Link Worker social prescribing to improve health and well-being for people with long-term conditions: qualitative study of service user perceptions

Objectives To describe the experiences of patients with long-term conditions who are referred to and engage with a Link Worker social prescribing programme and identify the impact of the Link Worker programme on health and well-being. Design Qualitative study using semistructured interviews with thematic analysis of the data. Intervention Link Worker social prescribing programme comprising personalised support to identify meaningful health and wellness goals, ongoing support to achieve agreed objectives and linkage into appropriate community services. Setting Inner-city area in West Newcastle upon Tyne, UK (population n=132 000) ranked 40th most socioeconomically deprived in England, served by 17 general practices. Participants Thirty adults with long-term conditions, 14 female, 16 male aged 40–74 years, mean age 62 years, 24 white British, 1 white Irish, 5 from black and minority ethnic communities. Results Most participants experienced multimorbidity combined with mental health problems, low self-confidence and social isolation. All were adversely affected physically, emotionally and socially by their health problems. The intervention engendered feelings of control and self-confidence, reduced social isolation and had a positive impact on health-related behaviours including weight loss, healthier eating and increased physical activity. Management of long-term conditions and mental health in the face of multimorbidity improved and participants reported greater resilience and more effective problem-solving strategies. Conclusions Findings suggest that tackling complex and long-term health problems requires an extensive holistic approach not possible in routine primary care. This model of social prescribing, which takes into account physical and mental health, and social and economic issues, was successful for patients who engaged with the service. Future research on a larger scale is required to assess when and for whom social prescribing is clinically effective and cost-effective.


AbstrAct
Objectives To describe the experiences of patients with long-term conditions who are referred to and engage with a Link Worker social prescribing programme and identify the impact of the Link Worker programme on health and wellbeing. Design Qualitative study using semistructured interviews with thematic analysis of the data. Intervention Link Worker social prescribing programme comprising personalised support to identify meaningful health and wellness goals, ongoing support to achieve agreed objectives and linkage into appropriate community services. Setting Inner-city area in West Newcastle upon Tyne, UK (population n=132 000) ranked 40th most socioeconomically deprived in England, served by 17 general practices. Participants Thirty adults with long-term conditions, 14 female, 16 male aged 40-74 years, mean age 62 years, 24 white British, 1 white Irish, 5 from black and minority ethnic communities. Results Most participants experienced multimorbidity combined with mental health problems, low self-confidence and social isolation. All were adversely affected physically, emotionally and socially by their health problems. The intervention engendered feelings of control and selfconfidence, reduced social isolation and had a positive impact on health-related behaviours including weight loss, healthier eating and increased physical activity. Management of long-term conditions and mental health in the face of multimorbidity improved and participants reported greater resilience and more effective problem-solving strategies. Conclusions Findings suggest that tackling complex and long-term health problems requires an extensive holistic approach not possible in routine primary care. This model of social prescribing, which takes into account physical and mental health, and social and economic issues, was successful for patients who engaged with the service. Future research on a larger scale is required to assess when and for whom social prescribing is clinically effective and costeffective.

Background
Social prescribing enables healthcare practitioners to refer patients to a range of non-clinical services. 1 Primarily, but not solely, directed at people with long-term conditions, social prescribing harnesses assets within the voluntary and community sectors to improve and encourage self-care and facilitate health-creating communities. [2][3][4] There is increasing interest in social prescribing as a means of addressing complex health, psychological and social issues presented in primary Link Worker social prescribing to improve health and well-being for people with long-term conditions: qualitative study of service user perceptions ► This is the first UK study to provide detailed insight into the impact of a Link Worker social prescribing programme on health and well-being among adults with long-term conditions living in an area of high socioeconomic deprivation. ► Our interview data showed that the Link Worker social prescribing programme engendered feelings of control and self-confidence, reduced social isolation and led to positive physical and behavioural changes such as weight loss, increased physical activity, improved mental health and long-term condition management as well as greater resilience and effective coping strategies to manage relapses. ► Key elements of the Link Worker social prescribing model are that it: addresses the coexistence of multimorbidity, mental health problems and social isolation; is long-term in nature; and, where applicable, tackles related socioeconomic issues. ► A strength of this work was the depth and consistency of participant accounts regarding the impact of the programme. Limitations were that we did not capture the experiences of patients with long-term conditions who refuse a referral or who drop out of the programme early, nor were we able to collect information on the frequency with which participants engaged in activities they were referred to. ► Our study adds to the emerging evidence base on Link Worker social prescribing by demonstrating improvements in health-related behaviours and long-term condition management.
Open Access care, as well as its potential to reduce health inequalities. 5 A recent review of social prescribing indicates that, despite a small and largely inconclusive evidence base, there is the potential for credible psychosocial benefits to be incurred by patients with mental health problems, and for health and well-being improvements to be seen in people with long-term conditions. 6 While less attention has been paid to the impact of social prescribing on physical health and resource use, 4 improvements in physical activity, 7 reductions in hospital resource use 8 and General Practitioner (GP) attendance 9 have been attributed to social prescribing, although longer-term studies with larger sample sizes are required for more definitive evidence. 4 As yet there is no agreed definition of social prescribing, 2 although there is broad consensus that it helps patients to access non-clinical sources of support, predominantly in the community sector, 3 and is a means to address the well documented social and economic factors that accompany long-term illness beyond the healthcare setting. 4 In the UK, social prescribing has been taking place on a small scale for a number of years and there are several operating models. 10 These models vary in two ways; the actual activities or services offered and the level of support given to patients following referral. Recognising that patients who are simply given information about a service will not necessarily take it up, most schemes involve a 'facilitator' coupled with personal support, 11 although the level of ongoing support offered varies considerably. Services into which patients are referred vary, and can include activities that involve physical activity such as gyms, walking groups, gardening or dance clubs; weight management and healthy eating activities, such as cooking clubs. Addressing wider economic and social issues can involve referral into services which address welfare, debt, housing and employment issues. Groups, such as those targeted at people with specific long-term conditions, for example diabetes, chronic obstructive pulmonary disease, may also be accessed via social prescription. Our definition concurs with that of the Social Prescribing Network of Ireland and Great Britain, 'enabling healthcare professionals to refer patients to a link worker, to co-design a non-clinical social prescription to improve their health and well-being' and use services provided by the voluntary and community sector. (p19) 2 Ways to Wellness 12 is one of the first UK organisations to deliver social prescribing on a large and prolonged scale, funded for 7 years through a social impact bond model, with an overall target of 11 000 users over this period. Based in west Newcastle upon Tyne, an area with some of the most socioeconomically deprived wards in England, Ways to Wellness covers 17 general practices. Referral criteria are men and women aged 40-74 years with one or more of the following long-term conditions: diabetes (types 1 and 2), chronic obstructive pulmonary disease, asthma, coronary heart disease, heart failure, epilepsy, osteoporosis, with or without anxiety or depression. Ways to Wellness is delivered by four voluntary sector organisations.
Following extensive consultation with patients and healthcare professionals over an 8-year period, 13 Ways to Wellness provides a 'hub' model of social prescribing in which a Link Worker trained in behaviour change methods offers a holistic and personalised service. Following referral from a primary care practitioner (GP, practice nurse, healthcare assistant), meaningful health and wellness goals are jointly identified and service users are connected, when desired, to community and voluntary groups and resources. The service comprises: (A) individual assessment, motivational interviewing and action planning; (B) completion of an initial 'Well-being Star' assessment and subsequent Well-being Star assessments every 6 months thereafter for the duration of the patient's involvement; (C) help to access community services (eg, welfare rights advice, walking groups, physical activity classes, arts groups, continuing education); (D) promotion of volunteering opportunities, and; (E) promotion of improved self-care and sustained behaviour change related to healthier lifestyle choices. Thus, the programme is highly individualised with patient engagement varying in terms of intensity, duration, personalised goal-setting and onward referral. Patients can remain with the programme for up to 2 years, but with Link Worker discretion beyond 2 years if required; frequency of contact with the Link Worker is mutually agreed, varies between and within patients depending on current need and circumstances, and can be face to face, via telephone, email and/or text message. Data for this study were collected in the first 14 months of the Link Worker social prescribing programme implementation.
This qualitative study aimed to capture the experiences of patients engaged with Ways to Wellness in its first 14 months of operation and to identify the impact of the Link Worker social prescribing programme on health and well-being.

MeThods setting
This study was set in an inner-city area of high socioeconomic deprivation in the west of Newcastle upon Tyne (population n=132 000), ranked among the 40 most deprived in England according to the Index of Multiple Deprivation. 14 Eighteen per cent of residents have longterm conditions and receive sickness and disability-related benefits, which is higher than the national average. 15

recruitment and sampling
The four Ways to Wellness provider organisations acted as gatekeepers and approached service users on our behalf, explaining the study and issuing a participant information sheet. Those who agreed for their details to be passed on to the researcher were contacted by telephone to ascertain willingness to participate, and, if willing, an interview was arranged. We set out to obtain a maximum variation sample across the four provider organisations based on the following criteria: age, gender, long-term condition, marital status, employment status, socioeconomic status and level of engagement with Ways to Wellness (intensive to non-intensive). For the purposes of sampling, longterm condition was ascertained by the Link Worker via the referral form, and had therefore been diagnosed by a GP or other healthcare professional. The recruitment period was January to June 2016. Ways to Wellness was operational from April 2015, and in the 14 months since it started, 864 women and 739 men, average age 59 years, were referred from primary care and attended at least one Link Worker session.

data collection
We undertook one semistructured interview with each participant between January and June 2016 while they were engaged with Ways to Wellness (length of engagement ranged from 4 months to 14 months). A topic guide was developed covering: referral procedures; level and type of engagement with Ways to Wellness; goal-setting; linkage to other services; long-term condition management; changes resulting from involvement with Ways to Wellness; and views of the service. Interviews took place in participants' homes or an alternative venue of their choosing (often where they attended their Ways to Wellness appointment). Interviews were carried out by two researchers (MS and SL). Following consent procedures, demographic details were collected. Interviews continued until consistencies were identified across participants and data. 16 Transcription, data management and analysis Interviews lasted between 8 min and 1 hour 27 min (average 41 min), were digitally recorded and transcribed verbatim. Field notes were made immediately after each interview and shared among the team. Transcripts were anonymised and checked against recordings for accuracy. Thematic analysis was used 17 with data management supported by NVivo V.10 software. 18 Following close reading of the transcripts, a coding scheme was developed which contained a priori themes based on the topic guide as well as further themes which emerged from the data. The scheme captured data relating to: referral, multimorbidity, experiences of Ways to Wellness service delivery and onward referral, relationship with the Link Worker, impact of Ways to Wellness and barriers to service engagement. The coding framework was applied to an initial randomly selected five interviews, which were double-coded by MS and SL. Following this, the coding frame was reviewed by all team members, modifications agreed and made before being applied to all interviews. Line-by-line coding and constant comparison were used to code the entire data set; 19 20 deviant case analysis, where we sought out opinions which modified or contradicted the analysis, was used to enhance validity. 21

resulTs
The impact of Ways to Wellness is described by our detailed analysis of the following three themes: negative impact of long-term conditions and multimorbidity; Link Worker roles; and positive impact of the programme.

Participant characteristics
As shown in table 1, 30 adults, 14 women and 16 men, aged 40-74 years (mean age 62 years) took part. Thirteen participants were over state pension age; 4 of the 17 participants of working age were in employment. Occupational social class 22 based on current or previous main employment indicates that the sample included individuals from across the social class spectrum, excepting social class 1; social classes 2-4 accounted for two-thirds of the sample and the remaining third were from social classes 5-8. Five participants were from black and minority ethnic communities, 1 identified as white Irish and the remaining 24 were white British. Multimorbidity was a prominent feature of the sample. Based on self-reported health conditions, only one participant (15) had a single longterm condition. Most participants had more than one 'referral' long-term condition, had other health problems and associated mental health issues, low confidence and social isolation. With the exception of the diagnosed long-term conditions that triggered a referral to Ways to Wellness (ie, diabetes (types 1 and 2), chronic obstructive pulmonary disease, asthma, coronary heart disease, heart failure, epilepsy, osteoporosis) other physical and mental health problems were self-reported at interview. No further assessment of physical or mental health was made during the study.
At the time of interview, participants had been receiving the social prescribing programme for between 4 months and 14 months. Table 1 shows that the number of services that each participant reported being linked into ranged from 0 to 5; the average number was 1.7. However, seven participants (11,12,13,16,24,25,30) obtained welfare benefits advice from their Link Workers, rather than being linked into welfare rights services, demonstrating that some Link Workers drew on their specialist knowledge to assist their client rather than make a referral. Table 2 shows that 54 referrals to community, voluntary and NHS services were made for the 30 participants. These are categorised as follows: long-term condition management; mental health; physical activity; weight management and healthy eating; NHS services (eg, physiotherapy), welfare rights advice (eg, benefits advice, aids and adaptations), learning/employment assistance (eg, curriculum vitae (CV) writing), voluntary work, arts-based activities (eg, choir, art therapy), community-based activities (eg, gardening, fishing, crafts). Services promoting physical activity were the most common linkage.

Impact of long-term conditions and multimorbidity
All participants had been deeply affected, physically, emotionally and socially by their health problems. Physical effects included pain, sleep problems, side effects of medication, continence issues and significant functional limitations. With increasing age, existing conditions worsened and multimorbidity increased: Open Access Table 1 Demographic characteristics and long-term health conditions of study participants ¶Conditions which triggered a referral to Ways to Wellness were: diabetes (types 1 and 2), chronic obstructive pulmonary disease, asthma, coronary heart disease, heart failure, epilepsy, osteoporosis) with or without anxiety or depression. This column indicates the number of 'Ways to Wellness' long-term conditions that participants had been diagnosed with by a medical practitioner. **Based on self-report at interview. † †A broad category that includes low mood, anxiety, depression, loneliness and social isolation and is based on self-report at interview where participants described or reported these conditions or feelings. ‡ ‡Not known § §Received welfare benefits advice from Link Worker and were not referred onto specialist welfare rights services.
WtW, Ways to Wellness.  The level of support that some service users required in order to engage with services, particularly those involving physical activity, appeared to be considerable. Link workers paced the level of support they offered, particularly in the initial stages: Mental health Social isolation, low mood, anxiety and depression were commonly experienced. For some, this was related primarily to physical health, but for others, this was compounded by life events such as bereavement. Offering opportunities for activities, which allowed people to meet and socialise in the community, reduced social isolation and positively impacted on self-confidence, self-esteem and mental well-being: Long-term condition management Weight reduction and increased fitness helped participants manage the pain and tiredness experienced as a result of their long-term health conditions. Some participants with diabetes noted being in better control of their condition due to reduced cholesterol and sugar levels. Accounts of positive improvements often followed years of worsening health and poor long-term condition management: Regularly engaging with services was challenging, particularly for people whose condition fluctuated and those suffering from more than one health problem. Service users worried about not always being able to attend, which was often a reason for not sustaining engagement with services in the past: Open Access applicable, tackles related socioeconomic issues. This study demonstrates that the rapport and quality of the relationship between the Link Worker and service user was central to achieving well-being, as well as key to successfully linking service users into a wide range of community, voluntary and NHS services identified as relevant to their situation. Change in health-related behaviour and longterm condition management was facilitated through the use of setting realistic, progressive and personalised goals, problem-solving, receiving regular feedback and social support. These behaviour change techniques have been shown to be effective in other lifestyle interventions. [23][24][25] Crucially these techniques were adopted while also supporting individuals to address social and economic problems. The Link Worker social prescribing programme engendered feelings of control and self-confidence, reduced social isolation and led to positive physical changes such as weight loss, increased physical activity, improved long-term condition management and mental health, greater resilience and effective coping strategies to manage relapses. Psychosocial problems, particularly mental health conditions and social isolation, are the most common reasons for referral into social prescribing programmes. 4 6 A review exploring the social prescribing evidence base identified 24 studies diverse in methodology and the service being evaluated. 6 The quantitative evidence in the review was limited with the exception of one randomised controlled trial demonstrating clinically important benefits in managing psychosocial needs at 4 months. 26 The quality of eight studies using quantitative methods was poor, with small samples and high dropout rates. 6 Qualitative evidence, from this review and more broadly, also varies in quality, but generally indicates that those referred into social prescribing schemes report improved mental well-being and reduced social isolation. 6 9 27 A systematic review and meta-analysis of exercise referral schemes, a type of social prescribing intervention, targeted at sedentary individuals with or without a medical diagnosis was inconclusive with regards to increasing physical activity, although the heterogeneity of the quality and the nature of the schemes is likely to have contributed to this conclusion. 28 The data presented in our study provide a much more in-depth account of how Link Worker social prescribing positively influences long-term condition management and how this programme can lead to improved physical and mental health outcomes.

strengths, limitations and implications
The strength of this work lies in the depth and consistency of the service user accounts regarding the impact of Link Worker social prescribing. Methodologically, we followed accepted practice in fieldwork, analysis and interpretation. 29 30 There are a number of limitations. First, although the sample did include people with a wide range of long-term conditions, almost all with multimorbidity, and many experiencing social isolation and mental health problems we did only interview people who agreed to a referral, then enrolled into and remained with Ways to Wellness. We therefore cannot make claims about patients with long-term conditions who did not engage in the first place or who dropped out of the programme early. Second, we cannot be certain of the extent to which the experiences of the 30 study participants reflect those of the 1603 who used the service, although maximum variation sampling was used to include a wide range of participant experience. Third, the study lacks precise data about levels of participation in 'linked' services. We therefore cannot draw specific conclusions about the effects on health and well-being with respect to intensity and duration of 'linked' service use. These areas are undoubtedly important for further research.
Long-term health conditions are arguably the greatest challenge facing the NHS; they have an adverse effect on quality of life and reduce life expectancy. Multimorbidity accounts for over 70% of total healthcare spend. 31 Non-medical interventions are proposed as a cost-effective alternative to foster self-management in people with long-term conditions. 32 33 People from lower socioeconomic groups experience higher levels of chronic disease, and also have poorer condition management, worse health outcomes and higher mortality. 31 Behavioural risk factors for long-term conditions include poor diet, smoking and physical inactivity, all of which are socioeconomically patterned. 34 However, lifestyle behaviours are also affected by wider health determinants and are not simply choices that individuals make. 35 36 Supporting people to make meaningful and sustainable lifestyle changes is complex, time-consuming, and a challenge for time-limited GPs. 11 Given the complex and long-term nature of the problems faced by service users, it is unsurprising that a holistic and relatively intensive approach, as offered by Ways to Wellness, is required in order to facilitate and maintain behaviour change, and it is clearly not possible, nor appropriate to offer this level of support routinely in primary care. Referral into social prescribing programmes is likely to continue due to the need to tackle long-term health conditions, multimorbidity and an ageing population in the face of stretched NHS resources. 33 37 The range of approaches to, and models of, social prescribing 38 make it challenging to amass good quality evidence to inform commissioning. 37 38 In order to inform practitioners and commissioners, future research should be robust and comparative, addressing when, for whom and how well the programme works, including validated measures of intervention impact and accurate costs. 37 To this we would add further qualitative, particularly ethnographic, research to examine potential wider impacts on families and communities and how community-based, non-medical and personalised interventions supplement healthcare.

Open Access
Contributors SM, LP and NO'B conceived and designed the research and obtained funding. MS and SL undertook interviews. SM, MS, LP and SL contributed to the data analysis. SM, MS, SL, LP and NO'B wrote the paper. All authors read and approved the final version.
Funding This work was funded by the Cabinet Office of the UK Government (grant number A1543). The researchers are independent of the funders and the views and opinions expressed in this paper are those of the authors and not necessarily those of the Cabinet Office. The funders and sponsors (Newcastle University) had no role in the design, collection, analysis and interpretation of the data, or the writing of this paper or the decision to submit this article for publications. All authors had full access to the data in the study and can take full responsibility for the integrity of the data and the accuracy of the analysis. Suzanne Moffatt is a member of Fuse, the Centre for Translational Research in Public Health. Fuse is a UK Clinical Research Collaboration (UKCRC) Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, under the auspices of the UKCRC, is gratefully acknowledged. The views expressed in this paper do not necessarily represent those of the funders or UKCRC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.