Social prescribing is defined as ‘a means of enabling primary care professionals to refer to a range of local, non-clinical services’.1 It recognises that a wide range of factors affect people’s health.
Services are typically provided by voluntary and community sector organisations and range from arts activities and gardening to befriending, volunteering and sports activities.2
A social prescribing link worker can help GP practices manage patients suffering from frailty, loneliness, mental illness and deprivation. These patients have more physical health problems, poor mental health, higher rates of mortality, and increased use of social care, secondary care and emergency services.
Around 9% of the population is over 75.3 Older people who live alone are at increased risk of loneliness and isolation and currently one in three older people lives alone. Those who live alone use the health services more than others: they are 50% more likely to go to A&E, while 21% visit their GP surgery at least once a month compared with 14% of those living with someone.4
The idea of social prescribing has been gaining traction since 2014 when CCGs transferred a pot of secondary care funding to primary care to support patients over 75, and with the development of the ‘Primary Care Home’ projects that were the forerunners of the primary care networks (PCNs) announced in the 2019/20 GP contract. All practices will this year potentially be able to access social prescribing through PCNs, with funding to cover 100% of the costs of employing a new ‘network link worker’.
The new contract indicates that funding will cover one social prescribing link worker per 50,000-patient network paid at Agenda for Change band 5 pay scale (maximum reimbursable amount for salary and on-costs set at £34,113 per annum) with each network defining their own job descriptions. Networks can choose to subcontract to existing voluntary organisations, subcontract to member practices, or outsource to federations or trusts.
By agreement with the CCG, the network can apply to have two social prescribing link workers instead of one link worker and one clinical pharmacist. Similarly, the network can apply to have two clinical pharmacists instead of any link workers.
For my practice and other practices supported by our link worker, the role involved identifying patients who are most likely to benefit from the service. Many of these patients were then simply signposting to appropriate services, but we also set up over-75s patient participation groups, quarterly tea dances, a monthly luncheon club, art classes, mosaic groups and macramé sessions, newsletters and practice-specific self-help booklets.
Our link worker also linked up with Silverline, discussed hospital discharge planning with secondary care, signposted to local pre-existing voluntary clubs throughout the area and completed benefits claims.
A link worker will need:
It is important for a link worker to enjoy making a difference and be able to empathise with the vulnerable. This is more important than clinical skills. The right person must also be an exceptional organiser, a tactful leader and a lover of people. The rest can be learned. We recruited by advertising in local newspapers and social services in-house publications. We asked for people with experience in social care and preferably an NVQ level 2. This produced good levels of interest and we found our link workers easily.
The success of our link worker was down to two essential things. First, we had the right person. Second, they worked across three or more practices. Because they were not employed by a practice (in our case we set up a company to provide the service), individual practices could not bend the job description without approval of all the other practices. Each practice received the same service with the opportunity to have social events and groups across boundaries, ignoring local politics. Quality was monitored and maintained by a management system responsible to, but independent of, the practices.
The reimbursed funds to employ a link worker will be held by an employing organisation and this could be a single lead practice, a GP federation, a community, mental health or NHS trust or voluntary sector organisation. Networks will need to assess the advantages and disadvantages of the array of service providers who will be bidding for their funding.
NHS organisations will have CQC registration but this may not be true of some potential fundholders. Initially, the employment of social prescribing link workers, and pharmacists, does not require CQC registration because they are not performing regulated activities. But as more services move to the networks, this will become a requirement.5
It is clear that networks will only succeed where there is enthusiasm and agreement between practices. Co-operation will be paramount. The promise of 100% reimbursement for the link worker is a big incentive, while the 70% reimbursement for a clinical pharmacist has the potential to cause division. Practices may want some of the new staff but not others. Networks working in a constructive way can introduce these new roles in a way that ensures fairness.
NHS England has set out the key responsibilities for social prescribing link workers under the new contractual arrangements.
Importantly it states that they will take referrals from the network’s members in the first year, expanding in 2020/21 to take referrals from a wide range of agencies. However, our experience suggests that rather than simply accepting referrals, it is important for the link worker to proactively identify patients who may benefit from social prescribing initiatives, otherwise only the obvious cases will receive attention. Behind this group are many who suffer in silence, becoming increasingly unwell both mentally and physically. As GPs we have the data to look at our populations holistically and identify those people in great need who are under the radar.
It is easily possible for the link worker to implement a system to identify priority cases , initially identifying those:
Link workers would then identify those living in deprived areas and with depression and high alcohol consumption. By giving each marker a score of one, the ‘top’ 1,500 can be identified and that list can form the starting point for the link worker. By using a managed roll-out of initial contact, followed by assessment using standardised questions and tests and then offering support, the workload of the link worker develops progressively so that it always remains manageable and effective. This is added to as GPs, nurses, receptionists, patients themselves and families also refer into the system.
From my involvement in providing social prescribing link workers, we found that success has been similar in both South Coast urban and Midlands rural settings, with an average reduction in GP appointments by frequent attenders of 26%, an average 5% reduction in avoidable and unplanned hospital admissions, and around a 3% reduction in A&E attendances by participating patients (compared with an 8% increase by non-participating patients).
Most usefully, having the link worker put a stop to calls to GPs from relatives wanting updates, 5pm requests for crisis home visits and social problems presenting as insoluble medical symptoms.
Along with the obvious measurable results, what we have also seen in all the practices, by all the staff (from receptionist to admin to doctors), is an enthusiasm rekindled for general practice, the lift in morale as projects arose from ideas that previously no-one had had time to develop. And what was particularly satisfying was that although this was achieved mainly by one dedicated member of the team, everyone basked in the praise from the patients.
Dr Tim Coker is a GP in Warwickshire and founder of the Prime GP consultancy, which developed the social prescribing scheme Prime 75
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