessing SP, the consistency of data collected and the missingness across both sites.

RESULTS

Both sites collected basic demographic data (age gender, ethnicity and deprivation). However, data collection was inconsistent; issues included poor recording of ethnicity in Site 2, and for both sites, referral source data and health and well-being outcome measures were missing. There was limited data on the wider determinants of health. These data gaps mean that impacts on health inequalities could not be fully explored.

CONCLUSIONS

It is essential that SP data collection includes information on user demographics and the wider determinants of health in line with PROGRESS Plus factors. Considering equity around who is accessing SP, how they access it and the outcomes is essential to evidencing how SP affects health inequalities and ensuring equitable service delivery.

Implement social prescribing successfully towards embedding: what works, for whom and in which context? A rapid realist review

BACKGROUND

Some clients who access healthcare services experience problems due to the wider determinants of health which cannot be addressed (solely) by the medical sector. Social Prescribing (SP) addresses clients ' wider health needs and is based on linkworkers who support primary care clients in accessing social, community and voluntary care services that support their needs. Previous literature has provided valuable insights about what works (or not) in an early stage of implementing SP. However, there is limited insight into what works for the implementation of SP towards embedding. This study provides guiding principles by which SP can be successfully implemented towards the embedding stage and identifies which contextual factors and mechanisms influence these guiding principles.

METHODS

A Rapid Realist Review was conducted to examine what works, for whom, why, and in which contexts. A local Dutch reference panel consisting of health and care organisations helped to inform the research questions. Additionally, a workshop was held with the panel, to discuss what the international insights mean for their local contexts. This input helped to further refine the literature review's findings.

RESULTS

Five guiding principles were identified for successful implementation of SP at the embedding stage: • Create awareness for addressing the wider determinants of health and the role SP services can play; • Ensure health and care professionals build trusting relationships with all involved stakeholders to create a cyclical referral process; • Invest in linkworkers' skills and capacity so that they can act as a bridge between the sectors; • Ensure clients receive appropriate support to improve their self-reliance and increase their community participation; • Invest in the aligning of structures, processes and resources between involved sectors to support the use of SP services.

CONCLUSION

To embed SP, structural changes on a system level as well as cultural changes are needed. This will require a shift in attitude amongst health and care professionals as well as clients towards the use, role and benefit of SP services in addressing the wider determinants of health. It will also require policymakers and researchers to involve communities and include their perspectives.

A meta-ethnography of the factors that shape link workers' experiences of social prescribing

BACKGROUND

Social prescribing is gaining traction internationally. It is an approach which seeks to address non-medical and health-related social needs through taking a holistic person-centred and community-based approach. This involves connecting people with and supporting them to access groups and organisations within their local communities. It is hoped that social prescribing might improve health inequities and reduce reliance on healthcare services. In the UK, social prescribing link workers have become core parts of primary care teams. Despite growing literature on the implementation of social prescribing, to date there has been no synthesis that develops a theoretical understanding of the factors that shape link workers' experiences of their role.

METHODS

We undertook a meta-ethnographic evidence synthesis of qualitative literature to develop a novel conceptual framework that explains how link workers experience their roles. We identified studies using a systematic search of key databases, Google alerts, and through scanning reference lists of included studies. We followed the eMERGe guidance when conducting and reporting this meta-ethnography.

RESULTS

Our synthesis included 21 studies and developed a "line of argument" or overarching conceptual framework which highlighted inherent and interacting tensions present at each of the levels that social prescribing operates. These tensions may arise from a mismatch between the policy logic of social prescribing and the material and structural reality, shaped by social, political, and economic forces, into which it is being implemented.

CONCLUSIONS

The tensions highlighted in our review shape link workers' experiences of their role. They may call into question the sustainability of social prescribing and the link worker role as currently implemented, as well as their ability to deliver desired outcomes such as reducing health inequities or healthcare service utilisation. Greater consideration should be given to how the link worker role is defined, deployed, and trained. Furthermore, thought should be given to ensuring that the infrastructure into which social prescribing is being implemented is sufficient to meet needs. Should social prescribing seek to improve outcomes for those experiencing social and economic disadvantage, it may be necessary for social prescribing models to allow for more intensive and longer-term modes of support.

Why did this happen to me? Causal attributions of illness and cultural health capital

This study examines how conversations between patients and clinicians about the causes of their health conditions relate to patient engagement in care. Leveraging cultural health capital (CHC) theory, we find that patient-physician discussions of health attributions are one mechanism to build patient understanding and activate engagement. We present a qualitative interpretive analysis of data collected in three phases with adult home health care patients: phone interviews (n = 28), field observations (n = 61), and semi-structured field interviews (n = 38). We find that engaging in discussions of causal health attributions with clinicians enables patients to overcome uncertainty, envision preventive actions, and engage in setting future goals. Such discussions must be supported by acknowledgement of the co-responsibility of individual factors and structural factors such as social determinants of health. These discussions are not easy to navigate but they can potentially help patients transition from a mindset of treating the disease (pathogenic approach) to an awareness of their available capabilities to improve health (salutogenic approach). This study contributes to research on attribution theory and cultural health capital theory by demonstrating how discussing causes for poor health can enable patients resolve doubts and accrue instrumental and symbolic resources that facilitate healing.

"You don't get side effects from social prescribing"-A qualitative study exploring community pharmacists' attitudes to social prescribing

OBJECTIVES

Social prescribing is an approach that enables the referral of patients to non-clinical support and places a focus on holistic care. This study explored views of community pharmacists regarding social prescribing in pharmacies.

STUDY DESIGN

A qualitative phenomenological approach was used.

METHODS

A convenience sample of eleven community pharmacists from Northern England were recruited via social media (Twitter, Facebook) and took part in a semi-structured, one-to-one qualitative interviews that asked about their knowledge of social prescribing, the advantages of community pharmacist involvement and any barriers they predicted to its implementation. Interviews were transcribed verbatim and thematically analysed.

RESULTS

The sample included largely male pharmacists (63.3%) with less than five years' experience (45.5%) and included pharmacists working as employees (63.6%), locums (27.3%) and owners (9%) in both chain (36%) and independent stores (54.5%). The main findings indicate an enthusiasm for but limited understanding of social prescribing. Factors which appeared to influence involvement were training requirements and time available to complete an additional service in busy pharmacies. Opportunities centred on the broader pharmacy team's role to optimise health outcomes.

CONCLUSIONS

The findings indicate pharmacists may be an underused resource due to a poor understanding of the full scale and scope of social prescribing beyond health promotion, lifestyle interventions. Further work is needed to explore the transferability of the findings to the broader pharmacy workforce to understand how social prescribing can be positioned within pharmacy practice.

Social prescribing for individuals with mental health problems: An ethnographic study exploring the mechanisms of action through which community groups support psychosocial well-being

Background

Social prescribing involves connecting individuals to community groups and activities, often to support their mental health and well-being. It has received increasing support in recent years across the NHS. There is a strong evidence base for the benefits of different types of community activities, including exercise groups, arts groups and nature interventions, on mental health outcomes, however, less is known about how these groups impact mental health and well-being. This study explores through what individual-level mechanisms (the 'how') these groups support psychosocial well-being.

Methods

An ethnographic study was conducted over 12-months to explore key shared, individual-level mechanisms across 4 social prescribing community groups: football, singing, gardening and reading. This study focused mostly on those with severe mental illness, whereas previously most social prescribing studies have focused on mild to moderate mental health problems. To frame the findings, a 'multi-level theoretical framework of mechanisms of action' of leisure activities was used.

Results

Key shared psychological mechanisms were: increased self-confidence and self-esteem, increased purpose/meaning, increased sense of achievement, experience of pleasure; social mechanisms included: increased social support, formation of friendships and reduced loneliness, enhanced sense of community and belonging; behavioural mechanisms were: increased independence and openness to experience, reduction in addictive behaviours and building healthier habits, increased work-seeking behaviour, and provision of structure & routine.

Conclusions

It is hoped that the findings of this study can help referring professionals increase their understanding of exactly how such groups support individuals' mental health, thus enhancing referring practices.

A rapid review of opportunities and challenges in the implementation of social prescription interventions for addressing the unmet needs of individuals living with long-term chronic conditions

BACKGROUND

People with long-term chronic conditions often struggle to access and navigate complex health and social services. Social prescription (SP) interventions, a patient-centred approach, help individuals identify their holistic needs and increase access to non-clinical resources, thus leading to improved health and well-being. This review explores existing SP interventions for people with long-term chronic conditions and identifies the opportunities and challenges of implementing them in primary healthcare settings.

METHODS

This rapid review followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines and searched relevant articles in three databases (PubMed/MEDLINE, EMBASE, and Web of Science) by using subject headings and keywords combined with Boolean operators. The search encompassed articles published between January 2010 and June 2023. Two authors independently conducted study screening and data abstraction using predefined criteria. A descriptive synthesis process using content analysis was performed to summarise the literature.

RESULTS

Fifteen studies were included, with all but one conducted in the United Kingdom, and revealed that social prescribers help guide patients with long-term chronic conditions to various local initiatives related to health and social needs. Effective implementation of SP interventions relies on building strong relationships between social prescribers and patients, characterised by trust, empathy, and effective communication. A holistic approach to addressing the unmet needs of people with long-term chronic conditions, digital technology utilisation, competent social prescribers, collaborative healthcare partnerships, clinical leadership, and access to local resources are all vital components of successful SP intervention. However, the implementation of SP interventions faces numerous challenges, including accessibility and utilisation barriers, communication gaps, staffing issues, an unsupportive work environment, inadequate training, lack of awareness, time management struggles, coordination and collaboration difficulties, and resource constraints.

CONCLUSION

The present review emphasises the importance of addressing the holistic needs of people with long-term chronic conditions through collaboration and coordination, training of social prescribers, community connections, availability of local resources, and primary care leadership to ensure successful interventions, ultimately leading to improved patient health and well-being outcomes. This study calls for the need to develop or utilise appropriate tools that can capture people's holistic needs, as well as an implementation framework to guide future contextual SP interventions.

Theories used to develop or evaluate social prescribing in studies: a scoping review

OBJECTIVE

This scoping review aims to provide an overview of how theories were used in the development or evaluation of social prescribing (SP) intervention studies.

BACKGROUND

SP describes a patient pathway where general practitioners (GPs) connect patients with community activities through referrals to link workers. This review seeks to understand the explanations provided for the outcomes and implementation process of SP.

INCLUSION CRITERIA

Studies using a defined theory to develop or evaluate a specific SP intervention in primary care and the community sector.

METHODS

This scoping review was conducted in accordance with JBI methodology. The following databases were searched on 8th of July 2022: PubMed, ASSIA, Cochrane, Cinahl, PsycINFO, Social Care Online, Sociological Abstracts, Scopus, and Web of Science. The search only considered English language texts. Additional literature was identified by searching relevant web pages and by contacting experts. The selection of sources and the data extraction was done by two reviewers independently.

RESULTS

The search resulted in 4240 reports, of which 18 were included in the scoping review. Of these, 16 were conducted in the UK, one in Canada and one in Australia. The majority of reports employed a qualitative approach (11/18). Three were study protocols. 11 distinct theories were applied to explain outcomes (4 theories), differences in outcomes (3 theories), and the implementation of the intervention (4 theories). In terms of practical application, the identified theories were predominantly used to explain and understand qualitative findings. Only one theory was used to define variables for hypothesis testing. All theories were used for the evaluation and none for the development of SP.

CONCLUSION

The theories influenced which outcomes the evaluation assessed, which causal pathway was expected to generate these outcomes, and which methodological approaches were used. All three groups of theories that were identified focus on relevant aspects of SP: fostering positive patient/community outcomes, addressing inequalities by considering the context of someone's individual circumstances, and successfully implementing SP by collaboratively working across professions and institutional boundaries. Additional insight is required regarding the optimal use of theories in practical applications.

Social prescribing outcomes: a mapping review of the evidence from 13 countries to identify key common outcomes

Introduction

As a means for supporting a range of health and wellbeing goals, social prescribing programs have been implemented around the world. Reflecting a range of contexts, needs, innovation, and programing, a broad array of outcomes has been studied in relation to these programs. As interest in social prescribing grows, more targeted study of key outcomes and in turn evidence synthesis that can inform evidence-based practice, policy, and investment is needed.

Methods and Results

This mapping review identified, described, and synthesized the broad array of social prescribing outcomes that have been studied in 13 countries and maps the outcomes that have been most commonly studied. From 87 articles included in this review, a total of 347 unique outcomes were identified, including 278 unique patient outcomes and 69 unique system outcomes. The most commonly studied categories of patient outcomes were found to be mental health, lifestyle and behavior, and patient/service user experience. The most commonly studied system outcomes were healthcare/service utilization and financial/economic outcomes.

Discussion

This review highlights the value of heterogeneity and mixed methods approaches in outcomes studies for capturing nuanced experiences and outcomes in this nascent area of practice, while contributing to the advancement of evidence synthesis for social prescribing globally by quantifying and offering insight into the outcomes that have been studied to date. It also lays a foundation for the development of key common outcomes and a Core Outcomes Set for social prescribing. Additionally, it identified key outcomes that, given their relationship to critical health and social issues, warrant both broader and deeper study.

Implementation and impact of a social prescribing intervention: an ethnographic exploration

BACKGROUND

Social prescribing involves referral of patients from primary care to link workers, who work with them to access appropriate local voluntary and community sector services.

AIM

To explore how a social prescribing intervention was delivered by link workers and the experiences of those referred to the intervention.

DESIGN AND SETTING

The study used ethnographic methods to conduct a process evaluation of a social prescribing intervention delivered to support those living with long-term conditions in an economically deprived urban area of the North of England.

METHOD

Participant observation, shadowing, interviews, and focus groups were used to examine the experiences and practices of 20 link workers and 19 clients over a period of 19 months.

RESULTS

Social prescribing provided significant help for some people living with long-term health conditions. However, link workers experienced challenges in embedding social prescribing in an established primary care and voluntary sector landscape. The organisations providing social prescribing drew on broader social discourses emphasising personal responsibility for health, which encouraged a drift towards an approach that emphasised empowerment for lifestyle change more than intensive support. Pressures to complete assessments, required for funding, also encouraged a drift to this lighter-touch approach. A focus on individual responsibility was helpful for some clients but had limited capacity to improve the circumstances or health of those living in the most disadvantaged circumstances.

CONCLUSION

Careful consideration of how social prescribing is implemented within primary care is required if it is to provide the support needed by those living in disadvantaged circumstances.

From domestication to imperial patronage: Deconstructing the biomedicalisation of occupational therapy

Occupational therapy knowledge emerged in the 19th century as reformist movements responded to the industrialisation of society and capitalist expansion. In the Global North, it was institutionalised by State apparatuses during the First and Second World Wars. Although biomedicine contributed to the rapid expansion and establishment of occupational therapy as a health discipline, its domestication by the biomedical model led to an overly regulated profession that betrays its reformist ideals. Drawing on the work of Deleuze and Guattari, our aim in this article is to deconstruct the biomedicalisation of occupational therapy and demonstrate how resistance to this process is critical for the future of this discipline. The use of arts and crafts in occupational therapy may be conceptualised as a 'nomad science' aesthetically resisting the domination of industrialism and medical reductionism. Through the war efforts, a coalition of progressive nurses, social workers, teachers, artisans and activists metamorphosed into occupational therapists. As it did with nursing, biomedicine proceeded to domesticate occupational therapy through a form of 'imperial' patronage subsequently embodied in the evidence-based movement. 'Occupational' jargon is widely used today and may be viewed as the product of a profession trying to establish itself as an autonomous discipline that imposes its own regime of truth. Given the symbolic violence underlying this patronage, the future of occupational therapy should not mean behaving according to biomedicine's terms. As a discipline, occupational therapy must resist the appropriation of its 'war machine' and craft its own terms through the release of new creative energy.

The feasibility of identifying health inequalities in social prescribing referrals and declines using primary care patient records

Background

Social prescribing (SP) is part of universal personalised care and available to everyone in the UK National Health Service. However, emerging evidence suggests access disparities in social prescribing. This study aimed to investigate the feasibility of using primary care records to access and analyse data on social prescribing. Our secondary aim was to compare characteristics of patients who are offered referral, referred to or decline referral for social prescribing to explore possible inequalities in access to social prescribing.

Methods

Patient records (n=3086) were extracted from 11 GP practices across Northwest England for accepted, offered and declined social prescribing referrals. Patient demographics collected included sex, age, ethnicity, mental and physical health diagnoses. Patient characteristics in social prescribing referrals were compared to the overall practice population (practice information from Public Health England). Referral and decline rates were compared by group (e.g. male/female decline rates).

Results

GP referral data showed inconsistent recording of wider determinants of health. Patient age, sex and mental and physical health conditions were consistently recorded. Other variables (marital status, interpreter need, education, disability, sexual orientation, non-English language, nationality) were recorded only sporadically and could not be used for analysis. Practices varied in referral patterns. Our preliminary findings identified under-referring of younger age groups and Asians, and higher declined referrals among individuals with physical health diagnoses.

Conclusions

Recording discrepancies meant that many patient factors could not be used to identify trends in social prescribing referrals and declines and assess equity. Primary care data recording must be consistent to understand SP referral trends and inequalities relating to the wider determinants of health. Preliminary results suggest some patient groups may be underrepresented in SP referrals, however this requires further investigation.

Models of social prescribing to address non-medical needs in adults: a scoping review

BACKGROUND

The health and wellbeing consequences of social determinants of health and health behaviours are well established. This has led to a growing interest in social prescribing, which involves linking people to services and supports in the community and voluntary sectors to address non-medical needs. However, there is considerable variability in approaches to social prescribing with little guidance on how social prescribing could be developed to reflect local health systems and needs. The purpose of this scoping review was to describe the types of social prescribing models used to address non-medical needs to inform co-design and decision-making for social prescribing program developers.

METHODS

We searched Ovid MEDLINE(R), CINAHL, Web of Science, Scopus, National Institute for Health Research Clinical Research Network, Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registry Platform, and ProQuest - Dissertations and Theses for articles and grey literature describing social prescribing programs. Reference lists of literature reviews were also searched. The searches were conducted on 2 August 2021 and yielded 5383 results following removal of duplicates.

RESULTS

148 documents describing 159 social prescribing programs were included in the review. We describe the contexts in which the programs were delivered, the program target groups and services/supports to which participants were referred, the staff involved in the programs, program funding, and the use of digital systems.

CONCLUSIONS

There is significant variability in social prescribing approaches internationally. Social prescribing programs can be summarised as including six planning stages and six program processes. We provide guidance for decision-makers regarding what to consider when designing social prescribing programs.

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions

BACKGROUND

Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions.

METHODS

A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice.

RESULTS

We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest.

CONCLUSION

The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

Constituting link working through choice and care: An ethnographic account of front-line social prescribing

Link worker social prescribing has become a prominent part of NHS England's personalisation agenda. However, approaches to social prescribing vary, with multiple discourses emerging about the potential of social prescribing and different interpretations of personalisation. The transformational promise of social prescribing is the subject of ongoing debate, whilst the factors that shape the nature of front-line link working practices remain unclear. Based on 11 months of in-depth ethnographic research with link workers delivering social prescribing, we show how link workers' practices were shaped by the context of the intervention and how individual link workers navigated varied understandings of social prescribing. Following the work of Mol, we show how link workers drew differentially on the interacting logics of choice and care and trace a multiplicity in front-line link working practices within a single intervention. However, over time, it appeared that a logic of choice was becoming increasingly dominant, making it harder to deliver practices that aligned with a logic of care. We conclude that interpreting personalisation through a logic of choice could potentially undermine link working practices that privilege care whilst obscuring the need for wider investment in health care systems and the social determinants of health.

Impact of a link worker social prescribing intervention on non-elective admitted patient care costs: A quasi-experimental study

Healthcare systems in many countries are enthusiastically adopting link worker social prescribing interventions that aim to tackle the social determinants of health by linking patients to voluntary and community sector activities and sources of support to address their social needs and improve condition management. Social prescribing interventions aim to improve health and reduce healthcare spending. However, despite the diversion of healthcare budgets to fund social prescribing, we still lack robust evidence for its effectiveness. In this study we evaluate whether participation in a social prescribing intervention reduced non-elective admitted patient care use and costs for 8283 patients aged between 40 and 74 years, with a diagnosis of type 2 diabetes and living in an area of high socioeconomic deprivation in north-east England. Patients were followed for a total of 6 years: 2 years pre-intervention and 4 years post intervention. Exploiting a natural experiment, we used a two-part difference-in-differences regression model to estimate costs conditional on healthcare use. We also estimated intervention effects across several intervention and control groups and sample subgroups. Participation in the intervention resulted in reductions of up to -£77.57 [95% CI: -152.30, -2.84] (for high engagement patients) per patient, per year, in non-elective care costs. Reductions were greater for patients with higher levels of engagement with the intervention. Sub-group analyses showed greater cost reductions for non-White patients, older patients, and patients without additional co-morbidities. Our findings suggest that engagement with a link worker social prescribing intervention may reduce non-elective healthcare spending, perhaps through enabling better condition management that results in fewer avoidable health crises.

Case study research and causal inference

Case study methodology is widely used in health research, but has had a marginal role in evaluative studies, given it is often assumed that case studies offer little for making causal inferences. We undertook a narrative review of examples of case study research from public health and health services evaluations, with a focus on interventions addressing health inequalities. We identified five types of contribution these case studies made to evidence for causal relationships. These contributions relate to: (1) evidence about system actors' own theories of causality; (2) demonstrative examples of causal relationships; (3) evidence about causal mechanisms; (4) evidence about the conditions under which causal mechanisms operate; and (5) inference about causality in complex systems. Case studies can and do contribute to understanding causal relationships. More transparency in the reporting of case studies would enhance their discoverability, and aid the development of a robust and pluralistic evidence base for public health and health services interventions. To strengthen the contribution that case studies make to that evidence base, researchers could: draw on wider methods from the political and social sciences, in particular on methods for robust analysis; carefully consider what population their case is a case 'of'; and explicate the rationale used for making causal inferences.

Impact of COVID-19 on social prescribing across an Integrated Care System: A Researcher in Residence study

Emerging evidence suggests that connecting people to non-medical activities in the community (social prescribing) may relieve pressure on services by promoting autonomy and resilience, thereby improving well-being and self-management of health. This way of working has a long history in the voluntary and community sector but has only recently been widely funded by the National Health Service (NHS) in England and implemented in Primary Care Networks (PCNs). The COVID-19 global pandemic coincided with this new service. There is wide variation in how social prescribing is implemented and scant evidence comparing different delivery models. As embedded researchers within an Integrated Care System in the Southwest of England, we examined the impact of COVID on the implementation of social prescribing in different employing organisations during the period March 2020 to April 2021. Data were collected from observations and field notes recorded during virtual interactions with over 80 social prescribing practitioners and an online survey of 52 social prescribing practitioners and middle managers. We conceptualise social prescribing as a pathway comprising access, engagement and activities, facilitated by workforce and community assets and strategic partnerships. We found that these elements were all impacted by the pandemic, but to different degrees according to the way the service was contracted, whether referrals (access) and approach (engagement) were universal ('open') or targeted ('boundaried') and the extent to which practitioners' roles were protected or shifted towards immediate COVID-specific work. Social prescribers contracted in PCNs were more likely to operate an 'open' model, although boundaries were developing over time. We suggest the presence of an explicit, agreed delivery model (whether 'open' or 'boundaried') might create a more coherent approach less likely to result in practitioner role drift, whilst allowing flexibility to adjust to the pandemic and enhancing practitioner satisfaction and well-being. The potential consequences of different models are examined.

Do people perceive benefits in the use of social prescribing to address loneliness and/or social isolation? A qualitative meta-synthesis of the literature

Social prescribing is a means by which clinical services can link individuals who have psychological, social and/or practical needs with non-clinical services within their local community. There is a lack of empirical evidence investigating whether social prescribing helps such individuals and which interventions are the most effective and accepted by them to address their loneliness. This meta-synthesis aimed to synthesise findings from qualitative studies exploring experiences of people (of any age) who participated in any social prescribing intervention aimed at loneliness and/or social isolation to ascertain whether they felt it helped address loneliness/isolation and the potential mechanisms by which this might occur. We conducted a systematic search of 5 electronic databases and 4 other databases that would yield grey literature in April 2021 to identify qualitative articles on this topic written in English or French. We assessed the quality of the included studies using recognised tools, and synthesised findings using the approach of thematic analysis. We identified 19 records analysed (e.g. journal articles) from 18 studies meeting inclusion criteria. Our analysis identified three themes: (1) increased sense of wellbeing (with six subthemes), (2) factors that engendered an ongoing desire to connect with others, and (3) perceived drawbacks of social prescribing. These themes illustrate the benefits and difficulties people perceive in social prescribing programmes addressing loneliness and social isolation, with an overall balance of more benefits than drawbacks in social prescribing participation. However, given the unhelpful aspects of social prescribing identified by some participants, greater thought should be given to potential harms. Moreover, further qualitative and quantitative research is needed to better understand mechanisms and effectiveness, and how different components of social prescribing might be best matched to individual participants.

'He called me out of the blue': An ethnographic exploration of contrasting temporalities in a social prescribing intervention

Social prescribing, a way of connecting patients to local services, is central to the NHS Personalised Care agenda. This paper employs ethnographic data, generated with 19 participants between November 2018 and July 2020, to explore the socio-temporal relations shaping their experiences of a local social prescribing intervention. Our focus is on the ways in which the intervention synchronised with the multitude of shifting, complex and often contradictory 'timespaces' of our participants. Our focus on the temporal rhythms of everyday practice allows us to trace a tension between the linearity and long horizon of the intervention and the oft contrasting timeframes of participants, sometimes leading to a mismatch that limited the intervention's impact. Further, we observed an interventional 'drift' from continuity towards unsupported signposting and 'out-of-the-blue' contacts which favour the temporality of the intervention. We demonstrate a need for intervention planning to be flexible to multiple, often conflicting, temporalities. We argue that health interventions must account for the temporal relations lived by the people they seek to support.

Challenges and Approaches to Green Social Prescribing During and in the Aftermath of COVID-19: A Qualitative Study

The last decade has seen a surge of interest and investment in green social prescribing, however, both healthcare and social enterprise has been impacted by the COVID-19 crisis, along with restricted access to public green spaces. This study examines the challenges and opportunities of delivering green social prescribing during and in the aftermath of COVID-19, in the light of goals of green social prescribing to improve mental health outcomes and reduce health inequalities. Thirty-five one-to-one interviews were conducted between March 2020 and January 2022. Interviewees included Link Workers and other social prescribers, general practitioners (GPs), managers, researchers, and volunteers working in urban and rural Scotland and North East England. Interview transcripts were analyzed in stages, with an inductive approach to coding supported by NVivo. Findings revealed a complex social prescribing landscape, with schemes funded, structured, and delivered diversely. Stakeholders were in general agreement about the benefits of nature-based interventions, and GPs and volunteers pointed out numerous benefits to participating in schemes such as parkrun. Link Workers were more circumspect about suggesting outdoor activities, pointing out both psychological and practical obstacles, including health anxieties, mobility issues, and transport deficits. Exacerbated by the pandemic, there was a way to go before older and/multi-morbidity clients (their largest cohort) would feel comfortable and safe to socialize in open air spaces. Our findings support the premise that time spent in open green spaces can alleviate some of the negative mental health effects compounded by the pandemic. However, the creation of healthy environments is complex with population health intrinsically related to socioeconomic conditions. Social disadvantage, chronic ill health and health crises all limit easy access to green and blue spaces, while those in the most socially economically deprived areas receive the lowest quality of healthcare. Such health inequities need to be borne in mind in the planning of schemes and claims around the potential of future nature-based interventions to reduce health inequalities.

What does the literature mean by social prescribing? A critical review using discourse analysis

Social prescribing (SP) seeks to enhance the role of the voluntary and community sector in addressing patients' complex needs in primary care. Using discourse analysis, this review investigates how SP is framed in the scientific literature and explores its consequences for service delivery. Theory driven searches identified 89 academic articles and grey literature that included both qualitative and quantitative evidence. Across the literature three main discourses were identified. The first one emphasised increasing social inequalities behind escalating health problems and presented SP as a response to the social determinants of health. The second one problematised people's increasing use of health services and depicted SP as a means of enhancing self-care. The third one stressed the dearth of human and relational dimensions in general practice and claimed that SP could restore personalised care. Discourses circulated unevenly in the scientific literature, conditioned by a wider political rationality which emphasised individual responsibility and framed SP as 'solution' to complex and contentious problems. Critically, this contributed to an oversimplification of the realities of the problems being addressed and the delivery of SP. We propose an alternative 'care-based' framing of SP which prioritises (and evaluates) holistic, sustained and accessible practices within strengthened primary care systems.

Supporting Vulnerable Populations During the Pandemic: Stakeholders' Experiences and Perceptions of Social Prescribing in Scotland During Covid-19

Social prescribing schemes refer people toward personalized health/wellbeing interventions in local communities. Since schemes hold different representations of social prescribing, responses to the pandemic crisis will vary. Intersectionality states that social divisions build on one another, sustaining unequal health outcomes. We conducted and inductively analysed interviews with twenty-three professional and volunteer stakeholders across three social prescribing schemes in urban and rural Scotland at the start and end of year one of the pandemic. Concerns included identifying and digitally supporting disadvantaged and vulnerable individuals and reduced capacity statutory and third-sector services, obliging link workers to assume new practical and psychological responsibilities. Social prescribing services in Scotland, we argue, represent a collage of practices superimposed on a struggling healthcare system. Those in need of such services are unlikely to break through disadvantage whilst situated within a social texture wherein inequalities of education, health and environmental arrangements broadly intersect with one another.

Social prescribing during the COVID-19 pandemic: a qualitative study of service providers' and clients' experiences

BACKGROUND

COVID-19 public health restrictions, such as social distancing and self-isolation, have been particularly challenging for vulnerable people with health conditions and/or complex social needs. Link worker social prescribing is widespread in the UK and elsewhere and is regarded as having the potential to provide support to vulnerable people during the pandemic. This qualitative study explores accounts of how an existing social prescribing service adapted to meet clients' needs in the first wave of the pandemic, and of how clients experienced these changes.

METHODS

Data were collected in a deprived urban area of North East England via remote interviews with clients (n = 44), link workers (n = 5) and service provider managerial staff (n = 8) from May-September 2020. Thematic data analysis was conducted.

RESULTS

The research found that service providers quickly adapted to remote intervention delivery aiming to serve existing clients and other vulnerable groups. Service providers experienced improved access to some existing clients via telephone in the first months of remote delivery and in some cases were able to engage clients who had previously not attended appointments at GP surgeries. However, link workers also experienced challenges in building rapport with clients, engaging clients with the aims of the intervention and providing a service to digitally excluded people. Limited link worker capacity meant clients experienced variable contact with link workers with only some experiencing consistent support that was highly valued for helping to manage their conditions and mental wellbeing. Limited access to linked services also adversely affected clients. Clients living in less affluent circumstances and/or with worse health were more likely to experience negative impacts on their long-term condition. Some found their health and progress with social prescribing was 'on hold' or 'going backwards', which sometimes negatively affected their health.

CONCLUSIONS

Social prescribing offered valued support to some during the pandemic, but remote support sometimes had limited impact for clients and findings highlight the vulnerability of social prescribing's success when linked services are disrupted. Findings also show the need for more to be done in the upscaling of social prescribing to provide support to digitally excluded populations.