Tensions and opportunities in social prescribing. Developing a framework to facilitate its implementation and evaluation in primary care: a realist review

A Qualitative Study of National Perspectives on Advancing Social Prescribing Using Co-Design in Canada

INTRODUCTION

Social prescribing offers a formal pathway of connecting patients in the health system with sources of support within the community to help improve their health and well-being. Since its launch in March 2022, the Canadian Institute for Social Prescribing has acted as a collective impact network to identify, connect and build upon established social prescribing initiatives using a co-design methodology. The institute received input from a participant advisory council, co-design partners and several communities of interest groups. This study aimed to describe the perceptions of the Canadian Institute for Social Prescribing's role in advancing social prescribing using a co-design approach and the barriers and facilitators to implementing social prescribing in Canada.

METHODS

We used a qualitative descriptive study design, document analysis, participant observation and semi-structured individual interviews (n = 7) with members of the Canadian Institute for Social Prescribing co-design group and the institute's leadership. We also analysed documents, field notes and transcripts using codebook thematic analysis.

RESULTS

Four themes were developed representing the facilitators of implementing the Canadian Institute for Social Prescribing to support social prescribing: Creating relational mechanisms (i.e., partnerships and connections), Bringing awareness to social prescribing and contributing to the evidence (i.e., values and beliefs), Addressing systemic conditions (i.e., having a common language for social prescribing and organizing the community health sector) and Enabling funding and policy to drive social prescribing initiatives (i.e., shifting evidence into policy and securing sustainable funding).

CONCLUSION

Participants' reflections on the co-design process demonstrated that the Canadian Institute for Social Prescribing development provided networking opportunities and shared resources relevant to social prescribing. Co-design efforts also fostered relational and informational support, which laid the necessary groundwork in Canada to overcome the complex interplay between the macro- and micro-level settings in which social prescribing is practiced.

PATIENT OR PUBLIC CONTRIBUTION

The interviews and observations involved participants with lived experience of delivering, receiving or advocating for social prescribing.

Loneliness impact on healthcare utilization in primary care: A retrospective study

BACKGROUND

An increased number of patients seek help for loneliness in primary care.

OBJECTIVE

To analyze whether loneliness was associated with a higher utilization of healthcare facilities.

METHODS

Observational, retrospective study based on the review of routinely coded data in the digital medical record system in a random sample of patients aged 65 or older, stratified by population size of their residence area. A minimum sample size was estimated at 892 medical records. Loneliness was defined as the negative feeling that arises when there is a mismatch between the quantity and quality of a person's social relationships and those, they desire. Thirty-three primary care nurses (30 females and 3 males) were reviewing the data.

RESULTS

A total of 932 medical records of patients were reviewed (72% belonged to female patients). Of these, 657 individuals were living alone (71.9%). DeJong Scale average scores was 8.9 points (SD 3.1, 95CI 8.6-9.1). The average annual attendance to primary care ranged from 12.2 visits per year in the case of family practice, 10.7 nurse, 0.7 social workers. The average number of home visits was 3.2, and the urgent consultations attended at health centers were 1.5 per year. Higher feelings of loneliness were associated with extreme values in the frequency of healthcare resource usage. Compared to their peers of the same age, the additional healthcare resource consumption amounted to €802.18 per patient per year.

CONCLUSION

Loneliness is linked to higher healthcare resource usage in primary care, with individuals experiencing poorer physical and mental health utilizing these resources up to twice as much as their peers of the same age.

Implementing a social prescribing program in primary care units in Portugal: A qualitative study exploring enablers, barriers and lessons learned from the perspectives of stakeholders involved in the program implementation

Social prescribing (SP) is a promising intersectoral strategy of integrated and person-centered care that can improve individual health and well-being by going beyond medical treatment, potentially reducing overall disease burden on health system. SP addresses health and social determinants of health by linking patients to community responses, i.e. services and initiatives fostering social interaction, physical activity and creativity, among other health-promoting aspects, provided by local public, private, and non-profit entities. There is limited research on the implementation processes of SP beyond the UK, hindering improvement and scale-up. This study aims to identify enablers and barriers of implementation of an SP program conducted in Portugal. A participatory and qualitative approach was used to assess the implementation of an SP program in health units. Semi-structured interviews were conducted with family doctors, social workers and representatives of community partners who participated in SP implementation. The Consolidated Framework for Implementation Research was used to conduct thematic analysis. The main enablers of SP implementation included its recognition as an evolution towards a holistic model of health, the personal characteristics of professionals as being proactive, motivated, and concerned with social determinants of health, and the communication strategy used to engage the stakeholders. Perceived challenges included raising users' awareness of SP and ensuring intervention adherence. Lack of preparedness for intersectoral working processes, including insufficient communication channels, limited community responses and the need for a more systematic collection of data on activities adherence and progress were also highlighted as barriers to SP implementation. SP implementation seems simple, but the results show that in practice, we are facing a complex intervention with multiple stakeholders, diverse community responses and factors influencing project success. A deeper understanding of SP specificities, local context, enablers, and barriers is vital to develop strategies for improvement and successful implementation, ensuring scalability and sustainability.

Contextually appropriate nurse staffing models: a realist review protocol

INTRODUCTION

Decisions about nurse staffing models are a concern for health systems globally due to workforce retention and well-being challenges. Nurse staffing models range from all Registered Nurse workforce to a mix of differentially educated nurses and aides (regulated and unregulated), such as Licensed Practical or Vocational Nurses and Health Care Aides. Systematic reviews have examined relationships between specific nurse staffing models and client, staff and health system outcomes (eg, mortality, adverse events, retention, healthcare costs), with inconclusive or contradictory results. No evidence has been synthesised and consolidated on how, why and under what contexts certain staffing models produce different outcomes. We aim to describe how we will (1) conduct a realist review to determine how nurse staffing models produce different client, staff and health system outcomes, in which contexts and through what mechanisms and (2) coproduce recommendations with decision-makers to guide future research and implementation of nurse staffing models.

METHODS AND ANALYSIS

Using an integrated knowledge translation approach with researchers and decision-makers as partners, we are conducting a three-phase realist review. In this protocol, we report on the final two phases of this realist review. We will use Citation tracking, tracing Lead authors, identifying Unpublished materials, Google Scholar searching, Theory tracking, ancestry searching for Early examples, and follow-up of Related projects (CLUSTER) searching, specifically designed for realist searches as the review progresses. We will search empirical evidence to test identified programme theories and engage stakeholders to contextualise findings, finalise programme theories document our search processes as per established realist review methods.

ETHICS AND DISSEMINATION

Ethical approval for this study was provided by the Health Research Ethics Board of the University of Alberta (Study ID Pro00100425). We will disseminate the findings through peer-reviewed publications, national and international conference presentations, regional briefing sessions, webinars and lay summary.

What does social prescribing look like in practice? A qualitative case study informed by practice theory

Social prescribing (SP) typically involves linking patients in primary care with a range of local, community-based, non-clinical services. While there is a growing body of literature investigating the effectiveness of SP in improving healthcare outcomes, questions remain about how such outcomes are achieved within the everyday complexity of community health systems. This qualitative case study, informed by practice theory, aimed to investigate how SP practices relevant to people at high risk of type 2 diabetes (T2D) were enacted in a primary care and community setting serving a multi-ethnic, socioeconomically deprived population. We collected different types of qualitative data, including 35 semi-structured interviews with primary care clinicians, link workers and SP organisations; 30 hours of ethnographic observations of community-based SP activities and meetings; and relevant documents. Data analysis drew on theories of social practice, including Feldman's (2000) notion of the organisational routine, which emphasises the creative and emergent nature of routines in practice. We identified different, overlapping ways of practising SP: from highly creative, reflective and adaptive ('I do what it takes'), to more constrained ('I do what I can') or compliant ('I do as I'm told') approaches. Different types of practices were in tension and showed varying degrees of potential to support patients at high risk of T2D. Opportunities to adapt, try, negotiate, and ultimately reinvent SP to suit patients' own needs facilitated successful SP adoption and implementation, but required specific individual, relational, organisational, and institutional resources and conditions. Feldman, M.S., 2000. Organizational Routines as a Source of Continuous Change. Organ. Sci. 11, 611-629.

Exploration of Evaluation Practices in Social Prescribing Services in Ireland: A Cross-Sectional Observational Study

National health services in Ireland and the UK fund the majority of social prescribing services and have issued recommendations for evaluation. However, it is not known what outcomes are prioritised for evaluation within individual services and what evaluation methods are used to capture recommended outcomes. A survey was carried out to examine evaluation practices of social prescribing services on the island of Ireland. This study used a cross-sectional observational design. The sample was all the staff involved in delivering and/or managing SP services on the island of Ireland. Questionnaires were distributed at a national SP conference and online. Closed-response questions were analysed using descriptive statistics. Content analysis was used for open-ended questions. Eighty-four usable surveys were returned (50% from the Republic of Ireland and 50% from Northern Ireland). All respondents (100%) agreed on the importance of measuring SP outcomes. The most frequently measured outcomes were health and well-being (89.2%) and loneliness (84%). The least frequently measured outcome was the satisfaction of healthcare professionals referring to SP: 78.4% of respondents never measured this outcome. The most frequently used measurement tool was the Short Warwick Edinburgh Mental Well-Being Scale, with 38/76 (50%) respondents using this measure. There was a lack of standardised measures identified for some outcomes. For example, 70% of respondents reported always measuring physical activity (PA), but only four respondents identified a specific PA measure. In open-ended questions, respondents recommended flexibility in evaluation methods to reflect the complexity and individualised focus of SP. They also identified the need for protected time to complete evaluations and recommended a national strategy to inform priorities in evaluations. This study demonstrates a wide variation on the island of Ireland on how SP services are measuring outcomes, with many outcomes rarely or never measured using standardised measures. Agreement is needed on a core outcome set for social prescribing in order to guide service delivery and evaluations.

Current Trends and Future Directions in Urban Social Prescribing

PURPOSE OF REVIEW

Social prescribing (SP) is defined as a non-medical community referral program to support well-being and health. This review explores the current evidence about the effectiveness of SP.

RECENT FINDINGS

This review examined existing SP models that have been or are being tested to connect people to these opportunities through direct and indirect referral schemes. The review identified a fifth model that facilitates a group-based approach used to mental well-being and resilience. While the development of SP largely originates from the UK, the global interest in SP has increased, with over 31 nations reporting elements of SP. The main goal of SP is to better integrate care between the traditional medical setting and resources available in the community and voluntary sectors. Although this review found widespread optimism around SP, there remain concerns about its effectiveness and demands for high-quality evaluations to strengthen the evidence base for SP.

Factors influencing social prescribing initiatives: a systematic review of qualitative evidence

AIMS

Social prescribing is a growing health policy agenda to improve the quality and effectiveness of health systems. However, systematically collected knowledge on factors influencing the effective implementation of SP is scarce. A systematic review was conducted to identify and categorize factors influencing social prescribing initiatives.

METHODS

A search of three electronic databases (PubMed, Scopus, and ISI Web of Knowledge) was carried out to retrieve studies from inception to May 2022, supplemented by grey literature searching and snowballing of the relevant references. The inclusion criteria were original empirical research, qualitative data collection, and a description of factors affecting social prescribing initiatives. Study quality was evaluated using the Critical Appraisal Skills Programme tool. We categorized the results of individual studies using a narrative approach.

RESULTS

A total of 23 studies were included for analysis. Along with patient-related factors (patient-centeredness, clinical complexity, perception, knowledge), three main settings of social prescribing initiatives (including healthcare providers, link workers, and voluntary and community sectors) are affected by (1) individual characteristics (knowledge, perception, skill mix); (2) interpersonal relations (collaboration, trust, feedback, supportive climate, follow-up, sustained connection, peer support within and across sectors); (3) organizational contingencies (resource adequacy, staffing, training, role description, continuity of support, caseload management, monitoring, affordability, accessibility, referral criteria, and tailored support); and (4) political context (national policy and guidance, stewardship, planning, cocreation, bureaucracy, economic condition, and the number of support organizations).

CONCLUSION

Many factors influencing social prescribing initiatives were identified. The results of this review can be applied by different stakeholders of social prescribing to guide development, implementation, description, and evaluation.

Older adults and social prescribing experience, outcomes, and processes: a meta-aggregation systematic review

OBJECTIVE

Social prescribing is a complex care model, which aims to address unmet non-medical needs and connect people to community resources. The purpose of this systematic review was to synthesize available evidence from qualitative methods (e.g. interviews or focus groups) on experience, outcomes, and processes for social prescribing and older adults (from the person or provider level).

STUDY DESIGN

This was a systematic review using the Joanna Brigg's meta-aggregative approach.

METHODS

We searched multiple online databases for peer-reviewed studies, which included older adults aged ≥60 years (group mean age) and social prescribing experience, outcomes, or processes. We included all qualitative or mixed methods designs from all years and languages. Date of the last primary search was March 24, 2022. Two authors used online software to conduct the screening independently and then decided on the final list of included studies via notes and online discussion.

RESULTS

We screened 376 citations (after duplicates) and included eight publications. There were 197 older adult participants (59% women), and many people were living with chronic health conditions. Few details were provided for participants' ethnicity, education, and related factors. We created five synthesized findings related to (1) the approach of social prescribing; implementation factors such as (2) relationships, (3) behavior change strategies, and (4) the environment; and (5) older adults' perceived health and psychosocial outcomes.

CONCLUSIONS

Despite the limited number of available studies, data provide an overview of people and processes involved with social prescribing, identified research and practice gaps, and possible next steps for implementing and evaluating social prescribing for older adults in primary care.

Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation

BACKGROUND

Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D).

METHODS

Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods.

RESULTS

People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17-4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27-1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients' wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness.

CONCLUSIONS

Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.

Applying and reporting relevance, richness and rigour in realist evidence appraisals: Advancing key concepts in realist reviews

The realist review/synthesis has become an increasingly prominent methodological approach to evidence synthesis that can inform policy and practice. While there are publication standards and guidelines for the conduct of realist reviews, published reviews often provide minimal detail regarding how they have conducted some methodological steps. This includes selecting and appraising evidence sources, which are often considered for their 'relevance, richness and rigour.' In contrast to other review approaches, for example, narrative reviews and meta-analyses, the inclusion criteria and appraisal of evidence within realist reviews depend less on the study's methodological quality and more on its contribution to our understanding of generative causation, uncovered through the process of retroductive theorising. This research brief aims to discuss the current challenges and practices for appraising documents' relevance, richness and rigour and to provide pragmatic suggestions for how realist reviewers can put this into practice.

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 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.

Systematic review of social prescribing and older adults: where to from here?

OBJECTIVE

Social prescribing is a person-centred model of care with emphases on lessening the impact of unmet social needs, supporting the delivery of personalised care, and reducing non-medical resource use in the primary care setting. The purpose of this systematic review was to synthesise the effect of social prescribing for older adults within primary care.

DESIGN

We followed standard systematic review guidelines, including protocol registration, screening studies (title/abstract and full text) and assessing the study quality.

ELIGIBILITY AND INFORMATION SOURCES

We searched multiple online databases for studies that included older adults 60+ years (group mean age), an intervention defined and called social prescribing (or social prescription) via health provider referrals to non-medical services, and quantitative physical and psychosocial outcomes and/or health resource use. We included experimental and observational studies from all years and languages and conducted a narrative synthesis. The date of the last search was 24 March 2022.

RESULTS

We screened 406 citations (after removing duplicates) and included seven studies. All studies except one were before-after design without a control group, and all except one study was conducted in the UK. Studies included 12-159 participants (baseline), there were more women than men, the group mean (SD) age was 76.1 (4.0) years and data collection (baseline to final) occurred on average 19.4 (14.0) weeks apart. Social prescribing referrals came from health and social providers. Studies had considerable risk of bias, programme implementation details were missing, and for studies that reported data (n=6) on average only 66% of participants completed studies (per-protocol). There were some positive effects of social prescribing on physical and psychosocial outcomes (eg, social participation, well-being). Findings varied for health resource use. These results may change with new evidence.

CONCLUSIONS

There were few peer-reviewed studies available for social prescribing and older adults. Next steps for social prescribing should include co-creating initiatives with providers, older people and communities to identify meaningful outcomes, and feasible and robust methods for uptake of the prescription and community programmes. This should be considered in advance or in parallel with determining its effectiveness for meaningful outcomes at multiple levels (person, provider and programme).

Managing disruption at a distance: Unequal experiences of people living with long-term conditions during the COVID-19 pandemic

The COVID-19 pandemic and 'lockdown' restrictions have affected people's health and wellbeing globally. Those who are clinically vulnerable to COVID-19 mortality due to living with long term conditions (LTCs) are at greater risk of negative impacts on their health and wellbeing, and of disruption in management of their LTCs. This study explores how people with LTCs managed their health and wellbeing under social distancing restrictions and self-isolation during the first wave of the COVID-19 pandemic, and examines why some people were more able to manage than others. Interviews were conducted between May and July 2020 with people (n = 44) living in North East England, who had one or more LTCs and were recruited via a social prescribing intervention. Data were analysed using a social constructivist thematic analysis. We present our analysis of the possibilities afforded to people to manage the impacts of lockdown on their health and wellbeing. We find that while some people deployed a range of capitals and/or etched out 'tactics' to make life 'habitable', others experienced 'zones of impossibility' requiring that they rely on contingent events or formal support. Our analysis highlights inequalities amongst people with LTCs, particularly regarding access to and deployment of important resources for health and wellbeing under COVID-19 social distancing restrictions, including outdoor space or greenspace, exercise and social connection. The study is novel in showing the mechanisms for coping with a significant period of disruption in the life-course whilst highlighting that although resilience was common in people with LTCs, this was sometimes at detrimental costs to themselves.

Global developments in social prescribing

Social prescribing is an approach that aims to improve health and well-being. It connects individuals to non-clinical services and supports that address social needs, such as those related to loneliness, housing instability and mental health. At the person level, social prescribing can give individuals the knowledge, skills, motivation and confidence to manage their own health and well-being. At the society level, it can facilitate greater collaboration across health, social, and community sectors to promote integrated care and move beyond the traditional biomedical model of health. While the term social prescribing was first popularised in the UK, this practice has become more prevalent and widely publicised internationally over the last decade. This paper aims to illuminate the ways social prescribing has been conceptualised and implemented across 17 countries in Europe, Asia, Australia and North America. We draw from the 'Beyond the Building Blocks' framework to describe the essential inputs for adopting social prescribing into policy and practice, related to service delivery; social determinants and household production of health; workforce; leadership and governance; financing, community organisations and societal partnerships; health technology; and information, learning and accountability. Cross-cutting lessons can inform country and regional efforts to tailor social prescribing models to best support local needs.

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.

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.