Social prescribing

SP as an approach aims to reduce the burden on primary care in the UK NHS and healthcare systems globally. It is commonly reported that “Around 20% of patients consult their GP for primarily social issues” [2, p6]. As such patients with non-medical needs (i.e. social needs) are referred out of the ‘medical model’ of healthcare, and into existing social prescribing schemes, either directly or via social prescribing link workers, and public sector referral [3, 4]. This approach recognises that health is determined by a range of social, economic and environmental factors, commonly known as the social determinants of health, such as poverty and social isolation and aims to reduce social inequalities and promote health equity [5, 6].

As an umbrella term, SP offers varied routes into society which promise to support, enhance, and empower individual citizens to take control of their own health and wellbeing. Under the umbrella several subsets have emerged: creative or nature-based referrals, welfare services, exercise referrals, education programmes or befriending support [7]. Referrers can link patients to activities across these sub-sets, such as gardening, arts and crafts, or group exercise classes, which provide opportunities for social interaction and engagement [8]. Having stemmed from ‘grass roots’ initiatives significant heterogeneity is evident in the sector, as local communities and organisations develop services in response to local population needs [2].

While there is no current agreed definition, there is general agreement that SP is a systematic mechanism for linking people with existing services and sources of support within the community to help improve their health and wellbeing [9]. Equally social prescribing is understood to be a complex intervention, based on several key principles, including person-centred care. Working in partnership with patients [10], social prescribing link workers (SPLW), identify patients’ goals, aspirations and unique circumstances and develop personalised care plans that reflect individual needs and preferences [8]. This model also draws on a community and asset-based approach to health promotion [11]. SPLWs connect patients with local community services. Finally social prescribing adopts a collaborative approach; it is viewed as a partnership with and between stakeholders, including patients, healthcare professionals, community organisations, and local authorities [12]. It is important to note that social prescribing is not considered an emergency or acute service [13].

Globally 17 countries have a recognised SP agenda [13, 14] including England (UK) [15]. In Wales (UK) a national framework was announced in December 2023 that builds on multiple Welsh government policies which have consistently focused on supporting citizen health and wellbeing and articulated a solid commitment to a preventative approach to health. For example, the goal of the Future Generations Act (Wales) 2015 [16] “is a society in which people’s physical and mental well-being is maximised and in which choices and behaviours that benefit future health are understood”. ‘A Healthier Wales’ [17] voices this commitment.

Evidence

While political agendas have embedded SP into healthcare services, the evidence base remains mixed. For example, systematic reviews have widely reported positive effects of participation, including the establishment of new friendships and social links, a sense of belonging, reduced social isolation, increases in service users’ ability to take action to improve their own health and wellbeing, improved sense of social connectedness, reduced healthcare utilization, and improvements in meaningful employment and return to work rates [18–24]. Many of which have also reported that community-based schemes are well-received by patients and healthcare providers alike [21]. However systematic reviews have also consistently reported key limitations, such as small-scale studies, high risk of bias, lack of comparison, short follow-up periods [22–24] and no benefit for GP workload [25] despite noting many positive outcomes including improvements in service users’ self-esteem, self-value, and hope.

Looking at nature-based social prescribing (NBSP) specifically several studies have reported positive outcomes for service users. One green SP programme provided by Gloucestershire Wildlife Trust [26] reported significant levels of increased wellbeing for patients recovering from cardiovascular health conditions. Two green SP projects reported positive value, post pandemic [27, 28]. And a 12-week outdoor walking and climbing scheme in North Wales showed a positive financial return on investment; for every £1 invested, up to £5.36 was generated [29]. Thus, effectively contributing to national policy goals and improved health and wellbeing outcomes at individual level. Several recent reviews have also added support. For example, one American review [30] concluded that NBSP in urban settings improved social connectedness. However, authors noted additional research was required to understand the impact for at-risk populations. While a review of 38 studies [31] reported that group based, NBSP cultivated social connectedness with greater evidence for longer term interventions. Furthermore, benefits of NBSP are reported for mental health outcomes when combined with traditional therapeutic approaches [32]. While a large three-year UK evaluation study concluded there was clear evidence that NBSP leads to positive impact on people’s mental health and wellbeing.

However, as NBSP emerges and expands it is imperative to understand not just the service user perspective but also the service coordinator, referrer and service providers experience and perspective i.e., a multi-stakeholder perspective is critical. Without referrals into NBSP schemes and without provision of NBSP schemes, the approach will fail. As such the current study aimed to interrogate and explore the concept of social prescribing from a multi-stakeholder perspective, to develop understanding of the systems and services in place at a local level and the views and experiences of those currently involved. Qualitative enquiry enables in-depth examination and exploration [33].

Ethics

Ethical approval was obtained from Swansea University Medical School Research ethics committee (ref# 2022 SUMS RESC 2022-0016A).

Research objective

The study set out to answer the following question ‘how do different stakeholders conceptualise and perceive social prescribing, in South Wales (UK) with a focus on NBSP?’

Approach

A qualitative approach was used. A series of sequential group-based research workshops were facilitated to enable discussion and interrogation of the concept of SP and the local mechanisms in place to co-ordinate and deliver SP, from a variety of viewpoints; supplemented with one-to-one interviews to explore group identified issues in further depth and detail [33].

Recruitment

Local stakeholders currently involved in the co-ordination, referral and or delivery of NBSP initiatives in South Wales (UK) were identified through document review, review of local council internet pages, existing network contacts and through discussions with staff at one local NBSP scheme (Swansea Community Farm; who offer a structured programme of outdoor volunteering targeted at adults with mental health issues, long term unemployment and other disadvantages). Identified stakeholders were invited via email to take part in a series of research workshops. Those emailed were encouraged to share the invitation with relevant contacts, colleagues, and networks, to ensure as wide a reach as possible.

This purposeful, convenience sampling approach identified a range of stakeholders; including those who coordinated SP services in the local area, acted as link workers, provided SP schemes, and several social enterprisers involved in the creation of community schemes and academics involved in local SP projects. It was anticipated that each workshop would include 15–20 stakeholders of which, a range of stakeholder roles would be included, to ensure discussion from different perspectives and to enable networking and information sharing.

Participants

Participants were NBSP stakeholders in south Wales (UK). Inclusion criteria were

1. Actively involved in the co-ordination*, referral** or delivery*** of NBSP services in south Wales* and wider stakeholders****
2. Aged 18 and above.
3. Ability to provide informed consent.

*Service co-ordinators, defined here as those coordinating the delivery and funding of SP schemes in the local area.

**Service referrer, defined here as individuals working in a link worker role who had responsibility for patient referrals into a NBSP service/scheme.

***Service providers, defined here as those who are funded to facilitate and run the actual NBSP schemes that patients are referred into (form any source including self-referrals)

****other interested parties for example, academics and researchers, social enterprisers.

Data collection

Data were collected via three research workshops, and ten one-to-one interviews held between February and July 2023.

The first and third research workshops were held online using zoom technology and these were audio and video recorded and professionally transcribed. The second was held in-person at a local NBSP venue, Swansea Community Farm, a small city farm. The workshops produced group notes, recorded on flip charts and researcher field notes and observations.

All workshops included an initial welcome and project overview. However, each workshop was designed as a standalone event, to ensure a variety of stakeholders could attend. The workshops focused on exploring stakeholders’ understanding of SP, current models and practices in place locally, and the role of NBSP schemes in Wales in relation to current Welsh public policy. At each workshop two different stakeholders were invited to present and discuss their NBSP schemes which was followed by a question-and-answer (Q&A) section. This also provided an opportunity for knowledge transferral. After the presentations and Q&A the researchers introduced a specific topic for discussion as a stimulant for the remainder of the session. Workshop topics were: ‘what does SP mean to you?’ ‘Metrics, measurement and impact’, and ‘organisational needs’.

At the end of each workshop a summary and thank you speech was included. At which point all participants were invited to take part in a follow-up one-to-one interview, the purpose of which was to explore topics covered in the workshop in further detail and depth; to seek clarity on topics raised and find out more about individual stakeholder roles. The subsequent interviews were facilitated [MB] via zoom or in-person, and these were arranged via email and scheduled for a mutually convenient time and date. Each was audio or audio, and video recorded, and professionally transcribed for analysis.

Data analysis

Data were analysed using reflective thematic analysis informed by the work of Braun and Clarke [34]. This involved following a staged process; stage one involved re-familiarisation with the data collected via rereading of the transcripts and revising the flip charts, and researcher field notes. Stage two involved line by line coding of transcripts [MB] using inductive coding which informed the creation of a thematic map. This was then used repeatedly by the researchers to aid discussion of the data. For example, the thematic map helped the researchers to organise the data, to identify patterns in the data; this included noting reoccurring topics, issues and points of interest raised by the stakeholders and identification of areas of agreement or disagreement. The codes were mapped and grouped to identify themes. Themes were agreed and labelled and associated codes and raw data were re-examined for validity. Themes were then shared with stakeholders for commentary via email before being finalised.

Participants

In total 39 different stakeholders took part. A total of 55 invitation emails were sent ahead of workshop one, 12 of which generated interest, but recipients indicated that the date was unsuitable and 21 agreed to attend. A further 24 contacts were identified ahead of workshop 2 of which 15 responded to say they were interested but the date didn’t suit and 16 agreed to attend. However, one did not attend on the day. The final workshop had the least attendees, only 7 stakeholders were present, four of whom had attended a previous workshop. No additional contacts were identified and invited ahead of this workshop. Table 1 reports the breakdown of participants per data collection activity and reports the date, delivery format and type of stakeholder included. The variety of stakeholders included in each workshop meant that a range of different NBSP schemes were included for discussion across each workshop as planned.

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Table 1. Workshop and stakeholder descriptions.

https://doi.org/10.1371/journal.pone.0314107.t001

Social prescribing models

The workshops identified several different approaches to SP and these align with SP models described in the NFSP [7]. For example, the ‘social prescribers’ and ‘community connectors’ role align with the ‘SP link worker model’ whereby GPs and other primary care professionals refer patients into a coordinated social prescribing service, (see Fig 1) often based in GP clusters. For example, in the local health board area five ‘social prescribers’ offered services for a duration of 17.5 hours per week each across five GP clusters which covered the geographic range of the local health board, which until March 2023 was a virtual only service (due to COVID-19 pandemic) and which was slowly returning to an in-person service. Taking a person-centred approach these ‘social prescribers’ described their role as involving the identification of individual needs and the co-production of a personalised social care plan. They provided individual sessions which lasted between 30–60 minutes. Depending on geographical area, the number of sessions offered varied, in the local health board area it was up to six with an additional six available where need arose. In a different health board, only three sessions were available. These social prescribers offered supportive conversations, life coaching (however this has recently been removed from the role), signposting to ‘basic needs’ support services (which included, housing, employment, and financial support) and or transferral into therapeutic mental health services (at which point the patient exited the SP service). During the sessions, onward referral into third sector organisations was often made, based on individual interest, capacity and availability.

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Fig 1. Flow chart depicting the flow of patients into SP schemes in the local area.

https://doi.org/10.1371/journal.pone.0314107.g001

Other link worker roles identified were called community connectors. These individuals undertook a similar role, they supported individuals and made onward referrals, but their service was accessible independently of primary care.

Across Wales, the terminology used for social prescribers varied considerably. Table 2 shows a list of terms identified during the data collection phase. The Wales School for Social Prescribing Research (WSSPR) have published a glossary of terms to provide clarity and to standardise the language used within the field [35]. This may help address the confusion apparent in the field.

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Table 2. Social prescribing link worker titles and areas identified in use.

https://doi.org/10.1371/journal.pone.0314107.t002

The second model identified was the local area coordinator (LAC) model; funded by the local council and supported by additional grant funding this takes a long-term approach to supporting people within the community and is not time bound. For example, clients (not patients) are supported for as long as there is a need. In one example provided covered a three-year period. In the local health board area 23 LACs are embedded in the local community. LAC stakeholders described their role as ‘walking alongside clients’ (interview 9, LAC) taking a strengths-based approach. They initiated a connection directly with clients within their community or via informal and formal connections [36, 37]. LACs also made onward referrals into third and voluntary sector SP schemes including NBSP schemes and had a dual role to support the development of community schemes and facilitate social connections and the development of social capital.

In addition to these two models, citizens can self-refer directly into third sector or voluntary SP schemes, and they can also request to see a SP via a GP receptionist (if the surgery offer SP) or they could be referred by public servants e.g., (social workers, Occupational therapist, librarians, allied healthcare professionals etc.) who have a civic duty to upload the values of the future generations Act [14]. Both these referral routes are recognised in the newly announced national framework for SP [7].

Thematic findings

Five themes were identified from across the research workshops and interviews, three focused on current barriers and challenges faced by stakeholders and two focused on uncertainty regarding evaluation and monitoring efforts to capture effectiveness and value of schemes for service users. Service coordinators and referrers did not comment on these latter two themes. The themes were ‘Lack of consensus’, ‘Tension’, ‘Funding’, ‘Evaluation’ and ‘Uncertainty’.

Comparison to literature

We are unaware of similar studies which explored stakeholder views of SP which revealed or discuss a lack of consensus on how SP is conceptualisation. However, we are aware of the confusion in the sector resulting from the myriad of terms, roles and descriptions used to explain and describe those involved in its coordination and delivery. The SPLOSSARY [35] and NFSP [39] will be of value in addressing these differences.

When considering the themes identified in the current study, many are in line with recent literature. For example, Bertotti et al. [42] reported a realistic evaluation of a green SP intervention to address poor physical health. Authors identified that while social prescribing had benefits for individuals’ communities and society, key issues for service providers remained unaddressed. Those issues resonate with the findings of the current study. Namely the critical need for long-term, sustainable financial support for third sector voluntary organisations who provide the NBSP activities which GPs, SPLWs and LACs (and others) refer into. Secondly, they discussed the need for ‘buy in’ from primary care refers such as GPs to ensure visibility and increase service accessibility within the medical model. This was also a critical challenge for social prescribers (referrers) and third sector organisations (providers) alike. An issue which took valuable service time and required significant investment in terms of time, relationship building and resources. Of interest the one GP in attendance was aware of SP but did not work directly with the five social prescribers in the health board.

Analysis was also in line with qualitative findings reported by Fixxen & Barrett [27] who outlined critical challenges associated with green social prescribing in the context of the Covid-19 pandemic. For example, their data also indicated that stakeholders had critical concerns relating to longevity of funding, sustainability of schemes and, widespread agreement that social prescribing link workers were hesitant to refer into NBSP interventions due to worries about relevancy, age and accessibility. Equally Sumner, Sitch, & Stonebridge [26] reported similar barriers to engagement which included mobility and fitness concerns and differing priorities. While McHale et al. [43] reported similar stakeholders’ (n = 55) concerns relating to sustainability of funding in Scotland.

Improving population health requires SP to be comprehensive and to address domains beyond the traditional medical model to include health promotion and the social determinants to impact the entire population: it needs to be universal and accessible to everyone. Fragmentation in care means that those less able to manage their own health are more likely to ‘fall through the gaps’, and thus, integrating SP into the healthcare system can improve accessibility and navigation through services systems are integrated, they have an increased ability to adapt in tandem with other services [44].

Study limitations

While this study explored stakeholder perspectives using qualitative data collection methods the findings reported here should be interpreted in the context in which they were gathered. Equally they are time bound. They represent views of the current system and models in place in Wales, UK and the benefits and challenges highlighted may change over time. As noted earlier, the study was conducted prior to the Welsh government publishing their national framework for SP and thus stakeholder perceptions are likely to change following the formalisation and standardisation of the services in place. As such, future work should continue to explore multiple-stakeholder perspectives to understand and address sector challenges following the implementation of the framework to understand the impact this has had on stakeholders as well as service users, not to mention society. It would be valuable to return to these stakeholders and find out how the national SP framework has impacted their roles and organisations and whether funding challenges for example have been alleviated.