Social prescribing scoping studyHeather McIntosh, June 2020

SummaryGina Alexander, July 2020

IntroductionThe scoping study [link to document] document provides comprehensive information on:-

Population insights which support the case for social prescribing Definitions of and methods of social prescribing Research supporting social prescribing Description of social prescribing activities in North Lanarkshire Commentary on the challenges and opportunities in implementation Suggested actions included in recommendation section

Recommendations Summary of bullet point in the recommendation section:-

Funding insecurity needs to be remedied – significant risk to success of any sp work (being addressed by strategic investment work)

CS model and governance approach is fit for purpose – use it! Define social prescribing for NL Examine learning from current social prescribing activities from those working well Review online tools and resources – Well Connected, MLE, Locator include Elament (not

included in report) Develop understanding of local needs, gaps and priority areas Ensure needs of children and families are taken in to account Avoid limiting range of activities which can be socially prescribed Ongoing participation and engagement plan required – liaise with PforC Driving and embedding attitudinal change (within statutory services) via the Three

Conversations model Linked to above – initiate multi-agency workforce development – staff awareness, training

and support plan Developing agreed, realistic, robust and stable evidence measures

Describing social prescribing

Social prescribing as a continuum

Types and categories of social prescribing activity (Elemental 2018)

Model of social prescribing (NHS Lanarkshire 2015)

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Prerequisites for effective social prescribing

From Third sector perspectives on barriers and enablers to introducing social prescribing in a primary

care setting (Volunteer Scotland 2015).

Points for effective practice (of social prescribing):

Social prescribing works best where all those involved have a good understanding of what it is,

what it can offer and who it can benefit

Unlocking the full potential of social prescribing will only work if productive partnerships and

alliances are formed and key sector partners are connected

Social prescribing is not a quick fix or a bolt-on and it takes time to introduce an effective and

sustainable model

To really work in partnership may require giving away some power to other players

Good partnership working is crucial if healthcare practitioners are to know what community-

based services are able to provide and deliver

To be effective, social prescribing very much depends on primary care staff having a good

knowledge of what services are available in the community: the asset mapping of local groups

and services into electronic directories can help to establish uniform access.

Good communication and guidance is needed from all sector partners as to what patients can expect from social prescribing and how they can benefit from it: it’s important that patients see the support that they receive as part of their care package and not separate

From The National Lottery Community fund report on social prescribing activity (2019)

All stakeholders including commissioners, referrers and delivery partners need to have a

common understanding of key terms and principles

Social prescribing schemes need to be joined up and key partners need to be on board from the

start

Understanding the local context is important in preventing barriers to an effective and joined up

social prescribing service

Partners should cooperate at strategic and operational levels and recognise, from the planning

stage through to final delivery, what each has to offer the others

Standards and quality assurance for community-based services can improve confidence in social

prescribing

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Making a referral should be as simple as possible

Referrals to community-based services must be appropriate and at a level that is sustainable

Both the link worker role and the delivery of community-based services must be adequately

funded for social prescribing to flourish

Social prescribing works best when organisations are willing to work with each other towards

shared goals and to share learning, and when funding does not create perverse incentives and

competition

Showing how social prescribing contributes to preventing ill health and improving health and

wellbeing is essential to gaining credibility, buy-in and sustainable funding.

From Voluntary Health Scotland 2017 report which informed the national GP community link worker programme:

Actively involve the sector in the design and planning of services, recognising and drawing on its areas of expertise.

Provide a greater range of mainstream service delivery opportunities through contracts and Service Level Agreements.

Further develop its contribution to specialist service delivery, wherever it has a recognised specialism.

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Challenges and opportunities

Opportunities and enablers Challenges and barriersStrong alignment with strategic priorities Funding insecurity Development of a framework for social prescribing

Raising awareness and acceptance of statutory partners

Alignment of social prescribing activities including Link workers across NL

Developing knowledge, skills and understanding of referrers

Diversifying funding streams to support CVS provision

Sustainability and availability of activities to refer to

Developing a common view of social prescribing

Supporting referrals – awareness of, rationalising multiple on line tools

Experienced health improvement practitioners

Engaging the public and community

What matters to you/Three conversations approach

Developing realistic outcome measures

Collaboration on competencies, training and support for link worker roles

Referral and outcome tracking mechanisms/software

Identifying target areas using a stepped model approach (using local knowledge as well as locality profiles)Multiple online tools in existence – MLE, Well Connected, LocatorPublic and community engagement in the developmentNHSL evaluation managerPossibility of joint working NL and SLCommunity and voluntary sector infrastructure and networks

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Current initiatives in NL:Name Key features Hosted by To be consideredWell Connected For those experiencing

low moodBooklet format – NL, SLApp being developed

NHSL with NLC, SLC Cost?Keeping printed booklet up to date?Resource requirements?

Making Life Easier Online resourceLink to LocatorLTC/Older peopleSelf assessment featureLink to national and local supports

HSCNL/NLC Cost?Usage stats/satisfaction?Online collective review

SPRING 2 nation programme to 2023Based in GBT ShottsAdults and carers >18 who would benefit from a social prescriptionLinked GPs refer inUp to 12 interventions per personPartners delivering interventions funded £5k pa Uses tracking platform (Elemental)Influential at government level

Scottish Communities for Health and Wellbeing and NI partners

End date?Ongoing evaluation and feedback?

SAMH – GP link workers

6 workers (1 in each locality)6 week interventionPeople with mental health issuesVariety of referrersSelf referral possible

SAMH Follow up or evaluation of impact?

Community connectors

Funded to 2022 via Inspiring Scotland (SG fund)For people who are not (yet) eligible for self directed support payment56 people supported in first 6 monthsAwareness raising has been difficult

NLDF

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Hospital Discharge – CLOs

All NL residents >16 who have been in an acute settingTailored info, signposting service120 people supported in 19/20 (plus 39 in relation to discharge to assess test of change)

Community Solutions

Carer coordinators Work with GPs to identify adult and young carersInformation, signposting

NLCT

GP community link workers

For NL residents as referred by GPFunding by SG from 2019 to 20219 in NLSpecialist link works also a possibility – in other LA workers hosted in CVSBeing evaluated by Helen Alexander

Primary Care Improvement Team NHSL

No recent update reports to HSCNL due to COVID

Routes to work case workers

For people who face significant barriers to employment (furthest distanced from work)Via Specialist Health Case WorkerReferrals from exernal agencies

Routes to Work Review available

Elament

(Not included in scoping study)

For people with mental health issues- recovery focusOnline resource

NHSL and partners Up to dateUsage

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Perspectives and commentaryThe section on perspectives from statutory providers, community and voluntary sector providers and those of the public and people who use services has been replicated in full below. The section contains direct quotes from interviewees which have informed the study.

4.4 Stakeholder perspectives

4.4.1 Statutory providers

Social prescribing as a concept

Understanding of social prescribing within the statutory sector in North Lanarkshire is generally viewed as being uneven.

“If you’re talking about the senior leadership team and the core team in North Lanarkshire Partnership...I think there’s a reasonable level of knowledge – in very basic terms – around what social prescribing is.” (Interviewee 6)

“…generally, throughout all of the services, I’d say it was fairly mixed” (Interviewee 5)

“I don’t think it is particulary well understood on the local authority side, and within the health side I think its patchy” (Interviewee 1)

Familiarity with the concept of social prescribing is seen as broadly associated with particular areas of work and especially mental health care, which is consistent with the earlier adoption of the biopsychosocial model of mental health more generally. In primary care, it was felt there was reasonable acceptance of the concept among GPs but also accounts of unfamiliarity within wider primary healthcare teams. NHS health improvement practitioners’ greater understanding of social prescribing was often mentioned.

“Social prescribing is pretty well embedded within the mental health side of things, we are well used to the concept of working with all sorts of things…we have always thought of a biopsychosocial model as being our way of thinking about things” (Interviewee 3)

“I think the ideas are well received by GPs, the GPs certainly that I talk to are comfortable with the concept” (Interviewee 3)

I’ve been asking if people thought [non-clinical interventions to reduce the use of medication in general practice] can be achieved…but even the question, people looked at me as if I’m mad; I do think there’s a huge disconnect between the—not the health improvement side of the NHS—but other aspects of health provision and social prescribing” (Interviewee 1)

The agency of individuals however also transcends professional categories; that is, those who adopt a social perspective and the ethos of social prescribing in the way they work through personal conviction whatever their professional role.

“If people doing my role were a health professional…with a particular skill set and a particular way of training they might not see it the same way, and I know my colleagues who are also social workers that do the same job as me, I don’t think they’ve got into this at all" (Interviewee 1)

Language and meaning

Many of the expressed views on the term ‘social prescribing’ chime with those already documented by others as described in section 3.1.1. By seeming to place people in the role of passive recipients of a service, the medicalised language of prescribing could be seen as misrepresenting the

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fundamental principle of social prescribing to increase people’s control over their own health and lives and rebalance the relationship between statutory providers and service users. It was also clear that there is more to this than just arguing over semantics.

“Sometimes we get ourselves caught in the language of things that make it sound as though it’s a ‘servicey’ response when it isn’t, and it shouldn’t be; and we perpetuate the sense that people need something given to them…” (Interviewee 2)

“…is it prescribing? It’s a passive thing, its power relationships, prescribing suggests I tell you to do something, I prescribe it for you; but that’s not the relationship that we want to generate …it’s difficult to get the right term, but we do need to think about it.” (Interviewee 3)

Failing to clarify meaning for everyone involved was identified as a real risk that could hinder efforts to achieve a shared understanding and a rebalancing of the relationship between patients and healthcare providers.

“…prescribing, people probably think of drugs or medication, so if you’ve not got the [prescription] pad and you’re not being prescribed to do it, what’s people’s understanding of that?” (Interviewee 4)

“…if we’re valuing communities, essentially if we’re saying ‘how do we help communities be strong, be supportive of each other, be able to recognise what contribution everybody has to make – by us using professional language, does that help or hinder that?” (Interviewee 2)

On the other hand, advantages to professional language were noted in relation to buy-in from health and care professionals that could influence progress towards its wider adoption; and underlining integration authority responsibility to ensure sustainable funding.

“But you need to have something [a name] that’s going to have buy-in from the professions and at the moment ‘social prescribing’ does have buy-in from the professions; if you told them ‘you’re not allowed to prescribe anymore, you have to assist people to connect’…it might just stop you being able to make the progress you want to make” (Interviewee 3)

“One of the important reasons to use that medicalised language is that it protects the funding round it because it’s got that pseudo-sense of ‘we’re doing this because it helps people’s health and wellbeing, which will help on pressures on other parts of the system, so that’s quite a legitimate reason to use some of that language, to protect the sense that that’s not somebody else’s responsibility, that’s our responsibility to fund and see that as a whole” (Interviewee 2)

Creating shared understanding

Lanarkshire’s Well Connected programme (section 4.3.1) exemplifies the local branding of a social prescribing initiative using language that is more accessible to the community, which has also made the service more familiar among care providers.

“…when we say social prescribing people probably stop and think ‘what is that?’; if you say ‘Well Connected’ people might realise ‘Oh, that’s what they mean about physical activity, the library and looking after your wellbeing” (Interviewee 4)

“…if you then talk about Well Connected people probably understand that a lot more because it’s more understandable in the name Well Connected – you’re Well Connected…I presume that’s why they went with a local name, to try and make it a bit more understandable and accessible for people” (Interviewee 4)

But local branding does not in itself guarantee familiarity across all parts of the health service.

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“Say you were- to speak to our health improvement teams, right away they’ll know what Well Connected is; if you were maybe to ask some of our social work teams, mental health teams, I think they would know quite quickly, but some of our other teams I’m not quite sure, I don’t know if it would be as quick for them” (Interviewee 4)

Informal knowledge transfer in the course of everyday collaborative working was identified as a contributory factor to creating shared understanding of social prescribing: mechanisms included engagement with the Health Improvement colleagues, cross-sectoral relationships and shared learning within speciality and interdisciplinary teams.

“As far as my staff go, within my own service, I think there is a fairly high level of understanding of what it’s about…it’s just their knowledge of what’s happening round about them…there’s a bit about working with the professionals they work beside, health improvement staff etcetera, voluntary organisations they’ll come across, and it grows from there and we have team meetings and they share that” (Interviewee 5)

“…what [our local Health Improvement Advisers have] said to me is social prescribing is not just going to swimming or going to the gym, there are all sort of other things that people could do, green gyms, join all sorts of community groups, gardening groups and all sorts of things…so I’d be somebody who had a relatively narrow perspective on social prescribing in general but I’m sure lots of people are similar to me; I’m convinced now that that’s not the case – the broader we can be the better” (Interviewee 1)

Raising awareness

That a need exists to raise awareness within the statutory sector about what social prescribing is, what it can offer and who it can benefit, was not contested but there are prior considerations around how and when that is done.

“There is [more to be done about raising awareness]; there’s a tension in it about how we do that because if we file it all as social prescribing are we perpetuating that whole problem of professionalising it?” (Interviewee 2)

“…but we can’t promote it if we don’t fund it, or if it’s not funded in a range of ways, because if it doesn’t exist why would you promote it?” (Interviewee 2)

“…yea, I think there is [more to be done about raising awareness] but [social prescribing’s] not available is the problem…I don’t think we are equipped to do it the way we ought to.” (Interviewee 5)

There is also some work to be done around changing attitudes to the value of social prescribing and whose responsibility is it to take account of the wider determinants of health in the care they provide.

“There are the doubters out there…I think they would be marginally on top because you’ve got the traditionalists that believe in traditional models and some people just aren’t at that place where they can accept there’s another alternative…but I think it’s marginal and we’re getting there…” (Interviewee 5)

“…how do we get our wider teams to think about what’s out there for people…because people say that’s not my role, not my job” (Interviewee 4)

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The challenge this presents in the face of rising demands and competing priorities combined with fiscal constraints is clear and should not be overlooked in the judgement of ostensible negative attitudes to social prescribing.

“…that bit about the constant pull to the immediacy of the crisis…the ability to then say ‘no, we want to take a step back and do something that would stop so many people going to the hospital in the first place’ is really hard” (Interviewee 3)

“[There are] all sorts of pressures at this time of year on A&E and that just takes a grip of everybody and when you have that dynamic everybody’s perspective changes so you cease to think about ‘why are all these people at the hospital in the first place… maybe if people took a bit more care of their own health they might not have that particular issue that’s bringing them to the door of A&E’ so the two things are going on in people’s minds at the same time: I don’t think there’s a scepticism of the value of the social prescribing approach…it’s more that they would always privilege the traditional medical model, I’m convinced of that” (Interviewee 1)

“It’s about winning people’s minds over and saying ‘Right, ok, I see the validity in that’: that’s where the doubters are…particularly when you’re working at the clinical coal face you’re running hard to stand still and trying to get the work done.” (Interviewee 5)

There was some concern raised about the risk of wider opposition, which underlines the importance of a shared understanding of social prescribing among all stakeholders.

“What worries me slightly is…I think we run into some opposition from the partnership, so from the Union side of things I have heard that sense of ‘if we start putting resource across into the independent and third sector then that’s a form of privatisation; we’re taking work away from the statutory side and putting it into these slightly loose arrangements where people maybe won’t have the same terms and conditions’…so it’s akin to privatisation would be the opposition to it.” (Interviewee 3)

Strategic thinking

North Lanarkshire’s partnership strategic plans and the processes through which they have been developed reflect deliberative thinking about embedding core principle associated with social prescribing, although seldom referred to using that term; and this is viewed positively.

“We’ve got really strong discussions happening about it on the GP side [going through the process of primary care improvement implementation and planning]…and as we get into those discussions its very natural to get into ‘and are there things that could be done in the non-statutory side to support and help people at an earlier stage before they need the requirement for statutory…’, in those strategic discussions it’s definitely there.” (Interviewee 3)

“One of the things I’m quite encouraged by is that we’ve tried to simplify [the Strategic Commissioning Plan] and make the message more straight forward and make it clearer what it is we’re intending to do…prevention and early intervention is right up there in terms of what people see as important, and how do we focus on doing that” (Interviewee 2)

“The structure around [the Plan for North Lanarkshire] is trying to embed the sense that this is everybody’s responsibility and we need to be more joined-up and we need to be thinking about the whole population and our collective diminishing resources…how do we increasingly make use of the resource that we’ve got across the piece rather just in their split up silos: now, the rhetoric of that is really good but actually doing it is much harder than it seems, not because people are not willing but because that’s not the way we’ve traditionally done things, and that feels like it’s a really positive evolution and will continue.” (Interviewee 2)

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Investment dilemmas and decisions

When it comes to service delivery, decisions about funding social prescribing are nevertheless strongly influenced by current resource constraints. Relative to pressing demands on clinical care provision, social interventions are more likely to be low on the list of priorities, which may to some extent reflect how they are perceived.

“The timing of doing the Strategic Commissioning Plan would say yes [social prescribing] does [feature in strategic or planning level discussions around service delivery] because we’ve really recognised that significantly within the drafting to date; and the most recent Mental Health and Wellbeing Strategy, social prescribing, the approach to recovery, is embedded in that, so yes people do talk about it and do recognise the importance of it. The crunch comes when you’re talking about limited resources, that’s where there becomes a more difficult debate” (Interviewee 2)

“…the problem and issue is everything’s a priority; if you’ve got high waiting lists and government pressures…our hospitals just now are in a very tense situation so the priorities will always go to the acute and the unwell and its always been finding that balance…” (Interviewee 4)

“When it comes to hard financial discussions its hugely difficult…that is a problem for us, there is a sense that some of this is a bit woolly and a bit soft and therefore it can be a bit of a soft target when it’s compared to some of the hard stuff that needs to be done”. (Interviewee 3)

One interviewee contested the lack of financial resources argument, with emphasis on the words ‘decide’ and ‘priorities’:

“…the other myth of course is that there’s no money: a lot of our resources [allocation] you can’t pull out of…but there is always a margin and that margin is larger than many people think…that’s a lot of money around which we have to make decisions…people talk about a lack of resources [but] we decide what we spend money on and we spend money on priorities” (Interviewee 6)

Funding insecurity for the community and voluntary sector is recognisably a risk that threatens to diminish the local provider base and undermine the notable advances North Lanarkshire has already made through productive partnership working with the sector in the development and delivery of the Community Solutions Programme.

“If you look at North Lanarkshire compared with other areas we have invested significantly [in our third sector through Community Solutions] however we’ve never been able to give that guarantee of ‘this is us, we’ve got two-year, three-year funding to take the work forward’ there’s always that…its unsettled, its unsure” (Interviewee 4)

“We’ve lost so many staff from our third sector organisations because we can’t give them the guarantee of one, two or three-year funding…extremely frustrating” (Interviewee 4)

It is also recognised that sustainable funding for community and voluntary sector providers is the bedrock of a sustainable model for social prescribing.

“The other huge thing is that so many of the [community-based supports] that are on offer are on offer based on short term funding and with limited capacity or availability; and, it’s back to the money thing, about how do we shift this onto a more sustainable basis.” (Interviewee 3)

Wider healthcare system challenges

System-wide barriers and decisions enacted in the wider healthcare policy arena add further complexity to the local decision-making environment, which can get in the

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way of developing and embedding a locally appropriate, joined-up and effective social prescribing service.

“One of the interesting things about the way that we operate in a whole system is sometimes the Scottish Government decide to give money that actually makes that quite hard as well, the fact that some of the GP or primary care changes is coming with a very ’here’s this money and that’s how you’ve to use it’…you think, if we’d had a chance to do it a different way we might not have just gone completely down that route; so some of those tensions are very real and complex; because on the same hand the Scottish Government will be promoting third sector involvement and community empowerment so I just suppose it’s a demonstration of how complex the whole thing is. (Interviewee 2)

“You think about that [Scottish Government rolling out the national GP Link Workers Programme], where’s the capacity? So these workers are there and that’s great but the foundation below that…so if I’m one of those link workers and I’m referring to you as a third sector organisation, as a local group, you don’t have the capacity for all of this because you’ve not had that funding” (Interviewee 4)

Or is it complicated throughout the whole system that’s what I mean, like from Scottish Government right to communities, and Council’s layer in there and health boards layer in there and it makes it just hard to see how to do it; it’s not really solution focussed is it!” (Interviewee 2)

System-wide barriers are seen to impinge on local financial decisions and control over financial resources in ways that have to be negotiated.

“Our systems are not easily designed around longer-term solutions…like not moving to longer term financial planning is a tension, not because people aren’t willing to do it, it’s because structurally there’s a sense that you do year on year planning because it’s based on Scottish Government settlement and stuff like that…there is a difficulty there” (Interviewee 2)

“The problem with this is the big-ticket items for health and social care partnerships are always around service delivery and particularly those areas that are national priorities and targets…” (Interviewee 6)

“That’s actually a huge problem across our whole public sector because the Christie Commission etcetera set out the benefits we would have by taking a preventative approach yet our entire system is calibrated towards dealing with fixing the bits that are broken rather than taking a preventative approach. I can’t see how you would do that without separating the money somewhere, you need to have a set of money that’s for fixing the broken bits and a different set of money that’s for taking a proactive and preventative approach. Social prescribing kind of fits in between those though, it’s neither one nor the other…on the fringes of fixing things but it’s not quite prevention although some of it will be: it’s an interesting debate…” (Interviewee 3)

Relationships, reliance and trust in the community and voluntary sector

Achievements in building working relationships with the community and voluntary sector in North Lanarkshire are viewed positively and there is trust expressed in the sector as a dependable delivery partner as well as an unequivocal recognition of dependence on it.

“We’ve just done a load of engagement session round our strategic plan and at every single session and locality it was spoken about the work of the third sector and the relationship between our third sector and statutory organisations and over the years this is coming so much closer than what it was before” (Interviewee 4)

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“In terms of our long standing relationship with VANL, third sector, I think our recognition of the role that they have and the structure around their engagement with communities is one of the things that has worked well in North Lanarkshire; and things like local people coming together with support through VANL to make decisions…local people identifying [what the issues are] and doing something about it” (Interviewee 2)

“Yes [there is trust the community and voluntary sector as reliable providers]. I think it’s more of necessity; the independent sector [sic] now provide services that either didn’t exist or that people needed or [that] used to be provided by statutory services. Aye, there’s a very strong relationship of trust. And VANL…they’re key partners in everything we do.” (Interviewee 1)

“I think [statutory providers] do [trust the community and voluntary sector to be reliable providers]…and there’s a number of things that voluntary organisations can do that we can’t so there is a dependency and we definitely need them as partners, and trusting that will continue because…we couldn’t survive to support people out there if we didn’t continue to fund them: aye, there will always be a place for voluntary organisations, always. (Interviewee 5)

Evidence for investment and evidence of success

The difficulties inherent in establishing the evidence for the benefits of social prescribing hinders evidence-based decision-making about investing in it; and expectations differ on the level and type of evidence that would be sufficiently convincing.

“One of the other aspects particularly of social prescribing and taking a more preventative and proactive approach is how can you say for certain that what you’ve done there has this effect over here, you can’t say for absolute certain…or how do you know what you’ve done here has offset a range of things that haven’t happened, that’s even harder to show that; so inherently I think the things [for which] you can say ‘that money has bought that many clinical appointments or residential home placements or individualised support that has resulted in this number of people being supported’ that’s easier to understand; but this bit of work which might have touched 50,000 people, which might have helped the general wellbeing in this community, is harder to quantify” (Interviewee 2)

“…particularly GPs, I think it’s important that they can see there being evidence it can promote health change and health benefits; I think GPs tend, for good reason, to be much more empirically driven and look for hard evidence for things” (Interviewee 1)

This is also evident in relation to evidence of economic value:

“I do wonder if what you really need…is would you need an NHS economist to say this is a cost effective way to deliver a health service; it would give it a credibility as well” (Interviewee 1)

“…because of the pressing issues we have round resources, delivery plans, the enormity of the problem…if your core services are potentially going to be cut and you [want to] invest in something that’s going to show some profit or return in ‘x’ number of years, people will have doubts and that’s essentially where we are” (Interviewee 5)

I think what we do is we actually force people to take a very good idea but the only way it gets heard is if you tell people it’s going to save money: ‘I can’t go to SLT who are looking at financial savings and a whole pile of other things and say please start doing this because it’s better’, which is the right thing to do, what they have to say is ‘if I get a little bit of money this year you will save so much more down the line’ (Interviewee 6)

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The stakeholders questioned also expressed a range of views on what persuasive evidence of success would look like. Benefits for people were notably seen as being paramount:

“The most important thing is that the person themselves has got a feel-good factor” (Interviewee 5)

“There’s some people like me who would think, if you’re going to a GP for antidepressants the fact that at the end of the day your social circle has improved and you’re less lonely or whatever is a good thing…ideally they would be able to reduce your medication…but even if that’s not the case at least someone’s outcomes have improved” (Interviewee 1)

“…if my patient’s telling me ‘I went along to that community group and I feel so much better, I’ve made friends, it’s nice to know I’m not alone’ and they go off and they’re empowered…for me, that would be the biggest influence; [narrative] feedback you get from patients or from staff about a patient’s state of wellbeing and reduction in need for medical intervention…on a [GP] practice level, is probably one of the most powerful things” (Interviewee 6)

Benefits for healthcare providers included a change in attitudes towards social prescribing as well as anticipated benefits commonly mentioned in the literature such as having more options and reducing workload.

“The big thing for me is that we all have that knowledge and we all believe it’s got a place…you need to believe that it does make a difference, that it’s important” (Interviewee 4)

“…and softer things like a GP having at their fingertips the ability to access a variety of resources easily, so it’s easier to refer someone into a social prescribing route than to write a prescription or refer to another professional” (Interviewee 3)

“If we manage patients differently than what we’re doing just now, and the outcomes are evident then the clinician or social care worker would see the benefit of it, and if it is assisting them with managing their case load, managing that person, then I think that would be the convincing factor for them” (Interviewee 5)

In relation to benefits for the healthcare system, there were divergent views on the absolute need for quantitative evidence of reduced demand at the system-level.

“In a really simplistic sense, from a system point of view, social prescribing would be effective if there was less pressure on referral for more specialist services…so if you think about CAMHS and supporting young people with mental health difficulties, if a wider range of options is available for people at an earlier stage in terms of young people and their families feeling connected and valued in their community and valued as people then the logic would be that the number of people that experience psychological difficulty should reduce but the people that have got a need for specialist mental services for children [those] services will always be there, and if you get the people that really need it at the time then that would be a really good outcome. That’s ultimately the measure we would be looking for in the system we work in to make sure that response across the board demonstrates how it joins up and impacts positively” (Interviewee 2)

“When I look at the number of people who are referred for psychological therapy or CAMHS over the last 10 years I see a steady increase – success would be that that starts to flatten or drop; because there are such good alternatives out there…; I’m sure there will be other things you could look at…fewer people needing rehab for long term conditions, so a drop in the physiotherapy waiting list…” (Interviewee 3)

“At strategic level…you want something that works…the narrative stuff, for me, is probably the first thing, if you’re going to wait for a change in antidepressant prescribing you’re going to wait long

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and weary, if you’re going to wait for a change in hospital admissions you’re going to wait even longer…if we’re looking for that kind of evidence there are so many confounding factors [so] narratives, individual cases, individual success stories, very simple things…here’s a number of patient who were referred by their GP and four weeks later they’re still going to a particular class, a particular group…[evidence that] people are buying-in. How [should we] measure that? We don’t measure the number of consultations they have with their GPs, we don’t measure how many of them get admitted to hospital, we measure how many turn up and who turns up often; so in terms of evidence I think it’s very much keep it simple” (Interviewee 6)

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What else we can or need to do to support social prescribing in North Lanarkshire

The stakeholders interviewed have confidence in HSCNL’s strategic direction but are alert to the importance of making sure there is close alignment between delivery plans for its statutory services and the Community Solutions Programme.

“Having this central to our Strategic Commissioning Plan is helpful, it’s a good symbol that it’s there” (Interviewee 3)

“It’s not just about the funding, it’s about breathing space and I don’t think any of us ever gets breathing space to look and see are [our strategies] aligned, do they sit ‘like that’ as you want them to sit as our delivery vehicle…there’s that time [the Community Solutions Programme Manager] and others need to stop and breathe and say ‘what’s happening over the next three years, are our programmes fit to deliver what they need to deliver over the next three years’. We just need to make sure we are going together.” (Interviewee 4)

The success and durability of Community Solutions is a credit to the leadership and determination within the NHS, Council and Third Sector Interface in North Lanarkshire right from its origins in the Change Fund, and it’s governance arrangements are highly regarded, but ways have to be found to maintain that infrastructure and its financial sustainability in an uncertain health economy.

“…the strength is there but to maintain strength you need funding, we need to know they’ve got bills to pay, they don’t get their lets, venues, everything free…” (Interviewee 4)

“…moving to three-year funding commitments, and doing a three-year Commissioning Plan steps us towards that” (Interviewee 2)

The implications of lack of oversight to ensure coherence and avoid duplication across all social prescribing initiatives in North Lanarkshire that are funded and governed outwith Community Solutions, including the various link worker roles, and how that might be done, also warrants consideration.

“…and actually by funding them in that way…that part does that and this part does this, do you divide and weaken…or do you take all those bits and create a big monster of a thing that just becomes a bureaucracy in a different way…I don’t know the answer to that, it’s really a big tension” (Interviewee 2)

“In terms of the prevention and anticipatory care, the IPAC stuff, there is people who do look at that, but again the tension is do you have a group looking at employment, a group looking at poverty, a group looking at social prescribing, and actually what’s different and what’s the same about all of them? I think we’ve got to be careful not to assume that it’ll just happen but not to create structures that just stick things in boxes as well” (Interviewee 2)

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Creating a new relationship between health professionals and service users has been identified as an area for development, to make sure the ‘first point of contact’ has the right conversations and connects people to the most appropriate source of support, which is essential for social prescribing to work.

“One of the things we’re talking about now is that if somebody comes into contact with a member of our team is first point of contact, what is our response; our staff keep saying we do it but we have so many cases where people are saying I didn’t get the right response, help, I needed, so we need to create a different culture and if we use the principles of the 3 conversations, if we all adopt that approach hopefully [that will bring about] culture change; if I pick up that call it’s up to me not other people, that’s what we now need to look at, us being in a Health and Social Care Partnership, lets really look at what’s within our gift to do, that is within our gift to do.” (Interviewee 4)

Having the new GP Link Workers in post will be an important enabler for social prescribing in the primary care setting.

“I do think that through the Primary Care Improvement Plan our development of the link worker model will be a helpful thing in increasing the visibility and the access to social prescribing across primary care, so that’s one thing we can absolutely do” (Interviewee 3)

There is also potential to harness the influencing power of professional leadership and opinion leaders to change perceptions and encourage involvement of a broader range of practitioners in social prescribing.

“I think what’s missing is…these conversations I’ve had with pharmacists, I think the local pharmacists are able to hook into this but that’s not part of their… trying to get that slightly broader perspective; to get that lever there probably requires getting the buy-in from the chief pharmacists and that type of person…if it’s the pharmacist who’s asking these questions it would be a good thing—doing it from the inside” (Interviewee 1)

Not knowing what supports are available is a commonly cited barrier to social prescribing and making it easy to find out is a commonly cited enabler. North Lanarkshire is ahead of many areas in having developed several useful resources but there is a need to consider how to optimise their utility.

“Well Connected, that idea of bringing things [together] is a good idea, and whether some of the stuff we can do about improving Locator, or getting more stuff onto MLE, these different tools we have; somehow we need to make it easy for people to do what we think is the right thing, at the moment I’m not sure it’s as easy as it could be…I’m not sure that we have good ways of making sure that we are always aware of all the things that are available” (Interviewee 1)

“One of the problems from a SP point of view, one of the frustrations, is you’ll go out and speak to people who’ll say ‘nothing happens in Cumbernauld’. Nothing at all…are you sure? Then people have a debate about this happens, this happens, there’s this group and this group… richness of things out there and folk will say ‘I didn’t know about that’, so how do we equip people with that information…how do we start to get much more personalised responses in terms of how we quickly understand what the issue is for you or what your position is and join you to the right bits of information; so that’s a really exciting opportunity for us in terms of technology [that] changes it as much for practitioners and staff as it does for the public.” (Interviewee 2)

“I’m not sure that we have created the environment that encourages people with ideas to be able to put those into practice so, if I had the idea it would be good to do a park run or a walking group in my local park where do I go to get support to make that happen and get it onto the list of things that

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would be available for my GP to say to other people in the locality ‘here’s a good idea why don’t you do this’; so I think there’s a gap there” (Interviewee 1)

Feedback to referrers on the progress and outcome of the referrals they make is an important gap in the capability of current tracking mechanisms.

“…I think having the feedback loop is important because that fosters trust over time; part of the problem might be say if someone refers a patient to a voluntary organisation or a community group, if the patient doesn’t come back and tell them that was great they’re not really sure so they’re not sure when the next patient comes in ‘should I do that again or should I not?’ ” (Interviewee 6)

And currently, North Lanarkshire does not have IT systems that would enable social prescribing activity and tracking to be managed across statutory services and community-based providers.

“We’re way, way off that; I couldn’t even put a timeline on that, when that would happen” (Interviewee 5)

Final words

“…and there’s the whole issue about Scotland’s health, we haven’t touched on what priorities should be like smoking, breast feeding which is a high priority, and there’s also diabetes…social prescribing…it just takes you into a different world” (Interviewee 1)

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4.4.2 Community and Voluntary Sector providers

Language and meaning

Focus group participants agreed that ‘social prescribing’ is an unfamiliar term in the community and voluntary sector. They were also agreed on it being ‘health service’ language with advantages for the statutory sector including buy-in from health professionals but find it is not always familiar to health care professionals they work with either.

“I asked two of my staff today if they knew what social prescribing is and they didn’t, ‘Is that a new terminology?’…it’s one of those things where there’s this assumption that everybody knows what it means but I had to kind of look it up myself not that long ago to see what it meant…so [I] would say knowledge is fairly low”

“It’s coming from the medical side, they’re trying to get the GPs to buy into it to make sure that they are not overwhelmed, so if they put ‘social prescribing’ on it doctors will probably buy-in to it more”

“You think when you talk about a prescription, something the doctor prescribes for you, they give you something…we advise something for you to help you feel better, so whether that’s a medicine or an activity…they’re still putting you on that path to make you feel better”

“I think it’s important it does have a name for more clinical sides to say that healthcare is changing, it’s getting more holistic, but I was speaking to a nurse today and they didn’t know what it was, when I explained they said that sounds really good…they followed it”

It is clear however that the concept of social prescribing is nothing new to the community and voluntary sector: they recognise it as describing the principles that underpin the sector’s

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everyday way of working although they don’t call it social prescribing, and that terminology is not necessarily well-liked.

“It doesn’t mean that it’s not happening, it’s just we don’t use that terminology; I think it’s a horrible term…”

“I think for the majority of us we’re already doing it… we’re just not putting that tag to it.”

“I think we have been doing this for a long, long time but now the GPs are seeing that it’s a really good way of working”

‘We’re already doing it’

Further discussion elucidated what community and voluntary sector organisations mean when they say they are already doing social prescribing. Although the word ‘signposting’ was often used as a ‘catch-all’ term it does not adequately describe the spectrum of activity that it is being used to describe and could, therefore, be easily misunderstood to mean much less than what is actually happening in the sector.

“…and you’ve just said the word again there, ‘signpost’, I’m sure everybody in this room’s the same, it’s not just going ‘there’s a group you want to go to’…”

“Much more than that…”

As well as signposting in the sense of giving information or directing people to relevant resources where appropriate, and delivering the community-based services and activities commonly associated with social prescribing, many voluntary sector providers inherently perform a ‘link worker’ function in the way they work with people, taking a holistic approach, having “the conversation”, identifying wider needs, directly connecting people with other services and activities, and supporting those who need it to access and engage with those services and activities. Many organisations offer support at more than one level depending on the needs of the people they serve.

“…we find that all the time, we get people phoning us up, ‘I’m a carer’, wanting information and you listen to them and you go ‘I think there’s something more here’ and you say ‘why don’t you come and meet with us’ and they’ll come in…basically they’re looking for a solution to something then they start to open up and there’s all these other things…layers and layers”

“…not just the person the whole home environment you’ll take into consideration, if there’s other siblings in the house, if there’s addictions, then there’s that bit about ‘what else can I link people in to?’”

“It’s potentially physically taking them there, arranging transport, checking in with them ‘how did it go; are you going to go next week?’ It’s not just saying there’s a group you can go to…if somebody’s really quite isolated of suffering from anxiety or poor mental health issues to actually ask them to walk into a new group – it’ a big task…even getting on a bus…”

Community and voluntary sector organisations generally do not see this holistic approach happening in statutory services.

“[with GPs] there’s prescription or referral to mental health services…there’s not that kind of bigger picture of thinking: we’re getting the full picture, how are you meeting the needs of your kids, how are you managing with the house, food, budget and things and then from that you’re [connecting them] to CAB and HOPE [for Autism] and everywhere…”

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“On an initial visit the other day just to gather information from a mum, I know straight away that she’d got no food, I’m contacting the welfare fund, waiting half an hour on the phone, and had to go back and get social work on the phone who weren’t interested because we’d provided that service but didn’t see the bigger picture…of mum’s anxiety and depression…’youse have provided food for her so that’s fine’ ”

What is more, community and voluntary sector organisations are often doing this while ‘filling the gap’ as people wait for access to statutory services.

“I think even looking at time for appointments because one of our families, suicidal and things, [waiting for] a GP appointment weeks down the line, so you’re in action – who can I refer you to, Cruse Bereavement Care…what can I get you?”

“Your biggest problem is now social work picking up, I’ve been waiting since October for a family I referred in with massive issues and they’ve still not allocated a worker and from there I’ve referred mum to x, y and z just to fill in the gaps because social work just aren’t picking up…”

“We’re doing all the social prescribing whilst you’re waiting for that”

It is not having more time available or spare capacity that explains this way of working it’s a mindset, and many community and voluntary sector providers add more intensive support provision to their role informally.

“…and it’s not because we’re not rushed off our arses…it’s because we see the need and we see the desperation and we’re prepared to speak to people quickly”

“You’re going above and beyond what you’re commissioned to do because you will not see that person [left] high and dry”

“…and it’s not my remit to do this, but I went because I knew it was important to go to a walking group with her, I went twice, got her to meet and chatting to people and, it’s two years now, she’s still going to that walking group; so, see, it’s just a small investment for people, if they just have that confidence to attend, or phoning up to make sure…because it is a big step if you’re not used to it”

“We’d be in a sorry state if we stuck to what our remit was”

Being well-placed to do it

Community-based organisations feel well-placed to do social prescribing, and that they are seen as being more accessible to local people, more likely to be responsive, and less likely to be judgemental; and to reach people who won’t necessarily seek help from statutory services, even their GP.

“Social Prescribing is happening at the moment, we’re doing it and we’re really well placed to do it and it shouldn’t be less valued because we’re doing it as opposed to clinical services doing it because we’ve got a better understanding, better relationships with people that need these interventions.”

“…and the thing is the third sector is much more accessible to them so if you try to get hold of a doctor or someone in the third sector you’re more likely to get hold of us and we’re more likely to step up to the plate quickly when you need it…”

“But then people also…they still tell us that in terms of statutory services they can find that really off putting too so what you tend to find is somebody could sit with us for an hour, two hours, and really open up; they’ve phoned you for one thing and before you know it you are looking at everything holistically and you’ve maybe got a dozen different referrals and all of a sudden that person’s on

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your radar where they wouldn’t necessarily go to the GP, especially carers don’t, they’ve no got time for that so they probably won’t end up at the GP in the first instance, there’s more chance of them falling into one of the third sector organisations and carers have said to us ‘I feel that there’s no judgment’ because there’s that perception with social work still, you know, ‘I’m no going to tell you I’m struggling, you might take my kids away’ or ‘you might put my mother in home’ ”

“You tend to find with the social prescribing that it comes naturally to us because conversation flows naturally when they engage with you…”

Partnership working and feeling valued

HSCNL is viewed as being ‘ahead of the game’ when it comes to working in partnership with the community and voluntary sector as exemplified by Community Solutions; but a persistent disconnectedness is experienced in practice that may be understood in terms of having unequal status in the partnership.

“What has to be said is that in North Lanarkshire there is really good partnership working within health and social care and the third sector, that goes without saying in terms of all the Community Solutions work that’s going on”

“I think health and social care see the value of the third sector but there’s still some of the dots still not joining up: it’s bizarre how it doesn’t work when you think about the number of events you go to, the strategic planning groups where you’re sitting with health and social care and you talk about the job that you do and how, for us, it’s about reaching out to the families, providing information, you know, we provide case studies about what that’s done for that family and they look at you as if to say ‘that’s amazing, where have youse been?’ but then you hear nothing. So you get the vibe that certain people really understand it and want to buy-in to it but I don’t know if there’s just that hierarchy…”

There is also a sense that statutory healthcare providers ascribe lesser value to what the community and voluntary sector do compared with clinical services; and can fail to recognise that this is often a strength.

“There are a lot of places that do value the voluntary sector and Lanarkshire as a whole is much better that other Local Authority areas but there is still a divide between clinical and non-clinical”

“I work quite closely with the NHS Health Promotion Team, who are great, but I’ve had to do quite a bit of work with clinical staff from the Sexual Health Team and there’s very much of a difference there, it’s taken me a long time for them to value what we do, what we bring in, and these are people I have worked with for over 15 years and I’m still sometimes blown away by their flippant remarks about our service”

“That was…we weren’t really valued…because we weren’t clinical”

“But it’s the fact that you weren’t clinical that made that [project] work.”

There is clearly a willingness to work in partnership but as equal partners within HSCNL, with appreciation of what each partner organisation has to offer the others in order to maximise the contribution that each can make to achieving shared goals.

“In the voluntary sector we see networking as a big part of our job, we don’t work in isolation we work together and that’s how we can make the strides that we make, is by tapping into other people’s expertise…but the statutory services work very differently, it’s very much like ‘we don’t need you’ although in North Lanarkshire it’s much, much better than it is in other places in Glasgow, here

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you’ve got a good chance of getting somebody from health round the table to sit and speak to you or join in a conversation…so there is a willingness to work [together] and I really feel like the voluntary sector is valued in North Lanarkshire by NHS Lanarkshire especially different departments but whether that feeds down to GP services I’m unsure”

“To be fair GP practices are changing, they are piloting a lot of different posts, so the referral to CAMHS, referral to mental health services, they know that it’s really long, it’s terrible how long it is, but they’re having now a psychiatric nurse in the practice so they will assess the situation so the family or the person can get support sooner, or if they think it’s appropriate they’ll refer on or refer onto community services; we need to acknowledge that there is a lot of good work being done and I think it’s just trying to collaborate and trying to work together as equal partners”

“Because when it does work, you’ve got examples coming out your ears, when it works it’s amazing…and it is all about these preventative measures and getting people out the house and reducing isolation…we’ve all got the same goals but we just need to get better at statutory talking to us”

Supporting more social prescribing

Expanding social prescribing activity in the statutory sector can reasonably be expected to result in more referrals to community and voluntary sector service providers. Some increase in referrals already being experienced in North Lanarkshire is attributed to increasing dependence on the sector given financial constraints in statutory sector budgets. This exposes potential negative implications for community-based providers, and the service as a whole, if more referrals are generated by expanding social prescribing activity in the statutory sector unless steps are taken to prevent them from happening.

“…and what we’re noticing as well is not even just the amount of referrals that has really ramped up but [they are] often inappropriate, so it’s almost as if ‘well it’ll get it off my desk so I’ll fire it over to you’: there runs the danger, and I suppose that’s where I would be wary if we go down this, social prescribing, is that it’s just a case of ‘well, we need to get it off our desk so who could we punt in onto?’

“Then you’re messing that person about by saying this isn’t the service for you…”

The importance of embedding ‘first point of contact’ practice principles in social prescribing initiatives is plain to community and voluntary sector providers and, from their own experience of statutory provider attitudes, they appreciate how challenging that can be.

“…and as you say, that’s then bringing in other organisations that are unnecessary; certainly everybody around the table are working with vulnerable families and so it’s about regardless of where these families present themselves, it’s about the individuals making a bit of judgement…it’s looking at everything more holistic and not just looking at the wee bit of work that you do, where you expertise is, it’s about looking at everything so that regardless of where that person fits in they’re still getting the social prescribing”

“A while back…when there was a big push on GIRFEC I did quite a lot of training for GPs and pharmacies, because the idea was that it wasn’t just your teachers, janitors, lollipop men it was everybody’s issue…the people who were there didn’t really want to be there…I did feel there was this clear barrier of ‘that’s not our job’; but when I walked into that room I had the assumption that they’d all be on board and it wasn’t like that, it was very much ‘this is something else I have to do’ ”

Grave concerns were expressed about lack of investment to build and sustain the community provider capacity required for staff and volunteers to feel able to support social prescribing; even within Community Solutions where financial insecurity threatens

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capacity-building provided through Locality Consortia as well as provision of community-based services and activities.

“I know through a number of groups that we fund [through the Locality Activity Fund], they’re saying ‘we’ve had the referral in from the Community Mental Health Team, we’ve had the referral in from the GP’, we’ve had an example where they’re saying ‘we’ve had 12 referrals from the GP in the past two months’; you’re saying that’s great but then you’re struggling for finance so where are you going to get the finance?”

“They can’t just refer on people to the voluntary sector because the money’s not there: [Community Solutions] for example, we don’t know what’s going to happen after June, we’ve got the first quarter [funding] for the next year to fund groups but I’m thinking if I give out funding to that group they still rely on [the Locality Consortium] to give a bit of support but what’s going to happen if we’re not there to support those groups who depend on that input, what’s going to happen when that money’s gone?”

“…we’re already struggling, not even just the organisations that are paid to deliver a service, even the groups that Community Solutions fund, you’re relying a lot of the time on the good will of volunteers”

“…an example, Elim Church in Motherwell, fantastic group, we’ve funded them a few times [through the Locality Activity Fund]…the Community Mental Health Team are referring people in there, the volunteers are getting free training through VANL or other organisations like Equals Advocacy but it’s going to get to a point where it’ll still be the same number of volunteers there but more people will be coming through the door and more complex people [so] there’ll be more training needed. It’s that thing about ‘we’ll just refer onto them’ and not looking at the impact that that’s going to have…Elim…volunteers are doing fulltime hours”

Models and menus for social prescribing

As with the term ‘social prescribing’, community and voluntary sector providers see the idea of developing a model for social prescribing as coming from and having advantages for the statutory sector such as securing buy-in, facilitating implementation and it “being measurable”.

“I feel that this model’s more for the clinical side, I really do”

“…and really, should we have a model or should we be thinking about [the person]…we need this/that model, no, somebody needs help, what can you do there and then on the spot with what you’ve got, and if I’ve not got the answer who do I contact?”

“…and I know exactly what you were saying there about the model thing, and mostly agree with that, but I think sometimes if there’s a model it might be easier to get more statutory services to buy into it; as the voluntary sector we’re all quite used to working like this, we don’t need to have a prescriptive model but when you go to different disciplines like doctors, GPs, it might be easier to implement…”

The importance of funding for sustainability was underlined:

“…and, equally, funding, if they’re wanting to put models in, I know from running different projects, if I’ve only got a year’s funding a lot of people don’t refer in because they just think it’s going to go; so we need to be working much more longer term to set these services up…funding is important if they’re creating these models”

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The concept of offering a menu or list of options for people through social prescribing does not fit with community and voluntary sector providers’ understanding of social prescribing as a person-centred, assets-based approach that gives people choice to decide which services or activities can improve their personal situation and enable them to take control over their own health and lives; or their experiential knowledge of the range and complexity of needs they see within their local communities and the individuals and families they support, and the wide range of supports they know are locally available. Over reliance on a menu that is not comprehensive, therefore, risks undermining inclusivity as well as underutilisation of local assets.

“Should there be a menu…how’s the menu going to look…it’s going to be huge”

“…it’s no different from having a bunch of leaflets out”

“…and also excludes so many amazing organisations”

Concern was also raised that some statutory providers, lacking the depth of local knowledge that community-based providers have about what local services offer, might simply use a given menu prescriptively.

“If they’ve got a menu in front of them are they going to say ‘Oh, there’s physical exercise, ok [this organisation] is one that gets used all the time’ because they don’t know what’s involved at each service, so that’s not going to work as there’s no in-depth knowledge of…no linking up the activity and the person, there would need to be more…it’s not just ‘Physical exercise, there you go, it’s the first one there [on the menu]’ ”

The desire to designate approved providers is understood but a downside of a menu for social prescribing is if some community-based organisations are seen to be approved providers and others, possibly leading to less investment in organisations not on the menu; and raises the notion of mistrust in the sector as reliable delivery partner.

“…the liability thing is quite important, that’s perhaps an element of distrust between the clinical side and the third sector”

Focus group participants sounded a note of caution regarding reliance on North Lanarkshire’s Locality Profiles as the indicator of local need to inform local provision of social prescribing, because that could “promote your postcode lottery” with the risk of increasing inequalities, fail to address the range of problems that people seek help for, and put some providers of valued local services at a funding disadvantage.

“I know they’re there and they’re probably useful for something but whoever presents in front of me you deal with what’s happening with them…”

“Often they can be a precursor for funding, it shouldn’t be like that”

GP Link Workers Programme

Drawing on the richness of experience within the community and voluntary sector in Lanarkshire, views shared on the introduction of GP link workers stressed the importance of people skills and local knowledge for successful social prescribing link working.

“…in order for the GP, for social prescribing to start there and for it to work well, they need to have an understanding of absolutely everything that’s going on out there…I don’t think that the knowledge is there so I think in order for social prescribing to work these new link workers that are coming into post that’s the trick”

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“…if we don’t know what’s out there we can’t do our job and that’s going to be the absolute key bit for these link workers, not just to know there’s an organisation called [name]… they need to know who we are and what we do”

“…if these GP link workers are going to work they need to have the knowledge and the understanding of who does what out in the community so that they can confidently have that conversation with the person”

“…see if you’re a people person, chatty, make somebody feel at ease, you’ve more chance of somebody opening up and working with you to find alternative things that they can do whereas if you’ve got somebody who’s quite clinical you can see people being like ‘I’m just no gonnae tell them my problem’ ”

“I know some nurses that are classed as clinical and they’re amazing…it’s not so much pigeon holing people as clinical or not it’s having the right skills and background to liaise…”

And emphasised link worker capability to tackle barriers related to the attitudes of practice staff to the value of social prescribing.

“They’re going to have to influence quite a bit of change; they have to buy-in to it, know what they’re supposed to be doing but also have that willingness to push change not just to sit back and say ‘OK, I know it’s not your job but I’ll no say anything’ ”

Questions arose about integrating the new GP link worker role with existing link worker initiatives; and attention was drawn again to the risks of not adequately funding all parts of the system, including the risk of undermining the principle of strengthening community capacity.

“There’s these link workers coming through the NHS Health and Social Care Partnership but we already have link workers through SAMH who’ve been up and running 3 or 4 years, they’re still going to be there but they’re under the third sector and you’ve got these guys coming in from the health, how’s that going to work?”

“…the health link workers are going to have better pay and conditions and holidays, sick pay and all the rest of it. How are they going to balance that out…or is it that people from the third sector are going to go over to health?”

“Look at the amount of money that the GP link workers is going to cost…you can’t just stop there, what investment’s going to be put in place so that we are able to keep delivering these services?”

Community and voluntary sector organisations express a strong willingness to share their local knowledge and experience with GP link workers newly in post, work together towards shared goals and share learning.

“We all share…in Lanarkshire everybody wants to share, it’s quite good that way”

“…it would be good to find out how they’re getting on and what barriers have they come across”

Social prescribing for children, young people and families

As noted in sections 3.1.2, most of the attention on social prescribing to date has concentrated on adults. An informal discussion with members of North Lanarkshire’s community and voluntary sector thematic network for children, young people and families revealed a wealth of local expertise so focus group participants were asked specifically about their views on approaches to social prescribing for this population.

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Referral routes into social prescribing for children, young people and families should encompass health and care services and other organisations they are most likely to come into contact with including primary as well as high schools, which were seen as especially important particularly in relation to early intervention. Health visitors, family planning clinics, sexual health clinics and social work were among the health and care services mentioned, and many community and voluntary sector organisations are proactive in building connections with local statutory services to create local referral pathways.

“For young people I’d be looking a family nurses and high schools and things, to link them in so they’re aware of services because young people don’t tend to go to their GP on their own, it’s usually dragged along by their mum, but if we actually look at [linking] to nurses that are in high schools that would be really good”

“We’ve great links with the health visiting team because [we work with parents of] under 5’s, so we have that link direct and that’s where the majority of our referrals come in from; [we] went out and spoke to health visitors so we took responsibility for raising awareness”

Mechanisms for community and voluntary services to refer people back to statutory services are generally inadequate.

“It’s [relying on] faith in the services picking that up, to get an appointment…”

Discussion touched on particular social difficulties affecting children, young people and families in North Lanarkshire and where gaps in support services are most evident, and foremost among these was mental health.

“Financial’s always a biggie, housing, for me; and [for] young people ours is resilience…being able get back up again when you’ve been knocked down…I work with very vulnerable young people and some of them have to have resilience to be standing in front of me but how many knocks can you take; or you’ll see others with less resilience they’re self-harming, they’re maybe substance misusing, self-medicating with other things…resilience for me’s a biggie”

“Lack of provision for children with ASNs [additional support needs]…our phone calls always ramp up just before school holidays…there’s a huge lack of provision; even befriending… befriending is massive”

“Youth work resources have just been cut and cut and cut, you speak to any youth worker in North Lanarkshire, it’s desperate, and ASN provision among youth workers is even worse, there’s nowhere for kids to go; social isolation and mental health are huge issues”

“I think sometimes [social prescribing] models need to be relooked at… there’s so much physical activity services, a huge amount, but there is a gap or it’s not balanced with nutrition and food, we need to make the ‘food and mood’ link to mental health”

For many, being unable to afford childcare is an important barrier to participation in community-based activities and could, therefore, be a barrier to benefiting from social prescribing. It was thought that more families would benefit if social prescribing could offer free or low-cost opportunities for families to participate in activities together.

Final words

“Social prescribing, sometimes it would be nice if it was something to break the monotony, a wee bit of fun, something to lift somebody’s spirits…especially if you can do it as a family”Page Break

4.4.3 Public and service user perspectives

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Direct engagement with service user representatives and members of the public in North Lanarkshire was limited to one session during the Partnership for Change Quarterly Assimilation Meeting in January 2020. The session entailed a brief presentation introducing the concept of social prescribing followed by a short interactive exercise in which attendees engaged in small group discussions of two scenarios describing local people experiencing social, emotional or practical difficulties affecting their health and wellbeing. Participants easily recognised the potential for non-medical interventions to help improve health and wellbeing for people and readily identified a range of relevant community-based supports as well as potential barriers that could prevent individuals from accessing services and activities in their local community, frequently citing as barriers lack of awareness of what is available locally, affordability, lack of transport or money for bus fares, lack of confidence, and mobility problems.

The statutory stakeholders interviewed in this study expressed optimistic views about public understanding of the value of social interventions in North Lanarkshire, and the likelihood of this being an enabler for wider acceptance of social prescribing; and public engagement should not simply be thought about in terms of public education.

“I think the general public are open to [alternatives to medicine and medical prescribing] more than they were before” (Interviewee 5)

“I’ve got quite a strong belief that it’s a societal issue…so we need to move away from trying to fix people who are ill towards trying to help everybody understand more and do more to help their own mental health and physical health as well; physical health is more embedded already, people understand that you need to keep your weight down and keep fit and do these sorts of things but they don’t think actually you need to do things that support your mental health” (Interviewee 3)

“It’s a difficult one isn’t it because ‘how do we educate the public?’ frequently comes up in debate – do we need to educate the public? I think if we’re doing what we should be doing well then it doesn’t need education it just needs us to behave in a way that is helpful to people and change mindsets through building different confidence” (Interviewee 2)

The Partnership for Change Development Lead emphasised the importance of meaningful public engagement and the necessity to involve people in any service-level change agenda from the outset, reflecting on the lack of public engagement in the development of the Primary Care Improvement Plan and subsequent effort involved in changing negative public perspectives retrospectively.

The Partnership for Change Development Lead also stressed the need for clarity of language around social prescribing and a common understanding of the terms being used.

“…all these words mean different things and we need to be clear what we’re talking about” (Partnership for Change Development Lead)

[document ends]

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