Two sides of the same coin? An ethnographic exploration of primary care staff and link worker perspectives on social prescribing

Problem

Link worker social prescribing is increasingly accessed and delivered through UK NHS primary care, with plans to refer 900,000 patients to link workers by 2023. The evidence base for social prescribing has recently grown but clarity is still needed regarding what benefits can be delivered and to whom. Ongoing learning is also needed to ensure that the right approaches are adopted and embedded. This work draws on two ethnographic studies exploring delivery of a social prescribing intervention in North-East England. Link worker social prescribing was delivered to 17 GP surgeries from April 2015 by one of two provider organisations, themselves contracted by a company established to manage the intervention, which was part-funded by a social impact bond. The respective aims were to explore how the intervention was becoming embedded in primary care and to understand the lived experience of link workers.

Approach

The first ethnography took place between November 2018 and June 2019 at two primary care sites accessing the intervention. It involved extensive observation of routine general practice consultations alongside 13 interviews with staff, patients and stakeholders. The second ethnography took place between August 2019 and June 2020 at multiple sites including provider offices, GP surgeries and patients’ homes. It involved extensive observation of link workers’ daily routines and five interviews and three focus groups with link workers and link worker managers. Ethnography is an iterative process that allowed engagement with context and complexity. Data generated included ethnographic field notes and interview and focus group transcripts. All data was managed using NVivo and coded using thematic analysis.

Findings

There was considerable variability in understandings of social prescribing within primary care, including perceptions of scope and potential benefits. Several staff expressed frustration at having narrow referral criteria and the overall picture was of differentiated referral activity and variation in uptake from patients. For practice staff the visibility of link workers was also important. For link workers, however, becoming visible and building relationships with primary care was a challenge, and often shaped their work routines. This was both exacerbated by and contributed to high link worker turnover. The performative pressure on link workers to complete Patient Recorded Outcome Measures (PROMs) also created tensions and could be seen to shape the nature of patient contacts.

Consequences

Ensuring a shared understanding of social prescribing and the rationale for referral criteria could be important for securing primary care engagement and patient uptake. Building strong relationships with link workers is likely to be important in ensuring referrals are made and link worker continuity is maintained. Recognising that routes to capturing outcomes and demonstrating the impact of social prescribing interventions could in fact shape those interventions is also important as attempts to embed social prescribing in primary care accelerate.