Background:

Link worker social prescribing enables health-care professionals to address patients’ non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking.

Objectives:

To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement.

Data sources:

Quality Outcomes Framework and Secondary Services Use data.

Design:

Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April–July 2020).

Study population and setting:

Community-dwelling adults aged 40–74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK.

Intervention:

Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions.

Participants:

(1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients.

Main outcome measures:

The main outcome measures were glycated haemoglobin level (HbA_1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score.

Results:

Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA_1c level (–1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to –£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval –0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems.

Limitations:

The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise.

Conclusions:

This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances.

Future work:

To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts.

Trial registration:

This trial is registered as ISRCTN13880272.

Funding:

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

Why we did this research:

Social prescribing happens when health-care staff refer patients to a link worker. Link workers support and help patients to access community services to improve their health and well-being. Social prescribing is popular within the NHS, but there is little evidence that it works. We looked at a social prescribing model being delivered in a disadvantaged area in north-east England.

What we did:

We used different methods to find out if social prescribing improved health and well-being:

• We compared data from medical records of over 8000 patients with type 2 diabetes whose general practice used social prescribing with data from similar patients in surgeries that did not. Data included blood pressure and blood glucose control. We also calculated if social prescribing was good value for money.
• We spent time with link workers and patients observing their routines and interviewing them about their experiences.

What we found:

In general practices that accessed social prescribing, blood glucose control for people with type 2 diabetes improved by a small but statistically significant amount. Other health outcomes did not improve significantly. Social prescribing cost more than usual care.

Patients who were given support that matched their needs could achieve positive changes and deal with social and health-related problems, for example getting benefit entitlements helped with reducing anxiety. However, providing the right type of support was time-consuming and challenging because of the high caseload of link workers and because many patients were living in difficult circumstances.

What it means:

This model of social prescribing improved blood glucose control for people with type 2 diabetes but was not necessarily good value for money. Social prescribing provided other important benefits, such as support to connect with community services that help improve health and well-being, but it was challenging to deliver and its effects were difficult to measure and varied from patient to patient.

Article history

The research reported in this issue of the journal was funded by the PHR programme as project number 16/122/33. The contractual start date was in July 2018. The final report began editorial review in April 2021 and was accepted for publication in December 2021. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The PHR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.