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

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.

Link workers’ perspectives on factors enabling and preventing client engagement with social prescribing

“…Our findings confirm the importance of primary‐care practitioners’ engagement with social prescribing (White, Kinsella, & South, )(Whitelaw et al., ). In common with other studies (Bertotti et al., ; Brandling & House, ; Mercer et al., ), we find that link workers’ experiences of primary‐care engagement with social prescribing indicate that practitioners can be both slow to identify patients who may benefit from social prescribing and to refer. We identify as an additional issue the referral of patients with severe and complex social problems who may be unable to engage with social prescribing.…”

“…Bertotti et al. () and Skivington, Smith, Chng, Mackenzie, and Wyke () identified the lack of availability of suitable onward referral services as a barrier to social prescribing. These deficiencies were frequently highlighted by link workers in both phases of this study, who identified that “a massive barrier is other services’ capacities” (P1, Interview, Phase 1).…”

“…The presence of a facilitator to link clients to community services “has been identified time and again as key to successful social prescribing” (Keenaghan, Sweeney, & McGowan, , p. 6). However, knowledge is lacking of the processes by which social prescribing achieve its aims and the specific mechanisms by which link workers successfully engage clients (Bertotti, Frostick, Hutt, Sohanpal, & Carnes, ; Mossabir et al., ; Rempel, Wilson, Durrant, & Barnett, ). An exception to this is a recent realist evaluation of a social prescribing scheme, which found that a skill‐mix comprising excellent listening and empathetic skills appeared to build trust between link workers and clients (Bertotti et al., ).…”

“…However, knowledge is lacking of the processes by which social prescribing achieve its aims and the specific mechanisms by which link workers successfully engage clients (Bertotti, Frostick, Hutt, Sohanpal, & Carnes, ; Mossabir et al., ; Rempel, Wilson, Durrant, & Barnett, ). An exception to this is a recent realist evaluation of a social prescribing scheme, which found that a skill‐mix comprising excellent listening and empathetic skills appeared to build trust between link workers and clients (Bertotti et al., ). A report by the UK Social Prescribing Network () also identifies effective link workers with the right skills and appropriate training as key components of successful social prescribing.…”

Supporting social prescribing in primary care by linking people to local assets: a realist review

“…To the best of our knowledge, no previous systematic synthesis of existing literature, using a realist lens, has explored how this role can be implemented optimally. Other reviews have looked more at clinical navigation, rather than the use of local assets to address social determinants of health [34,35], have not adopted a realist lens when working with data [36][37][38] or have not focused specially on connector schemes [39]. A realist review that explored social prescribing more broadly described link workers as essential but not enough, on their own, to ensure that desired outcomes are achieved [15]; other elements, as touched on in our review, need to be in place, such as a vibrant VCS, changing the medical model focus in some health settings, and a shift in the mindset of patients.…”