A realist evaluation of social prescribing: an exploration into the context and mechanisms underpinning a pathway linking primary care with the voluntary sector.

Marcello Bertotti,Ratna Sohanpal,Caroline Frostick,Patrick Hutt,Dawn Carnes

doi:10.1017/s1463423617000706

Marcello Bertotti, Ratna Sohanpal + Show 3 more

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https://doi.org/10.1017/s1463423617000706

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Abstract

This article adopts a realist approach to evaluate a social prescribing pilot in the areas of Hackney and City in London (United Kingdom). It unpacks the contextual factors and mechanisms that influenced the development of this pilot for the benefits of GPs, commissioners and practitioners, and reflects on the realist approach to evaluation as a tool for the evaluation of health interventions. Primary care faces considerable challenges including the increase in long-term conditions, GP consultation rates, and widening health inequalities. With its emphasis on linking primary care to non-clinical community services via a social prescribing coordinator (SPC), some models of social prescribing could contribute to reduce the burden on primary care, tackle health inequalities and encourage people to make greater use of non-clinical forms of support. This realist analysis was based on qualitative interviews with users, commissioners, a GP survey, focus groups and learning events to explore stakeholders' experience. To enable a detailed analysis, we adapted the realist approach by subdividing the social prescribing pathway into stages, each with contextual factors, mechanisms and outcomes. SPCs were pivotal to the effective functioning of the social prescribing service and responsible for the activation and initial beneficial impact on users. Although social prescribing shows significant potential for the benefit of patients and primary care, several challenges need to be considered and overcome, including 'buy in' from some GPs, branding, and funding for the third sector in a context where social care cuts are severely affecting the delivery of health care. With its emphasis on context and mechanisms, the realist evaluation approach is useful in understanding how to identify and improve health interventions, and analyse in greater detail the contribution of different stakeholders. As the SPC is central to social prescribing, more needs to be done to understand their role conceptually and practically.

Highlights

IntroductionPrimary care in the United Kingdom currently faces a number of key challenges including:(i) About 20% of people attend GP surgeries for problems that are primarily social rather than medical (Torjesen, 2016).(ii) A rising tide of long-term conditions which is set to grow by 5 million in the 10 years (DoH, 2013).(iii) Growing health inequalities which result in long-term medical conditions disproportionately affecting people in deprived areas (Hutt and Gilmour, 2010; Marmot et al, 2010; Cawston, 2011).In an attempt to seek solutions to these problems, the concept of social prescribing holds significant promise (South et al, 2008)
The initial hypothesis was that ‘a social prescribing intervention improves wellbeing outcomes for patients suffering from isolation and mild mental health problems by providing a support mechanism (GPs, social prescribing coordinators and community organisations) which enable each patient to consider a set of alternative actions and embark on changing or more effectively managing their current health’
The overall hypothesis underpinning the realist evaluation of social prescribing in City and Hackney is that social prescribing improves well-being outcomes for patients suffering from isolation, and mild mental health problems

Summary

Introduction

Primary care in the United Kingdom currently faces a number of key challenges including:(i) About 20% of people attend GP surgeries for problems that are primarily social rather than medical (Torjesen, 2016).(ii) A rising tide of long-term conditions which is set to grow by 5 million in the 10 years (DoH, 2013).(iii) Growing health inequalities which result in long-term medical conditions disproportionately affecting people in deprived areas (Hutt and Gilmour, 2010; Marmot et al, 2010; Cawston, 2011).In an attempt to seek solutions to these problems, the concept of social prescribing holds significant promise (South et al, 2008). (iii) Growing health inequalities which result in long-term medical conditions disproportionately affecting people in deprived areas (Hutt and Gilmour, 2010; Marmot et al, 2010; Cawston, 2011). “co-produce” their “social prescription” – so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary and community sector’ (SPN, 2016: 19). A useful way to conceptualise these is Kimberlee (2015) who has arranged models into signposting, light, medium and holistic, according to a range of aspects and, crucially, the level of support provided by link workers to patients. The research analysed in this article is based upon the ‘holistic’ model which includes a clear referral pathway, an holistic view of patient’s needs and aspirations, and an intense level of support provided by the link worker

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