21/06 National evaluation of the rollout of social prescribing link workers in primary care
The Health Services and Delivery Research (HS&DR) Programme is interested in receiving applications for research to help understand the impact of social prescribing link workers in primary care in the UK. This research will primarily be used to generate learning to support NHS England and NHS Improvement (NHSEI) following the five-year rollout of changes to the England GP contract around the implementation of link workers within primary care networks (PCNs). The programme is also interested in receiving applications that draw in learnings from similar link worker initiatives across the UK. Research is required that provides a national or at least multi-regional evaluation, local level studies would be out of scope for this funding call.
Social prescribing involves referral to local services and activities, often provided by voluntary community and social enterprise (VCSE) organisations to help address a person’s non-medical needs that are related to wider determinants of health (e.g. housing issues, financial issues, loneliness). Broadly there are four categories of social prescribing activities people may be referred to; advice and guidance, natural world, arts and creativity and sport and exercise.
The link worker model of social prescribing involves referral from a GP or other frontline healthcare professionals to link workers, whose role is to support people with social, emotional and practical needs find solutions to improve their health or wellbeing (1). Staff delivering social prescribing services are often referred to as link workers but there are many different titles used to describe this and similar roles such as social prescribers, enhanced care navigators, community link workers and health and wellbeing coaches (2). The focus of this research should be on link workers covering the full breadth of work they undertake.
Across the UK, link worker social prescribing models are being implemented and piloted in frontline health care services. Link workers are a key part of reforms to primary care services under the NHS Long Term Plan (3) in which a commitment was made to rollout social prescribing link workers in primary care, with over 1,000 trained link workers in place by the end of 2020/21 rising further by 2023/24 to reach 2.5million people. NHSEI has agreed to fund social prescribing link workers in Primary Care Networks (PCNs) as part of the England GP contract agreement to bring additional capacity to the primary care multidisciplinary team (4). In Scotland embedding community link workers into GP practices is a key priority as part of the 2018 General Medical Council contract (5). The Scottish Government community link worker programme hopes to introduce at least 250 community link workers by 2021 to strengthen connections between community resources and primary care, reduce health inequalities and alleviate pressure on GP practice teams. There is some monitoring and evaluation of the community link worker programme in place in Scotland (6,7). Elsewhere, in Wales social prescribing link worker pilots are being implemented including two pilots funded by the Welsh Government to deliver social prescribing pilots for mental health (8,9) and there are examples of social prescribing services being implemented in Northern Ireland (10, 11).
To date, research in this area has predominantly explored the impact of individual social prescribing interventions and services at a local level. A broader (national/multi-regional) understanding of the impact of social prescribing link worker initiatives across England and the rest of the UK is needed to inform future policy decisions about link worker models of social prescribing within primary care and where changes and further investment may be required to support their delivery in the future, or if alternative models of delivery are needed.
Areas of interest
The Programme wishes to fund high-quality, efficient, substantive studies to assess the impact of social prescribing link workers across the UK. This may take the form of several projects focused on complementary areas of research need (see list below) or a single national evaluation with multiple workstreams, similar to the large-scale NIHR assessment of the National Diabetes Prevention programme currently underway.
The following issues are of particular interest, though other research questions may be proposed with justification.
- Key features and variations in models of delivering link worker social prescribing services; what works best in what context?
- Demographic and need profiles and use of health services of people referred to link workers.
- The role of link worker social prescribing models to address health inequalities and cultural differences: who is being missed and how do models need to change to reach those in greatest need?
- Understanding the complexity of support and therapeutic relationships between link workers and service users.
- Characteristics, background and scope of activity of link workers, connectedness with local community, role identity and integration with primary care in relation to workforce theory and evidence.
- Testing and developing indicators of impact at individual and service level over time. This includes indicators relating to social isolation; capacity; wider measures of wellbeing; changes in health and use of existing health and social care services.
- Experiences and acceptability of the link worker model amongst health and social care professions, VCSE organisations and service-users.
- Types of support, activities and duration of interventions that are taken up.
- Use of routine data to support impact evaluation of link worker social prescribing models, for example, the RCGP/Oxford University social prescribing observatory.
- The impact of the COVID-19 pandemic, for example on the needs of people being referred, the link worker model of delivery, the capacity of local services and community groups and adaptations such as migration to remote services.
There is no prescribed study design, methodologies to address the areas of interest may include process evaluations, practitioner and service user surveys and observation/ethnography, longitudinal matched cohort studies and impact studies. Use of appropriate controls should be considered to increase robustness of evaluations. Mixed Methodologies utilising qualitative, quantitative and routine data to capture the complexity of link worker social prescribing activity and the richness of interactions would be appropriate. The Programme favours studies with appropriate theoretical frameworks to structure data collection and analysis and design choices within the project. Research applicants may want to consider the use of tracer care groups or services to allow for comparative evaluations across localities or activities.
Studies should explore assessment of costs and value of schemes, through appropriate economic appraisal, and should look at the sustainability of initiatives. This might include feasibility and early cost-effectiveness work, although the challenges of robust economic evaluation given heterogeneity of activity, data and scope is recognised.
All applicants should ensure they do not duplicate the existing evidence base or overlap with ongoing research in NIHR, and other funders. They should also be mindful of related professional and service initiatives to share learning and good practice, such as the National Academy of Social Prescribing and other schemes across the UK.
Research timings and reporting
To feed into commissioning decision making around the use of the link worker model, research would need to be underway as soon as possible in the 2021/22 financial year. The successful team(s) should expect to have regular contact with key stakeholders at NHSEI and propose appropriate plans for liaising with and sharing regular interim outputs tailored to different audiences as part of their application. A report with recommendations for commissioners is required by the end of 2022/23. However continued evaluation beyond 2022/23 is encouraged to facilitate longer term understanding of the impacts of the link worker model.
Research proposals should be co-produced with national organisations and professional bodies, health and social care service professionals, and service users. Links with health and social care planners and professional bodies is required to ensure impact and scaling up of research findings to benefit the wider health and social care system.
The COVID-19 outbreak is having a significant impact across the Health and Social Care Systems. As this research may be conducted during the COVID-19 response and recovery stage, applicants should consider how the impact of COVID-19 response and recovery may affect their ability to conduct the research.
The NIHR is committed to actively and openly supporting and promoting equality, diversity and inclusion (EDI). All NIHR applications need to demonstrate they have met the requirements of the Equality Act (2010) by embedding EDI throughout the research proposal, ensuring there is no discrimination across the following domains; age; disability; race, including colour, nationality, ethnic or national origin; religion or belief; sex; sexual orientation; gender reassignment; being married or in a civil partnership; being pregnant or on maternity leave. Applicants are expected to pay attention to populations that have been underserved, to carry out research in locations where the need is greatest, and to promote the inclusion of diverse participants.
The HS&DR Programme supports applied research with the aim of improving health and social care services across the nation and is open to any methodology which is appropriate to answer the proposed research question; this must be fully explained and justified. In order to enhance the success of a proposal a clear theory of change and pathway to impact with links into the NHS and social care delivery process is suggested. It is useful to consider in your study design how outcomes could be scaled up to maximise impact and value for money across the NHS and social care; the focus is on applied research with tangible impacts on systems that improve the quality, accessibility and organisation of health and social care services. This also includes stakeholder engagement and the development of processes, tools and guidelines to strengthen workforce capacity. Further general information about the Health Services and Delivery Research Programme can be found on their webpage.
Relevant on-going NIHR studies
NIHR131593. Feasibility Study for an impact study on social prescribing. Start date; 23/09/2020 End date; 30/10/2020. CI; Lena Al-Khudairy. University of Warwick.
NIHR130247. Understanding the implementation of link workers in primary care: A realist evaluation to inform current and future policy. Start date; 01/03/2021 End date; 31/08/2023. CI; Stephanie Tierney, University of Oxford.
- The Social Prescribing Network. What is social prescribing? 2018. Available Online. Accessed January 2021.
- Tierney, S., Wong, G., & Mahtani, K. Current understanding and implementation of ‘care navigation’ across England: a cross-sectional study of NHS clinical commissioning groups. 2019. British Journal of General Practice, 69(687). Available Online. Accessed January 2021.
- NHS England. The NHS Long Term Plan. 2019. Available Online. Accessed January 2021.
- NHS. Social Prescribing Link workers: Reference guide for primary care networks. 2020. Available Online. Accessed January 2021.
- Scottish Government. General Medical Services Contract in Scotland. 2018. Available Online. Accessed January 2021.
- Scottish Government. Scottish Government’s Community Link Worker Programme. Briefing Paper. 2017 Available Online. Accessed January 2021.
- Public Health Scotland. Learning from the community link worker early adopters. 2020. Available Online. Accessed January 2021.
- Welsh Government. Written statement – Social prescribing pilots for mental health. 2018. Available Online. Accessed January 2021.
- Clinical Trials database. A mental health social prescribing trial (British Red Cross) (PROSPECT). University of South Wales. Clinical Trials.gov ID: NCT04099095.
- Department of Health. New health project could transform health services for patients. 2017 Available Online. Accessed January 2021.
- Health and Social Care Board. Social Prescribing. 2018. Available Online. Accessed January 2021.