Ends and new beginnings: Research on the social prescribing link worker role

Social prescribing

Social prescribing has taken place in parts of England for decades. However, its national roll out within the NHS was prompted by a focus on social prescribing within the organisation’s Long Term Plan. This roll out has seen the introduction of over 3,000 link workers, who are key to social prescribing in primary care. These employees help patients to consider their health and well-being goals, and to access relevant support – often in the voluntary-community sector. At the start of this year, we completed a study that explored the implementation of link workers in primary care in England. It set out to address the question: When implementing social prescribing link workers in primary care to sustain outcomes – what works, for whom, why and in what circumstances?

The link worker implementation study

This 30-months realist evaluation had two work packages. It involved collecting data around seven link workers based in different parts of England. The first work package consisted of focused ethnographies, for which researchers travelled to spend three weeks with each link worker. During this time, researchers carried out fieldwork, observing link workers interacting with others - patients, healthcare staff, voluntary-community sector representatives. They also conducted interviews with 93 professionals and with 61 patients. Work package two involved re-interviewing patients and link workers 9-12 months after their first interview.

Using focused ethnographies enabled researchers to compare different data they collected on the link worker role – from documents (e.g. job descriptions, information on social prescribing given to patients) and accounts provided in interviews alongside what they saw happening in practice (e.g. when link workers met with a patient or interacted with healthcare staff). This yielded rich contextual details on the multiple elements of the role, in particular around how link workers approached initial engagement and subsequent planning about how to support a patient. It took time to organise this fieldwork. Researchers leading the study (Stephanie Tierney and Kamal Mahtani) held several ‘set-up’ meetings with primary care staff and link workers beforehand to answer questions and make clear what data collection would entail. As noted above, researchers then spent three weeks with each link worker. This ability to be with link workers, where they carried out their daily activities, was invaluable in understanding the role. 

What we found in the link worker implementation study

Some key concepts we developed from data we collected included: 

• Holding – this described the phenomenon we observed and heard described whereby link workers did not necessarily connect patients to external support in the community; rather, they offered ongoing assistance, containing the difficulties experienced by the patient and, in essence, became the intervention.
• Micro-discretions – this referred to the freedom link workers experienced in their role to decide what to do in a situation; areas of the role where they had the ability to act according to their own judgment. This autonomy was often exhibited in the interactions they had with patients and with primary care colleagues. In the seven link worker cases involved in our study, we saw variation in how much discretion they had over micro-level activities including time spent with patients; how often patients were seen; where patients were seen; types of referrals accepted; how referrals were made; training undertaken (shaped, to some degree, by the background of the link worker and previous jobs they had carried out).

These concepts highlighted the importance of conditions associated with the link worker role for job satisfaction and staff retention. This informed a further study we commenced in summer 2023. 

The link worker retention study

The link worker implementation study described above raised the issue of retention and turnover of these employees. This is supported by a survey completed by members of the National Association of Link Workers; it found that a third of respondents were considering leaving their post. We are in the process of conducting a 16-months project on this topic of retention of link workers. We have sent out a questionnaire, which was completed by 342 link workers. We are now in the process of interviewing some of the link workers (approximately 20) who completed the questionnaire. This is to explore in more depth some of the results from the questionnaire – e.g. around supervision, confidence in the role and other factors affecting link workers’ decision-making about whether to stay in or leave their job. As part of this research, we are inviting link workers we interview to take three photographs (which they will discuss with a researcher):

• One of something that illustrates/shows a typical part of their working day.
• One of something that illustrates/shows something that makes them feel confident or gives them confidence in their role as a link worker.
• One of something that illustrates/shows an unexpected part of their role or something not in their job description that they do on a regular basis.

We have had some really interesting examples of photographs taken to date. We will continue interviewing link workers over the coming months and anticipate that findings from this research will be available towards the end of the year.

Acknowledgements

We would like to thank the patients, link workers and other healthcare staff and voluntary sector organisations who have made the research described above possible. We would also like to thank our Patient-Public Involvement (PPI) group who supported us with this research.

The link worker implementation study mentioned in this blog was funded by a grant from the National Institute for Health and Care Research (NIHR130247). The link worker retention study mentioned in this blog is funded by a grant from the School for Primary Care Research (SPCR Award 678). The views expressed are those of the author and not necessarily those of the NIHR, the SPCR, the Department of Health and Social Care, or the author’s host institution.