What did we try to do?

Social prescribing, sometimes known as community referral, is where doctors and nurses work with someone called a 'link worker' to help patients find services from local, voluntary and community groups to improve their health and wellbeing. Link workers were introduced by the NHS across the UK. Link workers support people with emotional and practical needs by considering all aspects of their lives, not just their medical needs. Their role is to help connect people to information, advice, activities and other services provided by a range of voluntary and community groups. 

 

We used a multi-regional approach to map provision and service configuration of social prescribing and to assess whether access, engagement and outcomes varied by delivery model, geography and population characteristics over time. By doing this, we found out how link worker services operate, how well they work, who does and doesn't use them, whether they are of benefit to people and are a good use of NHS resources. 

 

 

Why was it important?

Social prescribing links patients in primary care with sources of support within the community. Previous research on social prescribing evaluated the effects of individual services, usually in isolation from the wider health system in which they were situated. It was well documented that the evidence base was of a low standard and subject to a high risk of bias. A lot of the evidence was taken from small scale studies that were limited by poor design and reporting, which made it difficult to reliably judge how, and in what circumstances, social prescribing could deliver benefits. 

 

There were few rigorous evaluations, and those that were rigorous failed to demonstrate improved health and wellbeing for service users. They suggested that finding ways to improve access and engagement with services may lead to better overall outcomes.

 

We knew that engagement in community assets could improve health and wellbeing. However, we didn't know how people became engaged with community assets and whether the link worker model would encourage engagement and/or enhance access and equity.

 

With national policy implementation underway across the UK, there was a need to understand the impact of social prescribing link worker services and how they can be developed in the future.

 

How did we do it?

Over the research award, which ran from 2022 to 2025, we used a multi-region mixed methods approach to map provision and service configuration and to assess whether access, engagement and outcomes varied by delivery model, geography and population characteristics over time. Our approach was broken down into six areas of focus:

 

• WP 1: Implementation - to establish the key features and variations in delivery models for link worker social prescribing services within and between each region.
• WP 2: Access and equity - to assess inequalities in access, uptake and engagement based on area-level and population characteristics (age, gender, ethnicity, area deprivation, availability of community assets, and rurality).
• WP 3: Experience and acceptability - to understand experience and acceptability of the referral process, the therapeutic encounter and the process of accessing and engaging with social prescribing services from a range of perspectives.
• WP 4: Health and wellbeing and service outcomes - to assess health and wellbeing and service outcomes, and whether outcomes varied within and between services delivered and by population characteristics (age, gender, ethnicity, area deprivation, availability of community assets, and rurality).
• WP 5: Economic sustainability - to explore the value and economic sustainability of link workers in primary care.
• WP 6: Dissemination and knowledge mobilisation - to ensure relevance to policy need and to maximise the impact and use of findings in decision-making processes as they occured.

 

 

Findings

 

Implementation

 

Work Package 1 aimed to find the key features and variations in delivery models for link worker social prescribing services in each region.

 

• Paper: Mapping Variation in Delivery Models and Data Recording of Primary Care Social Prescribing Link Worker (SPLW) Schemes Across Five Regions in England and Scotland

  In the paper 'Mapping Variation in Delivery Models and Data Recording of Primary Care Social Prescribing Link Worker (SPLW) Schemes Across Five Regions in England and Scotland', we identified that across the five regions involved in the study (Greater Manchester, North East & North Cumbria, West of England, Greater Glasgow & Clyde, and Lothian) four different Social Prescribing Link Worker (SPLW) models were being used:

   

  • Model 1: SPLWs are employed directly by their Primary Care Network (PCN), which manages their training and day-to-day activities. 
  • Model 2: A group of PCNs partners to manage, oversee and employ their SPLWs. Management of SPLWs could be under a central lead manager/social prescribing coordinator. 
  • Model 3: PCNs and Health and Social Care Partnerships (HSCPs) outsource SPLWs to the Voluntary, Community and Social Enterprise (VCSE) sector, but retain some element of oversight of training, support, and core activities.
  • Model 4: A more integrated system operates. For example, in the South West region, an Integrated Care Board (ICB) plays a strategic role in commissioning and funding is split between the county council (one third) and the NHS (two thirds). SPLWs are mostly funded, employed, managed and hosted either by a PCN or VCSE organisation.

 

Access and equity

 

The aim of Work Package 2 was to assess inequalities in access, uptake and engagement based on area-level and population characteristics.

 

• Paper: Geographic inequalities in need and provision of social prescribing link workers a retrospective study in primary care

  In the paper ‘Geographic inequalities in need and provision of social prescribing link workers a retrospective study in primary care’ findings show that:

   

  • In April 2020, there were an average of 0.093 FTE link workers within each PCN across England, increasing to 1.289 FTE by the end of 2021/22, and to 2.198 by Q3 of 2023/24.
  • Populations in urban, more deprived areas and with higher proportions of people from minority ethnic groups had the highest reported lack of support. Geographically these were in the North West and London. 
  • Initially, there was no association between need and provision. Then, from July 2022, the association became negative and significant. By October 2023, places with a 10% higher need for support were associated with a 0.035 lower FTE per 10 000 patients.
  • Overall, findings showed that the rollout of link workers has not been sufficiently targeted at areas with the highest need and that future deployments should be targeted at those areas.

   

  The following map of England shows employment of FTE link workers per 10,000 patients across integrated care boards (ICB), with darker outlines indicating the NHS regions. We show from March 2020 there are low employment levels of FTE link workers. Across all ICBs this increases, with the South West employing link workers at an increased rate compared to other regions of England. The North East and North Cumbria ICB have the highest number of link workers per 10,000 patients as of March 2023, with ICBs within the Midlands approaching those levels. However, there are distinct areas that are not fulfilling the NHS aims of link worker employment; those include the London region as a whole, Humber and Yorkshire ICBs and parts of the East of England.

   

  
  

    

 

Health and wellbeing and service outcomes

 

Work Package 4 was designed to assess health and wellbeing and service outcomes, and whether outcomes vary within and between services delivered and by population characteristics (age, gender, ethnicity, area deprivation, availability of community assets, and rurality).

 

• Paper: Impact of the rollout of the national social prescribing link worker programme on population outcomes: evidence from a repeated cross-sectional survey

  In the paper ‘Impact of the rollout of the national social prescribing link worker programme on population outcomes: evidence from a repeated cross-sectional survey’, to find out whether social prescribing could be deemed a success, a number of potential patient outcomes were examined, based on responses to the General Practice Patient Survey. These were:

   

  • Increasing the patient’s confidence in managing their long-term condition
  • Making them feel more supported by local services and organisations
  • Making them feel less isolated from others
  • Improving their experience with their GP
  • An increased feeling that their mental health needs were understood

   

  Findings showed that:

   

  • An additional full-time equivalent link worker per 50,000 patients (about 1 extra link worker per Primary Care Network, or PCN) provided a higher chance of patients with long-term conditions having confidence in managing their long-term condition(s) and having enough support from local services. 
  • For all patients, the same increase in link workers was associated with a higher chance of having a good experience at their general practice. 
  • For patients with mental health needs, this increase in link workers was associated with a higher chance of having their needs understood. 
  • For patients experiencing loneliness and social isolation, the increase in link workers showed no improvement. 
  • Having 1 extra link worker per 50,000 population in all PCNs would bring about a national increase of approximately 47,000 people reporting confidence in managing their long-term conditions and 132,000 people reporting having had a good GP experience.

   

  The rollout of link workers helped to make small improvements in patient experience and provided slightly better outcomes for patient groups that were specifically targeted for social prescribing. 

   

  However, future work is needed to find out whether the scheme is financially sustainable and to make sure it doesn’t widen existing health inequalities.

 

Further findings will be available in due course. 

 

 

The research team:

• Paul Wilson (Principle Investigator, WP1 & WP6 Lead)
• Dr. Luke Munford (Co-applicant, WP2 Lead & WP4 Co-lead)
• Prof. Matt Sutton (Co-applicant & WP5 Lead)
• Prof. Caroline Sanders (Co-applicant & WP3 Co-lead)
• Prof. John Wildman (Co-applicant & WP4 Co-lead)
• Prof. Kate O'Donnell (Co-applicant & WP3 Co-lead)
• Prof. Sally Wyke (Co-applicant & WP3 Co-lead)
• Prof. Stewart Mercer (Co-applicant)
• Prof. Chris Salisbury (Co-applicant)
• Dr. Hugh McLeod (Co-applicant)
• Prof. Eileen Kaner (Co-applicant)
• Charlotte Leonhardsen (Co-applicant)
• Claire Stevens (Co-applicant)
• Hugh Evans (Co-applicant) 
• Liam Gilfellon (Co-applicant)

 

Who did we work with:

• NIHR Applied Research Collaboration North East and North Cumbria
• NIHR Applied Research Collaboration West
• NHS Greater Glasgow and Clyde
• NHS Lothian
• NHS Greater Manchester Integrated Care
• University of Glasgow
• University of Edinburgh
• Voluntary Health Scotland
• Bristol City Council
• Mental Health Concern

 

 

Downloable resources:

 

Funding information: 

This study/project was funded by the National Institute for Health and Care Research (NIHR) Health Service and Delivery Research Programme (HS&DR), NIHR134066. 

 

The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. 

 

 

Contact:

 

 

Senior Programme Lead
Mike Spence
michael.spence@manchester.ac.uk