Social prescribing for people with complex needs: a realist evaluation

Realist evaluation (RE) looks at generative causation [15], a key strength is modelling complexity. Adopting a realist approach enabled us to go beyond identifying ‘barriers’ and ‘facilitators’ [16] to uncover underlying mechanisms and understand how, when and why they are activated. RE requires researchers to have an initial theory that can be challenged and refined during the study. Mid-range theories (which may or may not be novel) can be applied to the findings to improve generalisability of case study findings [17, 18].

RE recognises that wider context influences outcomes and specifically how individual actors respond to different parts of the intervention at different times. To describe this complexity, statements describing pathways between intervention or individual Context (C), and underlying Mechanisms (M) that subsequently shape patterns of outcomes (O) are created (CMO configurations) [15]. CMO configurations aim to describe why a person (or case) responds to an intervention in a certain way and how this can change depending on circumstances. CMOs can be linear or more complex [15, 19].

We focused on one large voluntary sector, community anchor organisation providing SP to an inner-city area of high socioeconomic deprivation, predominantly deprived white working class council estates. Clients often have multiple health conditions including co-existing physical and mental health concerns. Most have social needs associated with housing, benefits and lack of support networks. Many are isolated. Unlike some areas, there was no central referral point; general practices and other referrers (such as housing officers) referred to one or more of many community anchor organisations that provide services in their local area (Table 1 provides details of the setting). In some parts of the country, general practices have begun employing link workers but in this area, all social prescribing is provided by these third sector organisations, link workers are not provided by primary care networks.

The initial programme theory (IPT) was informed by the wider research team and relevant literature reviews of collaborative care [20], realist methods [18] and social prescribing [9, 10, 21]. It was formed over multiple meetings between researchers and stakeholders from the host site as well as another SP organisation in the same city, to further understand why and how SP works for certain populations. The IPT to be tested was that collaborative care and SP are overlapping concepts (Fig. 1). We hypothesised that SP organisations are potentially effective in improving self-management for adults with co-existing physical and mental health conditions because they work on a collaborative care model [12]. For the purpose of this study, intervention type was disaggregated from context in order to differentiate between interventions in one contextual setting.

The study was iterative in nature and conducted over three phases. Stakeholders from the host community anchor organisation were included in development and design meetings from the start. This helped ensure that the research was appropriate for the local model of SP delivery and that it would provide insights of value to both community anchor organisation s and researchers. Phase one tested the IPT through data collected in interviews with people working for the organisation, those receiving SP and external referring organisations, to test and refine this theory. In Phase two, we developed CMO statements which refuted the IPT, leading to modification of the theory. Phase three focused on applying and developing wider theory to synthesise the CMOs into a mid-range theory. A mid-range theory is a theory that lies between working hypotheses, contains testable predictions and evolves as efforts are made to develop a unified theory. It was developed and related, where appropriate, to existing theories [17, 18]. The mid-range theory provides a level of abstraction to the analysis and therefore a generalisability beyond the immediate context [17].

Realist analysis takes an iterative approach, moving between different sources of data and using deductive and inductive reasoning [25] (see Table 2).

The IPT was interrogated using data collected at interview, by testing our hypothesis that SP is consistent with collaborative care [26]. This was done by analysing experiences of three stakeholder subgroups (clients, staff and referrers) to see if their views corroborated or differed from the IPT. A deductive approach was used. Analysis consisted of applying data to the four key elements of collaborative care using a Framework approach. Themes about what worked for whom, when and why that did and did not fit with the IPT were used to continually refine the model. Coding was undertaken by SO; EW and JC independently coded 14 interviews to cross check the coding frame. NVivo software was used to assist in data management.

The developing themes became the premise for disputing the IPT as the data were related to wellbeing not ‘health’ and ‘disease management’. These were developed into a series of CMO configurations by the wider research team until agreement was reached. New configurations were then tested with data collected from the workshops in phase two.

Finally, we looked to extend generalisability beyond the immediate context [17] by relating, where appropriate, the newly created theory (mid-range theory) to existing theories [17, 18]. Client-led interventions and asset-based approaches emerged as key to the mid-range theory. This is closely linked with salutogenesis [27, 28].

Salutogenesis focuses on promoting health and well-being as opposed to managing symptoms of disease. It further posits that life experiences shape one’s sense of coherence (ability to comprehend a situation, find meaning and be able to act). A strong sense of coherence aids in mobilising resources (internal and external) for dealing with stress and helping a person move towards health rather than disease [27, 29]. Salutogenic interventions are those which seek to strengthen a person’s ‘sense of coherence’ [29].

The realist analysis was based on 35 interviews with clients (n = 15), staff (n = 13), and referrers (n = 7) who were all involved the health section of the SP community anchor organisation. All but one member of host SP staff (who was on leave during recruitment) from the health section were interviewed in phase one. Staff backgrounds varied and included health trainers, benefits/housing advisors and people who supported the organisation’s volunteers. The health section manager was also interviewed.

The stakeholder workshop had 15 delegates including seven staff, five referrers and three clients. Five staff at the workshop had been involved in the interviews. Two senior managers attended who had not been invited to interview. None of the referrers or clients at the workshop had been interviewed in a deliberate attempt to ensure we were getting a range of viewpoints. See Table 3 for participant information.

The IPT was that SP works in a similar way to collaborative care. We asked participants about specific elements of their experiences that would have aligned with collaborative care had it been a key underlying mechanism. They were then asked about what they felt was helpful about attending the SP service. When researching whether an intervention ‘works’ it is important to define its aims. One of the aims of SP is to improve health and well-being. However, other outcomes necessarily exist, the service is client-led so clients will have their own desired outcomes, which may or may not link directly to improved health as defined by health services. The answers allowed us to refine the IPT (Fig. 2).

The interventions in SP (Fig. 2), although superficially similar to collaborative care, were different in practice and activated a wider range of mechanisms and outcomes.

The CMO configurations derived from the data resulted in multiple interconnections, especially between mechanisms and outcomes, which did not fit [19] simple linear progressions such as ‘C + M = O’ [15]. Many configurations reported multiple contexts resulting in multiple mechanisms, which lead to an outcome attained which then became a mechanism to achieve another outcome. For example, many clients were referred or self-referred to the organisation because they were isolated (context). The social cafes (intervention) facilitated making new social connections (mechanism) which reduced isolation (outcome). Although this follows the CMO framework it does not represent the complexity found in the data, which were more multifaceted than the above statement implies. The familiar location of the cafés, which are set in local communities, was also a mechanism for increased engagement, and therefore also reduced isolation. As did the increased confidence (Mechanism (M)) clients gained from trusting staff (M) who could work flexibly (M) and were not sited within the NHS (Context (C)) but were still knowledgeable (M). Intermediate outcomes can, in turn become mechanisms for longer term outcomes. For example, increased engagement could be an outcome in its own right but it is also a mechanism for improved mental and physical health. Figure 3 shows an overview of the interweaving CMOs that we discovered.

Some of the configurations demonstrate the overlaps and differences between the original and modified IPTs. Points marked with a * are from the modified IPT but not the original, unmarked points stem from both, supporting quotes are illustrated below.

Adults with depression but no diagnosis/treatment* (C) are accessing SP services in community settings* (C), this is perceived as less stigmatising (M) and intimidating than clinical services* (M), resulting in increased engagement (Outcome (O)) and improved mental health (O).

SP [organisations] are there for people with low confidence (C) so they’re not going to look down on you (M). Client 1

Chatting to people (M), you know you’re not on your own (M). You know you’re not the only person who’s had problems (C/M). Client 3

This SP organisation offers a welcoming setting that helps the client’s mental health but does not focus on it directly.

Adults who are isolated* (C) possibly as a result of a bereavement* (C) with mental health issues (C) are receiving personalised client centred management plans in SP* (Intervention). This is can be provided on a flexible basis to meet their need* (M), partly due to the flexibility of the staff roles (M) and staff having time to listen* (M); resulting in improved Mental Health (O) and more appropriate health service use* (O).

Staff felt clients valued this approach as they would receive word of mouth self-referrals from friend and family of existing clients.

When thinking about person centred interventions one staff member spontaneously described their own idea of the CMO configuration.

When someone is new to the service (C), it’s crucial that we do it in an approached manner (M) that we can do it at their speed, (M) feeling comfortable about it (O), giving confidence that they can do it (M), and allowing that to flourish (O) and say ‘come on, we can move forward’ (M). So, it’s empowered them (O), they’ve got to make that choice (M) and they’ve got to make those decisions but it’s about being supportive isn’t it (M), to doing it. And that’s what I see my role, is supporting people and moving them on to next… every individual has structured management plan (O), speaks for itself. Every one’s different. It’s not my plan. It’s their plan (M). Staff 11

This suggests that staff valued the flexibility of their role working at the client’s pace, seeing it as integral to offering person-centred care. ‘It’s not my plan, it’s their plan’ implies that their role is to facilitate and guide the individual to choose rather than ‘intervening’ in the classic model. Whilst many health care workers do have a degree of autonomy and flexibility, they are usually constrained in this. The SP workers here described a level of working—supported by management—to meet the needs of clients however unusual, for example, aiding in house clearance for a hoarder.

Clients with the similar contexts attend social cafes: Have a space/location to engage in participative social function (meet people/peers/friends/shared experiences)* (M) are listened to (by peers)* (M), which improves/increases social functioning (O) and reduces isolation* (O) and improves mental health (O).

It’s building my confidence up great (C/O). I’m making loads of friends (O). I mean, I’m in a craft group but I don’t really do much crafting when I’m It’s more chatting (M) and helping the others (M), so it’s lovely, and they’re just so friendly(M). Client 14

Instead of once a fortnight, they’re going to somewhere twice a week now (O) so there’s, there’s always something for them to do (M) and it brings them together (M), I mean they say to me, things like oh, if I didn’t come here I’d have nowhere else to go (O), I’d be sat, four walls (C), I don’t know what I’d do if I didn’t have this group, and that type of thing. Staff 7

Clients value the peer support that the social cafes’ provide; reducing not only physical isolation but also emotional isolation by introducing clients to people with similar issues, who are able to support each other. This reduction in isolation was also felt to have an effect on the physical health of clients and ultimately their attendance at General practice clinics. For elderly widowed males who had been dependent on their partner for essential life skills (cooking) (C) personal help with shopping and guidance may increase confidence and motivation (M) to eat better and lose weight (O).

By regularly attending SP activities(C), clients often meet others who have been through similar situations (C) it creates a social network(O/M), shared experience gives peer support (O), Reducing sense of isolation and reliance on health services being the only place you can discuss your health(M/O). Leading to reduced primary health care use. (O).

Wider determinants of health are a range of economic, social and environmental factors that directly and indirectly affect people’s health [30]. Clients present with social issues* (C) contributing to mental health issues (C), staff in SP have skills to support social issues* (C). Clients receive personalised management plans, the interventions are adaptable to this individual need* (M) with staff being flexible in how this support is offered/delivered* (M) Resulting in improvements in housing/finances/employment* (O) and positive impacts on mental health (O).

We can even do a home visit (Intervention), because even asking someone to come and see us here for the first time is daunting (C). so I think with us, slotting in with them (M), I see it as like a jigsaw, so it just all slots in because they see us and we look at the barriers to health and put them steps in first and work through them with them (M), and then it’s just giving them that bit of self-belief that they can do something and show them how they can make small changes that that’s leads to bigger things so by us being there, they can then move on to volunteering (O) and then move on to employment advocacy (O), if they are on [employment and support allowance] they can help them sort out the benefits and what have you but then they can refer back into us again, to say well actually they are on ESA but they are looking at wanting to return to work but they have got no confidence (C), you know, so we sort of can keep seeing them (M). Staff 9

SP in this organisation contributed to health improvements by concerning themselves with the wider determinants of health, not just presenting health concerns.

Clients present with complex social issues* (C). Clients receive personalised management plans (Intervention). But poor shared systems with external organisations (M) and external organisations perceiving SP staff as non-professional (M) resulted in difficulty with systematic sharing of information (O) and longer waits with more chance for clients to disengage (O).

I think that would make a huge difference, because if a [General Practitioner] was to log in and see that they're working with social prescribers and they're going to groups and this has happened and that has happened, then we can work and keep encouraging them to go, you know those sort of things. General Practitioner 2

Very often there’ll be interruptions in claims, benefits will get suspended. If I could talk to [the Council] at that time when the client’s here I could stop that happening, whereas now… the letters’ll be god knows where… and in the meantime you know the benefit might get suspended… If I could talk to them I could solve a lot of problems because I can put in a nutshell what the client might struggle to sort of want to put across. Staff 3

Many SP organisations are in the voluntary sector and are isolated from statutory services. Data sharing is therefore problematic. Information is not passed between organisations in a timely manner and even when it is, there is no interoperability in IT systems. The lack of professional status of SP staff leads NHS and other staff to be unsure about what information they can or cannot share with them.

SP in this setting was a not collaborative healthcare intervention but rather a client led, person-centred, asset-based service addressing the wider social determinants of health including co-morbid conditions. In doing so, it worked on salutogenic principles, providing new resistance resources, helping people access existing ones and even strengthening low sense of coherence.

Personalised care is at the heart of social prescribing, staff refer to goal planning in SP as ‘ their plan not mine’; SP goals are set by the clients not staff. Even when clients are referred by health care staff for specific purposes, if that is not what the client wishes to address first (or at all) then this is not a condition of entring the service. Whilst this personalised approach clearly has its merits, and the repeated return to SP organisations and word of mouth recommendations show it is a popular policy, it may disadvantage those whose sense of coherence is so low that they cannot recognise or articulate the need to change. However, given the broad range of activities that is available via SP this should be less of a disadvantage than in traditional health care settings. It also suggests a significant departure from the collaborative framework of collaborative care. The client is not being consulted by the healthcare professional; they are leading the direction of the intervention. This has the potential to have an effect on the level of dependancy people have on the service. However, although many of the interviews with clients mentioned dependecy it was in relation to others. This suggests participants were aware of it but that it might be difficult to recongise or admit to, it is however, an issue that is both live and sensitive.

Pelikan concluded that salutogenic thinking has good potential to be applied in health settings [34]. Specifically in health promoting interventions, structures and cultures and improving a person’s sense of coherance could be an explicit goal of chronic disease management [34]. The wider determinants of health must not be underestimated when planning SP delivery [35], they are part of the context to our realist theory and may constrain the effects of the SP intervention. However, this does not invalidate the efforts made in providing these services. For example, people in financial hardship may struggle to access a service that requires bus travel to attend. One of the things participants liked about the organisation studied in this research was that it provided services in several local community locations, meaning most people could walk to services, knew the area and felt comfortable there.

Although sense of coherence is stable, it can be changed, but to do so in a positive way is slow and takes ‘hard work’, such as undertaking psychotherapy [27]. More recent research shows that sense of coherence can change across the life course and that many prerequisites for strengthening sense of coherence may be provided by or mediated by the community [36]. The version of SP that was delivered by the provider organisation, at the time of our research, and the ways that it was experienced by clients, was consistent with the theory of salutogenesis. This research and that of Payne and colleagues [5] found that SP facilitated change in perceptions of personal assets through personal and social development. Meaning that clients became more aware of what assets were available to them and more able to access them. This is consistent with theory of change for the sense of coherence and therefore supports Health Education England’s suggestion that the theoretical base for SP is Salutogenesis [4].

When considering what aspects of SP works for whom and in what circumstances, context is important. Access to a supportive community can strengthen a person’s sense of coherence through the life course [36]. People with a low sense of coherence may struggle to access these resources without help and these people can particularly benefit from SP interventions, although the specific intervention needs to be determined on a case by case basis and remain person centred.

A recent realist review [3] reported that there are three stages which contribute to pathway success in social prescribing. Enrolment, engagement and adherence and the link workers are key to avoiding disruption of the process. Our findings are consistent with these points. Link workers have a key role in ensuring people are supported to attend and understand what social prescribing is. Similarly, another recent realist review of social prescribing had two main concepts, creating and sustaining buy-in, and establishing and maintaining connections [37]. The first of these was not a major concern in our study as referrers were enthusiastic about social prescribing and keen to work with the organisation. Clients too, would regularly report recommending the organisation to friends and neighbours. The caveat here is that both were self-selecting samples and we did not (and could not) gauge how representative they were. The second, maintaining connections, was more of an issue, both in terms of logistics around data sharing and governance, but also regarding remit and scope of the social prescribing provider and its services. These changed over time and some family doctors reported that they were unsure about which service to refer too. This was the reason for developing the triage role, so that referrers had a single point of contact to improve relations. Our findings complement Tierney et al.’s conclusions that social prescribing can, through developing wider social networks, reduce isolation, increase meaning and activity and give people the confidence to manage their own health. Our theory development diverged from that of Tierney et al., whose primary focus was on the setting up of services whereas we studied a mature service that had existed for many years. This allowed us to look beyond logistical considerations into deeper theory behind social prescribing in action.

SP providers are very varied. The service we studied was provided by a large organisation was large and comprised multiple interventions. As the local authority did not have a central SP referral point the organisation had to liaise with referrers directly, attempting to find local solutions to a city-wide problem. This situation is not the same in other cities or for small single intervention SP groups. However, the central finding of the importance of being client centred and of acknowledging wider determinants of health remain relevant to a wide variety of different SP models of implementation.

This study focussed on an organisation that predominantly served deprived white working-class council estates. There were limited opportunities to capture the voices of people from minority ethnic and non-white British backgrounds.

We sought a better understanding of the mechanisms of action for social prescribing, to provide greater clarity about who can be expected to benefit and why, and therefore who to prioritise in referral practices. Although in-depth, our study was based on a single social prescribing provider in one city and our findings need to be viewed cautiously.

We found that people with long-term social difficulties who struggle with chronic health conditions because they have limited support networks may benefit the most from social prescribing. Our results support the view that this is because building support networks and developing coping mechanisms enables better engagement with sources of treatment. We therefore recommend that these individuals should be considered a priority for social prescribing referrals. It is important to note that those with the weakest sense of coherence, who might be expected to benefit most from social prescribing, may lack sufficient resources to access the service and may need significant help (from referrers and social prescribing providers). A key barrier to this is difficulty in information across organisational boundaries, and those who commission SP services are perhaps best placed to address this.

We found that flexibility on the part of link workers was critical, and they require sufficient time and resources to work this way. Link workers in our study recognised the need to support engagement and that regular attendance was key for reducing isolation. Processes or policies regarding discharge based on time spent in the service were therefore felt by many to be counter-productive, although the consequences for service capacity was also recognised. Commissioners and service providers need to find the correct balance for their chosen aims as different organisations may need to work in different ways to satisfy budgets and local need.

Theory development moved from a large scale IPT of SP, then modified to the SP organisation in the study then widened out again for the mid-range theory. The mid-range theory therefore should be tested in additional SP organisations to ensure it is not context specific.