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Evaluation Report of the Social Prescribing Demonstrator Site in Shropshire -Final Report

Authors:
  • Marie Polley Consultancy Limited; Meaningful Measures Ltd; Visiting Reader UEL; Social Presribing Network

Abstract and Figures

1 The Social Prescribing Unit @ University of Westminster is focused on innovation in the field of social prescribing and growing new ideas. The team has considerable expertise in contract research, consultancy, evaluation and mixed methods research. We are also experts in supporting the implementation of social prescribing within organisations in the VCSE sector, the public sector and the private sector. We have provided advice to policy makers and have led major initiatives in social prescribing nationally and internationally. We founded and Co-Chair the Social Prescribing Network, have produced guidance documents, collaborated to develop the Medical Student Social Prescribing Network and the Social Prescribing Youth Network. We have worked alongside NHS England to shape social prescribing and fully believe that change happens by collaboration not competition.
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Evaluation Report of the Social Prescribing
Demonstrator Site in ShropshireFinal Report
July 2019
Dr Marie Polley,
Dr Helen Seers,
Dr Alison Fixsen
University of Westminster
1
The Social Prescribing Unit @ University of Westminster
is focused on innovation in the field of social prescribing and growing new ideas. The team has
considerable expertise in contract research, consultancy, evaluation and mixed methods
research. We are also experts in supporting the implementation of social prescribing within
organisations in the VCSE sector, the public sector and the private sector. We have provided
advice to policy makers and have led major initiatives in social prescribing nationally and
internationally. We founded and Co-Chair the Social Prescribing Network, have produced
guidance documents, collaborated to develop the Medical Student Social Prescribing Network
and the Social Prescribing Youth Network. We have worked alongside NHS England to shape
social prescribing and fully believe that change happens by collaboration not competition.
Acknowledgements
We would like to thank all the participants who agreed to take part in the service evaluation. We
would also like to thank the Shropshire Council for commissioning this evaluation and in
particular the Help2Change team, including the public health consultants for their input and
teamwork throughout the first phase of this evaluation. In particular, we really appreciated the
help and support given to us by the people below:
Katy Warren Social Prescribing Project Lead Help2Change, Shropshire
Dr Kevin Lewis Director of Help2Change, Shropshire
Jo Robins Consultant in Public Health, NHS E Regional Facilitator - Midlands Social
Prescribing Network, Shropshire Public Health
Claire Sweeney Help2Change Lead Advisor, Shropshire
Emma Sandbach Public Health Specialist, Shropshire Council
Craig McArthur H2C Data Management and Audit Specialist, Help2Change, Shropshire
Disclaimer
The views expressed in this report are those of the authors and do not necessarily represent those
of Shropshire Council
How to cite this report
Polley M, Seers H and Fixsen A (2019). Evaluation Report of the Social Prescribing Demonstrator
Site in Shropshire Final Report. University of Westminster, London.
Main Contact:
Dr Marie Polley,
Director, Social Prescribing Unit, School of Life Sciences
University of Westminster, 115 New Cavendish Street
London, W1W 6UW T: +44(0)20 7911 5000 extn 64627
E: M.Polley@westminster.ac.uk
2
Contents
Executive Summary 8
1.0 Introduction 11
1.1 Challenges facing population health in Shropshire 11
1.2 Social prescribing 11
1.3 The development of the Shropshire social prescribing service 13
2.0 Methods 16
2.1 Design 16
2.2 Participants and recruitment 16
2.3 Data collection 16
2.3.1 Patient Reported Outcome Measures 16
2.3.2 Physiological Data and Health service usage 16
2.3.3 Stakeholder Interviews 17
2.4 Data Analysis 19
2.4.1 Qualitative Analysis 19
2.4.2 Quantitative Analysis 19
3.0 Results 21
3.1 Service Design and Implementation 21
3.2 Service referrals and demographics 26
3.3 Service user satisfaction and experience 30
3.3.1 Satisfaction 30
3.3.2 Service user experience 30
3.4 Impact of the service 35
3.4.1 Measure Yourself Concerns and Wellbeing (MYCaW) 35
3.4.2 Patient Activation 40
3.4.3 Loneliness 44
3.4.4 Physiological data 46
3
3.4.5 Health service usage 48
3.4.6 Working situation 50
4.0 Conclusion 51
5.0 Recommendations 52
Appendices
A Referring medical practices 55
B Organisations and services referred to by the Link Workers 56
4
Figures
Figure 1. The key foci identified for the Social prescribing demonstrator service. 14
Figure 2. Range and frequency of ages of service users. 26
Figure 3. Reasons for opportunistically referring individuals into the social
prescribing services. 27
Figure 4. Comparison of opportunistic referrals from Oswestry & Ellesmere GP
practices vs evaluation practices. 28
Figure 5. MYCaW concerns which related to modifiable risk factors for CVD. 36
Figure 6. All other MYCaW concerns not related to modifiable risk factors for CVD. 36
Figure 7. MYCaW concerns and wellbeing scores at baseline vs 3 months follow up. 38
Figure 8. A comparison of participant activation levels before and 3 months after
being referred into the social prescribing service. 41
Figure 9. A comparison of the proportion of participant’s activation levels. 41
Figure 10. De Jong Gierveld Loneliness scale scores. 45
5
Tables
Table 1. Summary of questionnaire data collected at baseline and 3-month follow-up. 17
Table 2. Characteristics of participants taking part in semi-structured interviews. 18
Table 3. Demographic data of individuals who participated in the evaluation. 29
Table 4. MYCaW Concerns and Wellbeing scores. 37
Table 5. Comparison of PAM score pre and post intervention. 40
Table 6. PAM questions that showed statistically significant improvements in scores. 42
Table 7. Comparison of levels of loneliness in evaluation participants. 44
Table 8. Levels of loneliness 45
Table 9. Comparison of physiological data upon referral to the social prescribing
service and at 3 months follow-up. 46
Table 10. Analysis of changes to BMI categories 48
Table 11. Changes to health service usage. 49
Table 12. Analysis of participant’s work-related activities. 50
Table 13. Breakdown of referral numbers to the social prescribing service
from medical practices in Shropshire. 55
Table 14. The organisations referred to by the social prescribing advisors. 56
6
Well, I can’t thank them enough for what they did for me”
What was the most important thing about this service? “Being able to
open up and discuss concerns, where doctors and nurses keep telling
me I need to lose weight but don't have time to advise…”
What was the most important thing about this service? “Helping me
reach my goals and not judging me, but most of all treating me as a
person and not a number.”
“The initial appointment with the social prescribing advisor has changed
my life. I am now fitter and have lost 2 stone in weight. I feel more
energetic and healthier”
7
Executive Summary
Aim: To develop a robust social prescribing service using best practice in development and
data collection.
Objectives: To evaluate the Shropshire social prescribing demonstrator site to understand why
the social prescribing programme is being used and how well the components of the social
prescribing model are working together.
Design: Formative service evaluation using mixed-methods data. A single arm, quasi-
experimental pre-post data collection design was used to see the longitudinal benefits of the
Social Prescribing service. A matched control was used to compare health service usage
between people who did and didn’t use the social prescribing service. Ethics approval was
received from the University of Westminster Research Ethics Committee before the evaluation
was started.
Participants and recruitment: Participants were identified retrospectively based on a CVD
Qrisk2 score of 10% or more, and by pre-diabetes risk from Hba1c 42-28 mmol/mol.
Participants were also opportunistically referred to the social prescribing link worker via Qube,
Adult Social Care, the Department of Work and Pensions, Adult Social Care, Oswestry library,
or by local GPs during appointments.
Data collection:
Quantitative data: A questionnaire pack was administered by the social prescribing advisors at
baseline and 3 months follow-up. Interviews with professional stakeholders setting up the social
prescribing service and with service users to were carried out to capture their experiences. The
questionnaire pack consisted of:
1. Measure Yourself Concerns and Wellbeing (MYCaW)measures patient concerns
self completion with five questions (either self-completion and/or as part of an initial
appointment).
2. Patient Activation Measure (PAM) series of 13 statements about beliefs and patient
confidence around the management of their individual condition (linked to health
behaviours, clinical outcomes and costs for delivering care)
3. De Jong Gierveld Loneliness scale 6 items
4. Working status and relationship status
5. Patient Satisfaction Survey (administered at 3-month follow-up only)
Qualitative data: Interviews with 24 stakeholders including service users were carried out,
recorded, transcribed and thematically analysed. Key themes were identified to understand how
people valued the social prescribing service and the impact it was having.
8
Findings:
The service design adhered to best practice as set nationally by the Social
Prescribing Network and NHS England, whilst developing the service on a practice by
practice basis and only using existing resources. This required encouraging
collaborations between many stakeholders, including the GP champion, GP practice
manager, Operational Project Lead, Data lead, and Lead Adviser role. Importantly this
project has enabled greater collaboration between the local authority and CCG.
The Shropshire social prescribing approach was highly aligned with the most
recent Public Health strategy1 as well as with potentially reducing the need for core
aspects of Adult Social Care services. The Care Act, 2014 explains that it is the
responsibility of the local authority to promote the wellbeing of individuals. Wellbeing is
comprised of personal dignity; physical, mental and emotional well-being; protection from
abuse and neglect; control over day-today life; participation in work, education, training or
recreation; social and economic wellbeing; domestic, family and personal relationships;
suitability of living conditions and the individuals’ contribution to society.
An agile management approach to service development was deliberately employed
and the local Help2Change team carefully tested things out, then paused and reflected
before proceeding. An expanding range of different sectors are now getting involved in
the social prescribing service and it has expanded from an initial demonstrator site in
Oswestry and Ellesmere to covering 5 regions in Shropshire.
Between May 2017 May 2019 515 referrals were made into the social prescribing
service via 4 services in Oswestry/Ellesmere, Albrighton, Bishop’s Castle, Bridgnorth and
4 GP practices in Shrewsbury, which incorporates 11 GP practices. 134 people were
recruited into the evaluation, with 3-month follow up data from 105 people.
Feedback from service users was very positive. Satisfaction ratings were 4.8/5 for
suitability of times, convenience of venue and feeling able to discuss concerns with
the social prescribing advisor. Participants reported feeling heard and supported, and
that the service was meeting their needs by addressing them not as a ‘condition’ or
disability, but as a person, with their own set of social and emotional wishes and wants.
The social prescribing service supported unmet needs beyond the expected remit,
due to the inclusion of link workers in the service, which provided an individualised
element. The MYCaW concerns that participants reported ranged from lifestyle advice
through to social determinants of health and concerns related to adult social care.
The patient reported outcome data demonstrated statistically significant
improvements in participants’ MYCaW concerns (p=0.001) and Wellbeing (p=0.001),
1 Department of Health and Social Care (2018). Prevention is better than cure. Our vision to help you live well for longer
9
activation levels (PAM) (p=0.000), and the De Jong Gierveld measure of emotional
loneliness (p=0.05).
Score changes translated into improvements in weight, BMI, cholesterol (p=0.043),
blood pressure (p=0.007, diastolic), levels of smoking and physical activity.
Reasons why the social prescribing service has triggered changes have been
captured via qualitative interviews and the MYCaW tool. Participants particularly valued
the role of the social prescribing advisor. Not only was this due to the 1:1 time with a
social prescribing advisor, but their training in motivational interviewing amongst other
things, and the support an individual received to access an appropriate group when the
time was right.
Overall the full set of data captured provides a compelling explanation for the
statistically significant (40%) reduction in GP appointments for participants at the 3-
month follow-up, compared to a matched control group of people who did not use the
social prescribing service.
Above all, the social prescribing service seeks to address real life social complexity
and inequalities by offering integrated, holistic solutions to multifaceted health and social
care issues.
Recommendations:
It is recommended that the social prescribing team discuss the intention and benefits of
the social prescribing service with GPs, to develop more relationships that will lead to an
increase in referrals and integration of social prescribing into the GP consultation.
Regularly review referral and audit processes to be to ensure that the people are clear
about why they are being referred to a social prescribing advisor, and that those whose
needs can be addressed by the service are being referred.
We would recommend seeking out more ways to access those people who are lonely and
isolated, including young people (widening the service to people under 18 years of age),
who could be referred Department of Work and Pensions, or even through colleges.
It is recommended that attention is given to informing service users if the social prescribing
advisor is going to change.
It is recommended that social prescribing advisors receive CPD training in areas such as
mental health issues and alcohol and substance abuse.
It is recommended that review of collecting physiological data such as weight, is
undertaken to address issues identified around lack of rooming or equipment if future
evaluation is to be carried out.
10
1.0 Introduction
1.1 Challenges facing population health in Shropshire
Shropshire is a rural county in the West Midlands of England near the border of Wales. The rurality
creates challenges for the local population, for example, with limited transport and difficulty
accessing services and response times for the emergency services.
The key public health issues in Shropshire which cause the highest demand for health and social
care expenditure include cardiovascular disease, musculoskeletal disease, respiratory disease
and falls in older people. Furthermore, an estimated 23,000 people in Shropshire have type 2
diabetes and 31,600 adults estimated to have prediabetes. Public Health funding of only £39 per
head has been allocated until 2019 (England average £59 per head); thus to achieve positive
impact on health and wellbeing requires strategic vision.2 These health inequalities in Shropshire
contribute to a difference in life expectancy of 5.8yrs and 2.6 years lower for men and women
respectively, compared with the least deprived areas.
Many of the ‘high spend’ non-communicable diseases affecting the Shropshire population have
modifiable risk factors which, with support, a person can change. The modifiable risk factors
include, obesity, high cholesterol levels, high blood pressure, physical inactivity, smoking, and
excess alcohol consumption. It is also understood that when a person becomes more physically
active, this will also improve other risk factors such as obesity and has multiple physical and
mental health benefits. These benefits include a lower risk of cardiovascular disease, high blood
pressure, breast cancer, colon cancer and delayed onset of dementia. 3
Interventions such as social prescribing can support a person to address these modifiable risk
factors and have a positive impact on a person’s health and wellbeing and reduce the usage of
health care utilisation. In a review of health service usage, where social prescribing schemes
were implemented, a significant reduction in GP appointments, admissions to A&E, unplanned
admissions to secondary care and a reduction in prescribing were all found.4
1.2 Social prescribing
Social prescribing is an innovation that formally links patients with non-medical sources of support
within the voluntary, community, social enterprise sector (VCSE), in order to improve their long-
term health and wellbeing. Identified individuals can be referred into a social prescribing service
2 Shropshire Council (2018) The public Health vision
3 World Health Organisation (2010). Global recommendations on physical activity for health. Geneva.
4 Polley M et al (2017). A review of the evidence assessing impact of social prescribing on healthcare demand and cost
implications. Commissioned by NHS England. Download at
https://westminsterresearch.westminster.ac.uk/item/q1455/a-review-of-the-evidence-assessing-impact-of-social-prescribing-
on-healthcare-demand-and-cost-implications
11
via a range of referral routes (e.g. primary care, secondary care, allied health, social care or
statutory services) by a link worker5. For the Shropshire social prescribing service, the link worker
is called a social prescribing advisor and therefore this role will be referred to as the social
prescribing advisor henceforth. The social prescribing advisor is a non-clinical person who excels
at developing relationships so that people feel able to explain what is happening in their life. A
consultation with a social prescribing advisor may last 1 hour, in which time a person’s
preferences and unmet needs are discerned. The individual is then supported to access
appropriate support, usually via the VCSE.6,7 For some individuals, they may have several
consultations with the social prescribing advisor before being ready to move onto a community
group or activity. The time spent building trust and agency with the social prescribing advisor is
seen as a key part of the social prescribing intervention.
Social prescribing was first reported in 2008. Since January 2016 with the development of the
Social Prescribing Network, and collaborative working with NHS England, social prescribing is
now a key part of the government’s Connected Society strategy.8 Under the new NHS England
universal personalised care strategy, the scaling up of social prescribing to all Clinical
Commissioning Groups (CCGs) is underway. For the first time in history, social prescribing is part
of a GP contract in the UK. This represents a system-level response to tackling loneliness and
social isolation as well as reducing health care utilisation and improving health and wellbeing.
From a public health perspective, the recently announced public health strategy9 emphasises the
need for substantial improvement to be made to lifestyles e.g. a reduction in smoking, reduction
in obesity, reduction in excessive alcohol intake. The strategy also acknowledges the value of
paid work and volunteering, and social connections and sets out a need for health and social care
system to be integrated with communities and employers. Importantly for public health, it
highlights the leadership role that directors of public health can have via place-based and
integrated offers to support the wider determinants of health. With the recent announcements
and funding commitments to social prescribing, it is critical to now develop robust, sustainable,
integrated and evidence-informed place-based services, where all key stakeholders are working
together.
The Care Act, 201410 requires the local authority to promote the wellbeing of individuals.
Wellbeing is comprised of personal dignity; physical, mental and emotional well-being; protection
from abuse and neglect; control over day-today life; participation in work, education, training or
5 The link worker is the generic name for this role, and is referred to in all national policy information about social
prescribing. For the Shropshire service this role is called the Social Prescribing Advisor.
6 Kilgarriff-Foster, A., & O’Cathain, A. (2015). Exploring the components and impact of social prescribing. Journal of Public
Mental Health, 14(3), 127–134. http://doi.org/10.1108/JPMH-06-2014-0027
7 Kimberlee, R. (2015). What is social prescribing? Advances in Social Sciences Research Journal, 2(1).
http://doi.org/10.14738/assrj.21.808
8 HM Government (2018). A connected Society. A strategy for tackling loneliness laying the foundations for change.
Department for Digital, Culture, Media and Sport.
9 Department of Health and Social Care (2018). Prevention is better than cure. Our vision to help you live well for longer.
10 The Care Act (2014) HM Government
12
recreation; social and economic wellbeing; domestic, family and personal relationships; suitability
of living conditions and the individual’s contribution to society. Social prescribing has been of
benefit for individuals who would have needed adult social care support e.g. where people need
support after discharge from hospital. This was evidenced by a significant reduction in unplanned
admissions to hospital.11
Research12 has indicated 7 core principles that provide new social prescribing with the best
chance of success. These include:
Collaborative relationships with people in different sectors
Funding commitment
Understanding of social prescribing and buy in from intended referring professionals
Simple, clear referral process
Skilled link worker, liaising with Voluntary Community and Social Enterprises (VCSE)
Person centred scheme, flexible in time and location
Vibrant and sustainable VCSE
Ingredients seen as integral to social prescribing schemes are:
Governance
Communication and feedback
Research data
1.3 The development of the Shropshire social prescribing service
The Shropshire health and wellbeing strategy aims to promote and maintain health by working
collectively and collaboratively to identify and test out solutions13. As part of this strategy, there
is an aim to reduce health inequalities within this community.
A scoping phase in November 2016 involved interviewing key stakeholders including those from
the voluntary sector, the local hospice, the Clinical Commissioning Group, Help2change and
council directors. The Social Prescribing Demonstrator Site in Shropshire identified several needs
11 Polley M et al (2017). A review of the evidence assessing impact of social prescribing on healthcare demand and cost
implications. Commissioned by NHS England.
12 Polley M et al (2016). Annual National Social Prescribing Network Conference report. University of Westminster, London
13 Shropshire Council (2018) The public Health vision
13
to focus its services on lifestyle risk factors, long-term conditions, low level mental health and
risk of loneliness and isolation. 14, 15
The aim of the initial phase of work was therefore to understand where social prescribing might
fit in to existing services represented in Figure 1 below.
Figure 1. The key foci identified for the Social prescribing demonstrator service
Different social prescribing schemes focus on different needs, which can be adjusted to the needs
of a given population. The Shropshire social prescribing service is targeting health and social
problems known to have a wide impact on its population. In practice this means identifying the
people with low agency, and those who are at risk of either poor health in the future or finding
themselves in difficult circumstances. Furthermore, relieving the load on GP practices was also
identified as a key aim of this social prescribing service.
14 Friedli, L., Jackson, C., Abernethy, H., & Stansfield, J. (2008). Social prescribing for mental health- a guide to commissioning
and delivery. Care Services Improvement Partnership (Vol. 9). Retrieved from
https://www.centreforwelfarereform.org/uploads/attachment/339/social-prescribing-for-mental-health.pdf
15 South, J., Higgins, T. J., Woodall, J., & White, S. M. (2008). Can social prescribing provide the missing link? Primary Health Care
Research and Development, 9(4), 310318. http://doi.org/10.1017/S146342360800087X
14
The development of this particular social prescribing service was innovative for several reasons.
Very few existing social prescribing services have a prevention focus to them, therefore there is
very little existing learning to go on. Furthermore, it is important to understand that no additional
budget was available to implement social prescribing, therefore integrating existing resources and
knowledge was essential. These are important considerations when contextualising progress
and outcomes achieved. Using a multidisciplinary team approach was deemed as essential. This
involved many professionals but particularly those from community enablement, adult social care,
Help2Change e.g. social prescribing advisors, data system lead and operational locality lead, to
get the social prescribing service up and running. There was also the involvement of GP and
CCG colleagues.
The aim was therefore to design and implement a demonstrator site service with referrals from
four GP practices. Working at a local scale would create the strong foundations of a successful
and sustainable integrated social prescribing demonstrator service. The learning from this
implementation phase could then be translated and scaled up across other parts of Shropshire,
as well as leaving a legacy over the next 20 years.
As well as GP surgeries, agencies who refer to the social prescribing advisor include adult social
care and voluntary sector organisations, e.g. Age UK, libraries, local groups (e.g. Qube, Support
for families), and the Department for Work and Pensions. This approach is aligned with the
strategic direction of integration for both public health and social prescribing.16,17
Alongside the implementation of the Shropshire social prescribing service, an independent
evaluation by the University of Westminster was commissioned. The evaluation aimed to
understand why the social prescribing programme is being used and how well the components of
the social prescribing model are working together.
This was represented by 2 key objectives:
1. To inform the implementation of a robust social prescribing service using best practice
in development and data collection.
2. To understand the impact of the social prescribing service
16 Department of Health and Social Care (2018). Prevention is better than cure. Our vision to help you live well for longer
17 HM Government (2018). A connected Society. A strategy for tackling loneliness laying the foundations for change.
Department for Digital, Culture, Media and Sport
15
2.0 Methods
This section will outline the methods used to recruit participants, collect and analyse data in the
service evaluation.
2.1 Design:
A single arm, quasi-experimental pre-post, mixed-methods, data collection design was used to
investigate the longitudinal benefits of the Social Prescribing service. Ethical approval was gained
from University of Westminster’s Faculty Research Ethics Committee.
2.2 Participants and recruitment:
Individuals were referred to the social prescribing advisor via 2 main routes. Firstly, patients at
two of the participating GP practices were identified retrospectively based on a CVD Qrisk2 score
of 10% or more, or pre-diabetes risk. These patients were contacted via letter from their GP
practice and offered an appointment with a social prescribing advisor to review ways of reducing
their risk of CVD in the future. Secondly, individuals who met any of the Social Prescribing Service
eligibility criteria (loneliness, mental health issues, long term conditions) could also be
opportunistically referred via the GP surgeries as well as organisations such as Job centres, and
Oswestry library.
Individuals who opted to have a consultation with the social prescribing advisor at the social
prescribing services were provided with information about the service evaluation, with a request
to consent to take part. Individuals were recruited into the service evaluation by the social
prescribing advisor at the first consultation before evaluation data was collected.
2.3 Data collection:
2.3.1 Patient Reported Outcomes Measures
Table 1 shows the range of quantitative and qualitative data collected using patient reported
questionnaires. A questionnaire pack was administered by the social prescribing advisors at the
first consultation (baseline) and 3 months follow-up (Jan 2018- onwards).
2.3.2 Physiological Data and Health service usage
Data on blood pressure, weight, body mass index (BMI), cholesterol levels, physical activity and
smoking status were retrieved from participants’ electronic medical records. The number of GP
and nurse appointments, visits to A&E, inpatient and outpatient appointment and unplanned visits
to hospital were also extracted from medical records.
16
Domain
Measurement tool
Information
Peoples concerns
about their health and
wellbeing
Measure Yourself
Concerns and
Wellbeing
questionnaire
Validated self-completed and patient led.
Capture concerns and wellbeing and
qualitative data on the value of the service
and other things affecting health.
Patient activation
Patient Activation
Measure
questionnaire
13 statements on beliefs and patient
confidence around the management of their
individual health condition. Linked to clinical
outcomes and costs for delivering care)
Loneliness levels
De Jong Gierveld
Loneliness Scale 6
items questionnaire
Validated 6 items questionnaire, which can
discern emotional and social isolation.
Work and relationship
status
Bespoke questions
To ascertain more information about
participants
Service satisfaction
Bespoke satisfaction
survey
Anonymous survey administered at the 3
months follow up only rating satisfaction and
providing space to feedback comments.
Table 1. Summary of questionnaire data collected at baseline and 3-month follow-up.
2.3.3 Stakeholder Interviews
One-to-one, semi structured interviews were carried out with 24 individuals over a 10-month
period. Participants included 6 staff members directly involved in the designing, implementation
and running of the scheme; 6 people from the CVD risk register who had met with a link worker
on at least one occasion; 4 non-CVD service users and finally, external stakeholders and
organizations referring into the scheme. Prior to all the interviews, participants were sent copies
of the participant information sheet to read and/or had the study explained to them. All but one
participant then consented to take part (one service user felt they were not up to doing it). Topic
guides rather than set questions were employed so that participants could feel free to relate their
stories and unanticipated issues could emerge. Interviews were held at the convenience of the
participant, and the dialogue was digitally recorded. Individual interviews lasted from 30-60
minutes. All participants were debriefed and thanked by email within a week of the interview.
Interview data were transcribed by an agency and stored securely as password protected files on
a password-protected computer.
17
Table 2. Characteristics of participants taking part in semi-structured interviews (real roles but
pseudonyms). Link worker = social prescribing link worker; DWP = Department of Work and
Pensions; Service user = a person who has met with a social prescribing link worker; CVD =
service user is on a CVD register; Other = service user has been identified or self identifies as
having health issues related to life style, weight; Mental health = patient has been identified as
having mental health needs.
Semi-structured Interviews
(* real role but pseudonyms)
Key Staff*
Year
Other
stakeholders*
Service
users
Year
Referral reason
Link worker
(Carol)
2018
Practice
manager
(Keith)
Female
2018
CVD
Public
health
manager
(Joan)
2018
DWP Disability
Employment
Advisor
(Sue)
Female
2018
CVD
Project
Manager
(Ken)
2018
DWP
Employment
Advisor (Pat)
Female
2018
CVD
IT manager
(Chris)
2018
DWP
Employment
Advisor (Ann)
Male
2018
CVD
Service
manager
(Kath)
2018
Adult social
care worker
(Jill)
Male
2018
CVD
Public
Health
consultant
(Elise)
2018
Adult social
care worker
(Mel)
Male
2018
CVD
Link worker
(Emily)
2019
GP (Nick)
Female
2019
Other
GP (Liz)
Female
2019
Other
Male
2019
Mental Health
Female
2019
Other
18
2.4 Data Analysis
2.4.1 Qualitative Analysis
Thematic data analysis was conducted in phases using NVivo to analyse different sections of the
data in various ways. By repeatedly listening to the digital recordings and reading transcripts of
interviews, the author familiarized herself with all the data covering the full range of themes. NVivo
was then used to extract more codes and analyse different sections of the data in various ways.
Maps and diagrams were then used to creatively synthesize ideas. As ideas were generated, they
were discussed with the research team and with different stakeholders. Data was coded using a
modified constant comparison approach inspecting and comparing all data and fragments arising
in a given case and moving from a larger to more compact data set.
2.4.2 Quantitative Analysis
The numerical data from outcome measures was not normally distributed, therefore non-
parametric Wilcoxon Repeated Measures statistical tests were used to test the data for significant
differences showing changes in scores on the questionnaires.
Measure Yourself Concerns and Wellbeing (MYCaW)
MYCaW concerns, wellbeing and profile score were calculated individually and the mean score
for the cohort calculated at each time point. Qualitative data from the MYCaW tool was analysed
using content analysis. 18,19
Patient Activation Measure (PAM)
All scores from PAM were analysed for total score change pre-post and individual score changes
of 4 or more points was deemed clinically significant. Scores were also calculated as activation
levels and comparisons of frequencies of activation levels made.
De Jong Gierveld Loneliness Scale
Pre-post score changes for social loneliness, emotional loneliness and total loneliness were
calculated individually and the mean score for the cohort calculated at each time point.
Physiological health data
Physiological health data was collected from the GP practice records or by the social prescribing
advisor. This measured height (cm), weight (kg), BMI, systolic BP (mmHg), diastolic BP (mmHg),
total cholesterol (mmol/L), HDL cholesterol (mmol/L), non-HDL cholesterol (mmol/L), cholesterol
18 Polley MJ, et al (2007). How to summarise and report written qualitative data from patients: a method for use in
cancer support care. Supportive Care in Cancer 15(8)963-71.
19 Seers HE, et al. (2009) Individualised and complex experiences of integrative cancer support care: combining
qualitative and quantitative data. Support Care Cancer.17(9) p1159
19
ratio, smoking status, level of declared physical activity and weight classification. Data was non-
parametric and, where possible was analysed by Wilcoxson Repeated Measures tests.
Health service usage data
Health service usage data was collected in terms of frequencies of attendance at: GP practice,
nurse, hospital unplanned, hospital inpatient, hospital outpatient for the three months before
attending the social prescribing service, and then the three months prior to follow-up appointment
at the social prescribing service. A matched control group of people who were offered social
prescribing but did not take it up was used to compare health service usage at each time point.
Employment status
Frequency of employment status was captured to see changes in frequencies in people’s social
status.
Service user satisfaction
An anonymous satisfaction questionnaire asked people to reflect on their experience of the
service using Likert scales of satisfaction, and provided qualitative data relating to patient
experience and satisfaction. The data generated from this tool was only post-service, and
therefore statistical tests were not performed on it.
20
3.0 Results
This social prescribing service was an innovative step forwards for Shropshire Council and results
are reported to reflect data gathered from May 2017 to May 2019 20.
This section is split into 4 sections, to allow the different aspects of the evaluation to be reported,
these are:
3.1 Service Design and implementation
3.2 Service referrals and demographics
3.3 Service user satisfaction and experiences
3.4 Impact of the service
Throughout the results, we have used qualitative data from the questionnaires and interviews of
stakeholders to provide real examples of people’s responses to the social prescribing service to
complement the quantitative data being presented.
3.1 Service Design and Implementation
This section themes that emerged from qualitative analysis of interviews relating to core elements,
learning and challenges experienced when setting up the social prescribing demonstrator site.
Best practice and action learning
Working according to certain core principles developed through early research into successful
factors in social prescribing21 gives the service the best chance of success. Our findings suggest
that the Shropshire social prescribing service is upholding and demonstrating these core
principles in a robust manner. This will provide the service with the best chance of sustainability
and long-term success.
The setting up of the service was both systematic and iterative. The ethos of action learning is
also fully embedded in the Shropshire social prescribing service, and the team is making use of
multiple opportunities to learn and progress the social prescribing model. Each step of the
learning process had been documented by the implementation team, through agile management
meetings.
The learning gained from the practices adopting social prescribing informed the development of
the service in later practices, with successful elements replicated, and less effective elements
discarded. For example, a practice manager explained how a decision had been made to free up
a practice room in the surgery one day a week, so that the patient knew the scheme was
connected to the GP service, and also to allow patients to combine the visit with other actions
20 Please note, a previous version of this report was generated for data collected between May 2017 and October 2018 this
was Phase 1, and this current report represents the full findings of the complete evaluation from May 2017 to May 2019.
21 Polley M et al (2016). Annual National Social Prescribing Network Conference report. University of Westminster, London
21
such as discussing a prescription. Service users who were interviewed agreed that having the
social prescribing meeting in the GP surgery had made attendance relatively straightforward.
“A young lady came and interviewed me from Shropshire Council, at the
doctor’s”
“The times were very convenient and the ease in which dates could be altered
was really helpful. The room and atmosphere in the appointments were very
relaxed which made 'opening up' so much easier.”
“We’ve got a large medical centre in Oswestry and I met her there.”
Collaborative working
All staff interviewed about the project agreed that it was a collaborative venture. An important
step was engaging with local stakeholders in the Shropshire area (GP practices, organisations)
and working on a model that they could start to implement. It was considered important to treat
these stakeholders as equal partners, and not dictate to them.
The top ‘go to’ organisations/groups were identified early on, which was useful in terms of linking
in with voluntary sector contracts commissioned by the council. These VCSE services could be
walking groups, talking groups, physical activity groups, whatever exists locally that could support
people.
The Shropshire social prescribing scheme is now making good use of the rich resources and
assets within the local area, while seeking ways to overcome local problems such as physical
isolation and transport limitations. Underpinning the service was the belief that communities can
come up with their own solutions, but that the social prescribing service offers them a framework
through which to do this. Voluntary organisations in the area had also benefited from the formal
referral and feedback system, because it helps to validate their work as a positive health
intervention.
Quality assurance (QA)
QA of the social prescribing interventions was regarded as a priority when designing the social
prescribing service. The social prescribing service shared the QA procedure with the VCSEs who
would receive individual referrals. These organisations then had to self-report about their policies
22
and procedures regarding safeguarding, health and safety and information governance. This was
necessary to ensure the organisations were suitable to refer to. Cases considered “too
challenging” or “too severe” for the social prescribing service, e.g. serious mental health issues
and suicidal cases, were referred by the social prescribing advisor to emergency intervention from
mental health services. It was important to give confidence to GPs to refer to the social
prescribing service.
Implementation challenges
Part of the team’s learning journey has been recognising and learning from the challenges of
setting up a new, fully integrated service from scratch with finite numbers of people and financial
resources. Team members identified the following challenges, and that others setting up similar
schemes could learn from them.
Time
Setting up a social prescribing project, with all its complexities, was a time-consuming process
involving much learning in action. The decision to create a service of a very high quality and
standard, which was fully documented and independently evaluated from the onset, made the
whole process more iterative than expected. While the enthusiasm, team spirit and dedication
across the team was emphasised, team members had other work duties as well.
Staff directly working for the social prescribing service did so on a part-time basis which slowed
down both the setting up of different aspects of the service (e.g. evaluation) and communication
between different parties. The various GP practices also needed to be invited in, and this required
time for discussion, but was acknowledged as an essential element in the implementation
process.
For those involved at the operational level, having an independent evaluation had created its own
set of challenges. Capturing the right data proved time consuming with delays in the rolling out
and collection of evaluation data. The national regulations around GDPR were also introduced
whilst this project was in process. A necessary but time-consuming part of the process was
ensuring that data sharing agreements and suitable ways of managing the data between GP
practices, Help2Change (Shropshire council) and the evaluation team (University of Westminster)
were all in place. This was balanced against the growing pressure to demonstrate the outcomes
to the financial stakeholders.
Data collection
The social prescribing advisors faced practical challenges when collecting evaluation data, in
particular how to negotiate or integrate data collection into the consultation process. There were
concerns at times as to how data collection may affect the consultation. The first social
23
prescribing advisors at the demonstrator site were supported by the evaluation team from the
University of Westminster, to enable high quality data collection to occur i.e. adhering to the
appropriate procedures associated with informed consent, outcomes measures and data handling
and storage. Whilst some stakeholders wanted particular data, it was acknowledged that a social
prescribing advisor may not be in a position to collect the data this was sometimes dependent
on how the first consultation was progressing. This was a fine line to navigate, however, the
individual service usersneeds were always put first.
Participants were interviewed by the evaluation team as part of the service evaluation, which
meant they had been asked to complete several questionnaires at the initial and follow up
meetings with the social prescribing advisor. None of the participants expressed any objections
to answering the questionnaires and at least two had appreciated being part of a research project.
One described the questions as “not taking very long” although another remembered that it had
involved “ticking a lot of boxes.”
Funding and resourcing
With a limited budget, resourcing was a challenge. The team managed with in-house resources
(across the wider council and public health) and the voluntary sector, which had been “very
positive” about contributing towards the scheme. They had taken a system wide approach, but
budget limitations meant the service had to be strategically targeted.
Pressure on the social prescribing team, from external stakeholders to “show results” led to some
“interesting conversations” when some team members were challenged about the data in terms
of impact and numbers of referrals, part-way through the evaluation. The social prescribing
service took longer to set up that anticipated, however, it adhered to the core principles associated
with long term success. Having these challenging conversations was viewed as constructive by
the social prescribing team. Having a development and reflection process that enabled critical
friends to be involved was part of the ethos of the action learning approach from day one.
Avoiding duplication
Another challenge was convincing some stakeholders that the social prescribing service was not
duplicating services already offered, such as by the Community Care Coordinators (C&CCs). The
focus of the C&CCs was primarily on practically supporting the frail and elderly (via care
coordination, aids, adaptations, alarms etc.) as well as supporting people who were experiencing
loneliness, whereas the Shropshire social prescribing service was aimed at preventing diseases
from occurring in later life and preventing loneliness.
To summarise
A robust and informed approach to developing a social prescribing service was used.
Efficient use of limited resources and existing assets in the local area was made and best practice
was adhered where possible. Choosing to have an independent evaluation carried out from the
24
beginning of the project added a layer of complexity but has enabled independent data analysis
to be captured. The iterative learning cycles and learning from the evaluation enabled the service
to evolve as necessary, responding to local challenges in the operating environment. Learning
gained was used to inform development of schemes countywide.
Governance, in the form of protection of vulnerable clients, ensured that people unsuited to social
prescribing were referred to the appropriate agencies, such as mental health services.
Other elements of a sustainable social prescribing service identified in this study include;
involving local communities from inception; a phased role out involved multiple testing of the
different parts of the model with the gathering of different stakeholder perspectives and
reflections; pre-service training and networking; collaborative relationships with external
stakeholders and supervision and support for social prescribing link workers.
Problems experienced implementing and running the service that were identified in this
study include; making choices around allocation of limited resources; establishing eligibility and
the suitability of clients and interventions; keeping communication and feedback loops active;
managing concerns about duplication or overloading of services, administrative and technological
challenges, and undergoing a rigorous, longitudinal service evaluation while being under pressure
to rapidly produce the evidence required to secure long-term funding.
Stakeholders recommendations for implementing future social prescribing projects were;
Use a sound methodology to develop the model and nail down the requirements of the
service and its evaluation as soon as possible.
Keep a data trail and recording the learning, “the steps and the iterations that we’ve gone
through.”
Cultivate the main sources of referral, i.e. the keenest GP practices. “They really want it
to happen, they’ve taken ownership of it… they’re part of the process from the beginning.”
The data collection process itself needs to be factored into any analysis of a real-world
social prescribing project.
25
3.2 Service referrals and demographics
In this section we present information on referrals into the social prescribing service across
Shropshire (n=515) and then referrals associated with the evaluation (n=105).
Shropshire wide
Overall the Shropshire social prescribing service has expanded to 4 services in
Oswestry/Ellesmere, Albrighton, Bishop’s Castle, Bridgnorth and 4 services in Shrewsbury, which
incorporated 11 GP practices. Data below reflects 515 referrals (both opportunistic referrals and
systematic identification through an audit of the patient record) made between May 2017 May
2019.
Opportunistic referrals were made by a range of other services as well as by the GP
surgeries which include Adult Social Care, Oswestry & Shrewsbury Job Centre,
Help2Change, Oswestry library, Early Help, Enable, Qube, Mental Health Access team,
Age UK, First Point of Contact, Pharmacy in Albrighton and Physiotherapy.
Opportunistic Referral rates from the GP practices were variable ranging from 4 referrals
(Caxton) to 56 referrals (Bridgnorth) which reflects the length of time they have been
involved in social prescribing and whether they are focussing on systematic or
opportunistic referrals (See Appendix A for breakdown of referrals by GP practices).
The social prescribing service is catering for a very wide range of ages, 79% of service
users are between 40-79 years old (See Figure 2 below).
Figure 2. Range and frequency of ages of service users.
1
76
11
18
29
21
6
1
0
5
10
15
20
25
30
35
18-19
years
20-29
years
30-39
years
40-49
years
50-59
years
60-69
years
70-79
years
80-89
years
90-99
years
Percentage of people
Age ranges
26
Reasons of opportunistic referral into the social prescribing service are presented in Figure 3
below. The most frequent reason was for mental health issues, closely followed by lifestyle risk
factors and loneliness or isolation issues.
Figure 3. Reasons for opportunistically referring individuals into the social prescribing services.
Individuals (n=301) were referred for a total of 415 reasons as individuals can be referred for more
than one reason.
A CVD audit of the medical records in 2 of the Oswestry and Ellesmere (O&E) GP practices was
carried out to find patients who had a CVD Qrisk2 score of ≥10%. Details of the process
undertaken between Jan 2018 February 2019 as follows (note not all CVD audit data available
therefore this only represents a proportion of the service activity):
294 people were invited by a letter from their GP practice to use the social prescribing
service
239 (81%) of these were successfully contacted by the social prescribing advisor after the
letter had been sent
o 109 (46%) accepted the offer of an appointment;
o 113 (47%) declined the appointment
o 17 (7%) had no record for declining or accepting.
1
2
3
3
11
20
26
34
0 10 20 30 40
NHS health check
Frequent attender
Other
Carer
Long term conditions
Risk of loneliness / isolation
Lifestyle risk factors
Mental health difficulties
Percentage of service users
27
Evaluation specific recruitment
The Oswestry/Ellesmere social prescribing service was the first social prescribing service to be
implemented and the only one running when the evaluation was set-up. Evaluation participants
were initially therefore only able to be recruited from the 4 GP practices involved in this social
prescribing service. Recruitment later expanded to include social prescribing clients from 3
practices in Shrewsbury, from Albrighton Medical Practice and from Bridgnorth.
Of the 515 individuals who used the social prescribing service between May 2017 and May 2019,
134 consented to take part in the evaluation: 113 Oswestry/Ellesmere; 17 Shrewsbury; 2
Albrighton; 2 Bridgnorth. 105 of these participants attended their 3 months follow-up appointment.
87 Oswestry/Ellesmere; 15 Shrewsbury; 1 Albrighton; 2 Bridgnorth.
As the social prescribing service was new, there was no prior data to inform the choice of inclusion
criteria. Initially the inclusion criteria was agreed as systematic referral of people at risk of CVD,
i.e. Qrisk2 score of ≥10% and opportunistic referral of people who were socially isolated or lonely.
Later on, the inclusion criteria of the opportunistic group was widened (See Fig 4). Overall, 68%
of evaluation participants were via the CVD audit, 32% were via opportunistic referrals.
Figure 4. Comparison of opportunistic referrals from Oswestry & Ellesmere GP practices vs
evaluation practices.
Opportunistic referrals into the whole service are recorded in blue on Figure 4. Individuals who
consented to the evaluation did represent the majority of categories of opportunistic referrals, but
not necessarily in the same proportions.
0 10 20 30 40 50
NHS health check
Frequent attender
Other
Carer
Long term conditions
Risk of loneliness / isolation
Lifestyle risk factors
Mental health difficulties
Percentage of service users' referrals
Evaluation sample Audit
28
Participant demographics
The demographics of the evaluation participants at baseline and at 3-month follow-up are shown
in Table 3. The 3-month follow-up group showed the same demographics as the full group at
baseline, except there were a smaller relative percentage of single people and higher percentage
of widowed people in the follow-up group. There were also a smaller percentage of employed
people in the follow-up group.
Table 3: Demographic data of individuals who participated in the evaluation. Data is presented
for all participants in the evaluation at baseline (n=134) and for those with 3-month follow-up
(n=105).
Demographic Detail
Number (%) of
Baseline
(n=134)
Number (%)
at 3
months’ follow-up
(n=105)
Gender
Male
62 (46%)
48 (46%)
Female
71 (53%)
57 (54%)
Mean age
61.31 years (SD
12.6)
62.21 years (SD 11.9)
Referral type
Systematic
(CVD risk identified)
90 (67%)
71 (68%)
Opportunistic (not
CVD risk identified)
18 (13%)
16 (15%)
Other
26 (19%)
18 (17%)
Marital status
Married
63 (47%)
48 (46%)
Single
40 (30%)
31 (30%)
Divorced
17 (12%)
13 (12%)
Widowed
11 (8%)
10 (10%)
Separated (same sex
relationship)
1 (1%)
1 (1%)
Other/Rather not say
2 (2%)
2 (2%)
Ethnicity
White
129 (9%)
103 (98%)
Other
1 (1%)
1 (1%)
Not declared
2 (2%)
2 (2%)
Employment
status
Retired
62 (46%)
53 (51%)
Employed
38 (28%)
27 (26%)
Unemployed
23 (17%)
16 (15%)
Disabled
7 (5%)
5 (5%)
Housewife/Husband
2 (2%)
2 (2%)
Sick leave
1 (1%)
1 (1%)
Volunteering
1 (1%)
1 (1%)
29
3.3 Service user satisfaction and experience
3.3.1 Satisfaction ratings
A service satisfaction questionnaire was completed anonymously by 72 participants. This was
done separately to the other questionnaires used in the evaluation as it is a standard part of the
service. As it was anonymous, it was impossible to chase up non-responders. Of the people
who responded, results showed an extremely high level of satisfaction with the social prescribing
service.
Convenience of times, (4.85/5)
Convenience and suitability of venue (4.82/5),
Feeling able to discuss concerns with the social prescribing advisor (4.89/5).
56/72 (78%) responded that they knew why they were referred, 9/72 (13%) did not know why
52/72 (72%) participants felt they were referred to a suitable intervention or support service, 3/72
(4%) did not.
3.3.2 Service user experience
Qualitative analysis was carried out on data from the service users, to understand what their
experience was like, what was particularly important or anything that could be improved. This
section briefly reports on key themes that were identified in the qualitative analysis relating to
service user experience. These include working with people with low agency and the value of the
social prescribing advisor which is split into the following aspects; the referral; the relationship
with the social prescribing advisor; tackling loneliness and isolation; incentivising.
Supporting people with low agency:
One aim of the social prescribing service was to support people with low agency. Initial feedback
from service users demonstrated that this group of people were being identified.
“I think I’d been to the doctors about my cholesterol and the issue of
weight came into it, which I had been aware of for some time, but really
done nothing about it”
“I was a regular smoker and of course every time I meet with a health care
professional they tell me, this is not a very good idea you know”.
30
The value of the social prescribing advisor
Service users (and staff) saw the role of the social prescribing advisor as crucial to the social
prescribing experience. Several aspects specifically relating to the social prescribing advisor
were highlighted by users as valuable and positive. These included the referral process, the
relationship they established, and the incentive provided, which are explained in more detail
below.
The referral
Whilst individuals were referred into the service via multiple agencies, all participants interviewed
had been referred by, and had received a letter from their GP surgery (as part of the CVD risk
audit). Most participants remembered receiving the referral letter and a follow up call from the
social prescribing advisor. This demonstrates the value of following up the letter with an
introductory call from the social prescribing advisor, particularly if a person had low agency and
was unlikely to proactively book an appointment.
“I got a call from xx (the SP Advisor), explaining who she was and saying
would I like to go down and talk to her for an hour, and it really snowballed
from there.”
Relationship with social prescribing advisor
Meetings with the social prescribing advisor were seen as central to the social prescribing service,
as it is here that individuals, through a process of co-production, could establish their health needs
and put a plan into place.
Most participants recalled their first meeting with the social prescribing advisor. Participants
expressed an appreciation of the length of time allocated for this meeting and for exploring their
personal health needs; e.g.
“I think partly the attraction of it was, that there was somebody who was
happy to talk about my problem and also say, I can give you an hour.
31
This participant acknowledged how rarely such an in-depth conversation about their health and
wellbeing needs took place in a GP practice; e.g.
How often do you get offered an hour’s chat about a particular problem
in a doctor’s medical centre? You don't and I do have to say that was
really quite an incentive.”
Impressions of the social prescribing advisors were generally very favourable. One participant
described their advisor as “very helpful” and “supportive,” remarking on how the advisor had
“listened carefully and came up with good answers and suggestions.”
Another participant described the Advisor as:
“a very nice lady… who suggested there were things I could do that would
not so much improve my health - but more sort out the wellbeing things.”
Participants appreciated the fact that it was that it was more like a sort of discussion about what
they wanted and what was going to work for them. One participant explained how useful it was to
discuss their problems concerning weight loss with someone who was really prepared to listen:
[It was] Very helpful. We talked over, obviously, weight issues and as to
how I might go about doing this more positively.
32
Tackling loneliness and isolation
Reducing and preventing loneliness and isolation was a goal of social prescribing service, and
user responses suggested that that the privacy and empathic nature of consultation process with
the social prescribing advisor played a part in this:
“The advisor has been a sensitive and helpful advisor, who’s given me
enough latitude to open up about what are quite private matters.”
“Issues are difficult to talk about but felt able to share things not shared
before because of advisors.”
While participants in our study had been referred to a wide range of services, many had opted
to pursue a group activity or intervention, which could bring social and emotional as well as
physical benefits:
“As a result of speaking with the Adviser, I have joined a weekly walking
group and also joined a leisure centre where I go to swim once or twice
a weekly.”
“Started baby and mother gym classes and will be starting group
activities too.”
Not all service users were able to engage in energetic activities, and for those who were
isolated, other solutions were found, such as home visits from professionals and volunteers.
33
Incentivising
It was clear from the interviews that the social prescribing advisor/client meeting had led people
to consider their health more seriously and to look for ways to improve it. The conversation and
trust established with their Advisor had, for some, acted as an incentive in itself:
Knowing that [the SP Advisor] had said to me, ‘I’ll see you in three
months and we’ll see how we’re going.’ That actually was a very good
incentive. I’ve been to things like Weight Watchers and things like that
before…but [the SP Advisor] was taking the trouble to see me, giving me
one to one, which I think is very important…I didn’t want to let her down
any more than I wanted to let myself down.
Important for some participants were the follow up calls by the social prescribing advisor to check
that the client had followed up their recommendation. One participant spoke of how they had gone
away and forgotten about the conversation until they received a reminder call;
“If they hadn’t persisted I’d have just forgotten about it. If it had just been
one visit to the surgery I’m sure…there would have been a very different
outcome.”
34
3.4 Impact of the service
This next section of the results reports on the measures that were used to capture changes as a
result of the social prescribing service. Underpinning these quantitative results is further data
ascertained from interviewing participants about their experience of the service.
3.4.1 Measure Yourself Concerns and Wellbeing (MYCaW)
Capturing and applying a person’s voice
Previous research has recognised that people may be referred to a service for one reason, but
upon consultation, (in this case with a social prescribing advisor), areas of unmet needs are
revealed that initial referring professional may not have been aware. Thus, the reason a person
is referred is not necessarily the thing that they most need addressing, for their health and
wellbeing to improve. This data can then be used to understand what a service could be providing
to fully meet the needs of the service users.
MYCaW allows an individual to easily voice what they feel really needs addressing within the first
consultation with the social prescribing advisor. Importantly this captures the true person-centred
aspect of social prescribing and demonstrates why the social prescribing advisor is such an
important part of the service provision. Participants in the evaluation were asked to say what two
things concerned them most and score the severity of these concerns – this was not restricted to
health but could be anything in their life at that point in time.
MYCaW Concerns
The MYCaW concerns data demonstrates the importance of the social prescribing advisor
consultation, to determine what unmet needs exist and how to most appropriately support these
unmet needs.
134 people reported 216 concerns and only 2% (6) people reported no concerns, showing very
few people were referred inappropriately.
Whilst 67% of participants were referred due to their risk of CVD, only 52% (113) of concerns
were about getting support to reduce their risk of CVDsee Figure 5.
A range of other concerns were also identified (See Figure 6), including social, welfare and
employment concerns. Participants who said they wanted to get out more, were interpreted as a
group of people who are either experiencing or at risk of loneliness or social isolation.
Some participants reported concerns related pain and arthritis. Getting people more physically
active is a priority in reducing current and future health problems in Shropshire and nationwide.
There is little chance, however, of these individuals becoming more physically active until their
pain is appropriately managed. Family relationships, money and work were all concerns that
participants reported urgently wanting support with all of which were not identified during the initial
opportunistic referral to the social prescribing service. Meeting these unmet needs could be
viewed as an additional benefit of the current social prescribing service.
35
Figure 5. MYCaW concerns related to modifiable risk factors for CVD. n=113 concerns
expressed by 52% of participants.
Figure 6. All other MYCaW concerns not directly related to modifiable risk factors for CVD. n=97
concerns expressed by 45% of participants.
Lifestyle related concerns
Lose Weight
Physical Activity
Diabetes
Cholesterol
Blood pressure
Smoking
Main concerns not related to lifestlye
Mental Health
Pain/ Arthritis
Get out more
Family
Money and work
Other
Cancer
36
MYCaW Scores
Participants were asked to rate the severity of each concern and to also rate their wellbeing, see
Table 4 and Figure 7.
There are clear improvements in concerns and wellbeing scores from this service. This indicates
that after going through the social prescribing service, participants’ unmet needs had been
supported. The mean change in Concerns are statistically significant in their improvement
comparing baseline paired to three months follow up (p=0.0001 Concern1 and p=0.003 Concern
2). Changes for both MYCaW concerns are over the minimum important change threshold which
means this change translates into an actual noticeable improvement in their lives.
There was also a statistically significant improvement in overall wellbeing for the participants at 3
months. The MYCaW wellbeing score reflects all parts of a person’s life and it is normal for these
score changes to be between 0.6-1.0. The smallest score change considered clinically relevant
is 0.522, and this was reached for the wellbeing, confirmed by the statistically significant test result.
Table 4. MYCaW Concerns and Wellbeing scores. Concern scores are rated between 0 -6, where
6 is most severe, hence a reduction in concern score is an improvement. Wellbeing scores are
rated 0-6 where 6 is the worst it can be, hence a decrease in wellbeing score is an improvement.
Statistical significance is reached when p ≤0.05. Not every participant filled in every section, n
values are provided accordingly. *An improvement over 1 represents a clinically significant
change in that problem.
22 Seers HE, et al. (2009) Individualised and complex experiences of integrative cancer support care: combining
qualitative and quantitative data. Support Care Cancer.17(9) p1159
MYCaW
scores
Baseline
Mean [SD]
(n)
Follow-up
Mean [SD]
(n)
Mean Score change
Wilcoxon Z score and
p value
Concern 1
4.86 [1.29]
(97)
3.34 [1.80]
(97)
-1.18* z = -6.23
p=0.0001
Concern 2
4.65 [1.36]
(60)
3.13 [1.96]
(60)
-0.93 z = - 4.17
p=0.003
Wellbeing
3.45 [1.48]
(99
)
2.51 [1.54]
(99)
-0.50 z = - 3.49
p=0.000
Profile score
4.32 [1.13]
(60)
3.11 [1.47]
(60)
-0.87 z = - 4.89
p=0.000
37
Figure 7. MYCaW concerns and wellbeing scores at baseline vs. 3 months follow-up. Concern
scores are rated between 0 -6, where 6 is most severe, hence a reduction in concern score is an
improvement. Wellbeing scores are rated 0-6 where 6 is the worst it can be, hence a decrease
in wellbeing score is an improvement. Statistical significance is reached when p ≤0.05. Not every
participant filled in every section, n values are provided accordingly. *An improvement over 1
represents a clinically significant change in that problem.
What else is going on in your life that is affecting your health?
On the follow-up MYCaW form, participants are asked if there was anything else happening in
their life that is affecting their health - 75 people responded to this. This question is most
commonly answered if the events are particularly positive or negative. 60 people reported
negative health issues, such are injuries, pain or operations and on-going worries with money and
family. All these other issues affect a person’s wellbeing and how able a person is to make and
sustain positive lifestyle changes.
Positive events (n=15) highlighted included changes to participants’ wellbeing due to the changes
they were making with their diet and physical activity. This serves to reinforce the impact that the
social prescribing services is having on their lives. Other events included having a holiday booked
or having more support with carer duties for parents.
What was the most important thing about the service?
On the follow-up MYCaW form, participants could write down what they found most helpful about
the social prescribing service they experienced.
This data corroborated the service user satisfaction and experience data (p30-34), as participants
appreciated feeling supported, being able to talk things through with someone and feeling
reassured.
4.86 4.65
3.45
4.32
3.34 3.13
2.51
3.11
0
1
2
3
4
5
6
Concern 1 Concern 2 Wellbeing Profile score
MYCaW Score
MYCaW questions and profile sore
Paired baseline Follow-up
38
Good to have the chance to talk to someone specifically about health
and well-being. This has prompted some dietary changes which have
resulted in weight loss and a reduction in total cholesterol/increase in
HDL.”
People appreciated the information and guidance received and feeling more confident. These
are two themes that are directly associated with patient activation.
“Meeting someone and being able to talk things through and feeling
supported, has given me confidence.”
Activation was also demonstrated by some participants who thought the best thing about the
service was that they had made changes as a result of the service.
“Increasing physical activity levels, improved health and mood. I am
walking 1.5 miles twice a day and trying other activities…my family have
noticed positive changes.”
Other people thought the referral from the social prescribing advisor out to the group/intervention
was most valuable.
“Referral to Active Buddies and info/advice”
Overall the data from all aspects of MYCaW indicated that participants concerns were
being identified and appropriately supported. Statistically significant improvements in mean
concerns and wellbeing scores were achieved. Participants appreciated talking through issues
with the social prescribing advisor, being listened to, and feeling supported, reassured, and felt
more confident to put changes into action.
39
3.4.2 Patient Activation
The Patient Activation Measure (PAM), assesses the confidence, knowledge and ability a person
has to improve their health. Thirteen questions are completed and scored. Observation studies
in England and the USA have demonstrated that clinically significant improvements in PAM
scores are associated with a reduction in health service usage and lower incidence of long-term
health conditions over time.23,24 This measure is also now being adopted by NHS England as
part of their personalised care strategy.
Change in PAM scores over time
The mean PAM score change for the 102 participants with baseline and 3 months follow up data
was 5.13. A change of 4 points or more denotes a clinically significant change. Over whole
dataset, therefore, a valuable increase in the activation levels and the ability of participants to
make and sustain lifestyle changes was achieved.
Upon further analysis 53/102 (52%) had clinically significant improvements in PAM scores. This
means that there is a likelihood that these 53 participants will use less health service resources
from now on, as a result of using the social prescribing service.
Table 5. Comparison of PAM scores for participants at baseline and at the 3-month follow-up time
point (n=102). A change of 4 or more points denotes a clinically significant improvement. Data is
statistically significant when p ≤0.05.
Changes in PAM levels of activation
PAM scores can also be designated as levels of activation, where level 1 = least activated and
level 4 = most highly activated. Figure 8 shows that after receiving social prescribing there were
23 J.H.Hibbard, M.Tusler (2007)Assessing activation stage and employing a ‘next steps’ approach to supporting patient self-
management. J Ambul Care Manage, 30 (2007), pp.2-8
24 Turner A, Anderson JK, Wallace LM, Bourne C. An evaluation of a self-management program for patients with long-term
conditions. Patient Educ Couns. 2015 Feb;98(2):213-9. doi: 10.1016/j.pec.2014.08.022. Epub 2014 Oct 22
PAM
Paired
baseline
Mean
[SD] and
(n)
Follow-up
Mean
[SD] and
(n)
Score change
Mean
Wilcoxon Z score and
p value
PAM Score /100
58.11
[11.4]
(102)
63.23
[12.9]
(102)
5.13
z = -4.54
p = 0.000
40
more participants with the highest levels of activation (levels 3 & 4), and an overall reduction in
the lowest levels of activation (Levels 1 & 2).
Figure 8. A comparison of participant activation levels before and 3 months after being referred
into the social prescribing service (n=102 people).
The PAM data can also be reviewed in terms of low activators (Level 1+2) who are unlikely to
make change without support, and high activators (Level 3+4) who can make and sustain change
with minimal support. As shown in Figure 9, when people entered the social prescribing service
(baseline), there was a near equal split in high vs. low activators. After three months of the social
prescribing service, over two thirds of these participants scored as high activators (70%)
Figure 9. Comparison of the proportion of participant’s activation levels. Participants scored as
low or high activators on the patient activation measure (PAM), upon entering the social
prescribing service (baseline) and when followed up 3 months later.
13
40
37
12
19
52
26
5
0 10 20 30 40 50 60
Level 4
Level 3
Level 2
Level 1
Patient Activation Levels
After 3 months Before
29.8
48
70.2
52
0 20 40 60 80 100
3 Months Follow-
up
Baseline Matched
Comparison of % of Low and High Activators
% Low Activators % High Activators
41
Not all participants improved their PAM scores, 18/102, (18%) had a decrease of 4 or more points.
Interestingly, 11/18 of these of these participants also reported other negative events occurring in
their lives on the MYCaW questionnaire. The effect of these negative events, such as
bereavement, job loss, moving to a new house are a possible explanation for some of the
decreases in activation levels, which occurred externally to the social prescribing service.
Changes in key items on the PAM
To understand why participants’ activation was being improved we analysed each PAM question
separately and found that 6 items in particular showed statistically significant improvements at
follow-up (n=102). Significant change designated when p≤0.05.
PAM Question
Z
P
value
1. I am the person who is responsible for taking care of my health
-1.52
0.13
2. Taking an active role in my own healthcare is the most important
thing that affects my health
-2.78
0.005
3. I am confident I can help prevent or reduce problems associated with my
health
-1.30
0.19
4. I know what each of my prescribed medications do
-1.51
0.13
5. I am confident that I can tell whether I need to go to the doctor or whether
I can take care of a health problem myself
-1.34
0.18
6. I am confident that I can tell a doctor or nurse concerns I have even
when he or she does not ask
-2.14
0.03
7. I am confident that I can carry out medical treatments I may need to do at
home
-1.18
0.24
8. I understand my health problems and what causes them
-2.82
0.005
9. I know what treatments are available for my health problems
-2.99
0.003
10. I have been able to maintain lifestyle changes, like healthy eating
or exercising
-3.60
0.000
11. I know how to prevent problems with my health
-1.22
0.22
12. I am confident I can work out solutions when new problems arise with
my health
-1.27
0.20
13. I am confident that I can maintain lifestyle changes, like healthy
eating and exercising, even during times of stress
-3.27
0.001
Table 6. PAM questions that showed statistically significant improvements in scores. Significant
change designated with p≤0.05.
This PAM data correlates with the data from the interviews with service users on their experience
of the service (p30-34), and what they deemed most important about the service (p38-39).
42
All but one participant opted to pursue an activity or intervention that had been suggested and
discussed at their first meeting with the social prescribing advisor. Examples of how this led to
positive action are below. One participant took up exercise in the form of swimming;
“[I met a] really nice lady who…said, ‘Come along to the pool and see
what we do and if you think it’s for you…all you have to do is get your
GP to sign a form.’…So I went and saw what is was like and thought,
yes, that’s, I could cope with that.”
“I opted for Help2Slim and Help2Swim…I was certainly on
Help2Slim…And then I was introduced to a lady…who organised for me
to have swimming lessons with a buddy.
One participant explained about the fun they had from joining a weekly swimming class,
“It’s an arthritis group, and I have been going ever since…a
physiotherapist leads it and we all try to follow what she is doing…which
is a bit of a laugh really.
Another participant had stopped their hydrotherapy sessions and instead had become a regular
at a low-cost gym.
“I haven’t got time to go there [the hydrotherapy] now because I go to
the gym three times a week.”
43
3.4.3 Loneliness
Understanding to what extent the social prescribing demonstrator service could be used to
support people who were lonely was an aim of the evaluation at outset. 15% of opportunistic
referrals to the social prescribing service were for issues relating to loneliness, however, only a
small proportion of these individuals consented to take part in the evaluation.
As the social prescribing service was new all participants were asked to complete the De Jong
Gierveld Loneliness scale, irrespective of their referral reason. This scale measures total
loneliness, emotional loneliness, (absence of an intimate relationship or close emotional
attachment) and social loneliness (absence of broader group of contacts/ engaging in social
network).
The overall scores showed that loneliness at baseline for the whole cohort was not severe, yet at
the 3-month follow-up there was still a statistically significant reduction in the mean emotional
loneliness component of the scale (Table 7 below). Therefore, despite the majority of participants
not expressing primary concerns about loneliness, the scores show that engaging in social
networks or with a broader group of contacts had increased significantly, which is a very positive
finding.
Table 7. Comparison of levels of loneliness in evaluation participants (n=100). The total De Jong
Gierveld scale is scored out of 6, this is split into the emotional and social components, each
scored out of 3. A reduction in score denotes an improvement. Significant change designated
when p≤0.05.
Further analysis was carried out to determine whether there were significant improvements in
scores for people who were specifically referred for or reported loneliness to the social prescribing
advisor. In total, 30/42 participants who reported loneliness provided questionnaire data and a
statistically significant improvement was reported at the 3 months follow up in Total Loneliness
and Emotional Loneliness (Table 12, Fig 10). This indicates the ability of the social prescribing
service to successfully support people who are experiencing loneliness.
De Jong
Gierveld
Loneliness
scale
Paired
baseline
Mean [SD]
(n)
Follow-up
Mean [SD]
and
(n)
Mean
Score change
Wilcoxon Z score and
p value
Total
loneliness
2.47 [2.12]
(100)
2.25 [2.08]
(100)
-0.22 z = -1.23
NS
Emotional
loneliness
1.23 [1.17]
(100)
1.07 [1.16]
(100)
-0.16 z = -2.02
p = 0.044
Social
loneliness
1.25 [1.21]
(100)
1.18 [1.23]
(100)
-0.07 Z = -0.43
NS
44
Table 8. Levels of loneliness. 30 evaluation participants were specifically referred for or stated
loneliness as a MYCaW concern. The total scale is scored out of 6, this is split into the emotional
and social components, each scored out of 3. A reduction in score denotes an improvement.
Significant change designated when p≤0.05.
Figure 10. De Jong Gierveld Loneliness scale scores. baseline vs. 3 months follow-up (n=30).
The total scale is scored out of 6, this is split into the emotional and social components, each
scored out of 3. A reduction in score denotes an improvement.
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
total loneliness Emotional Loneliness Social loneliness
Baseline 3 month follow up
De Jong Giervald scores
De Jong
Gierveld
Loneliness
scale
Mean
Paired
baseline
[SD] (n)
Mean
Follow-up
[SD]
(n)
Score change
Mean
Wilcoxon Z score and
p value
Total
loneliness
3.9 [1.77]
(30)
3.17 [2.04]
(30)
-0.73 z = -1.94
p = 0.05
Emotional
loneliness
2.07 [1.17]
(30)
1.63 [1.16]
(30)
-0.44 z = -2.29
p = 0.02
Social
loneliness
1.83 [1.12]
(30)
1.53 [1.16]
(30)
-0.30 Z = -1.5
NS
45
3.4.4 Physiological data
To understand if statistically significant score changes from the patient reported outcomes in
activation and supporting concerns translated into changes in physical health, analysis of
physiological measurements was carried on 44 pairs of baseline/follow-up data (Table 9). This
data set was the most challenging to collect, as not all participants wanted measurements to be
taken, sometimes a clinical room was not available to carry out the measurements or the
appropriate equipment was not in the room when needed by the social prescribing advisor.
The data in Tables 9 and 10 indicate the potential that the social prescribing service has in terms
of improving physiological parameters that are known to be modifiable risk factors for several
long-term conditions such as CVD, diabetes and cancer.
Despite the low n value, enough data was collected to enable statistical analysis, and statistically
significant improvements in diastolic blood pressure (p=0.007), total cholesterol (p=0.043) and
LDL cholesterol (p=0.04) were achieved.
Baseline
mean
paired
(n=44)
Follow
up
Mean
(n=44)
Difference
Baseline/
Follow up
Statistically
Significant
difference?
Height (cm)
170.5
N/A
N/A
N/A
Weight (kg)
94.76
93.97
-0.79
NS
BMI
32.5
32.2
-0.3
NS
Systolic BP (mmHg)
135
131
-4
NS
Diastolic BP
(mmHg)
82
78
-4
0.007*
Total Cholesterol
(mmol/L)
5.48
5.01
-0.47
0.043*
HDL Cholesterol
(mmol/L)
1.16
1.16
0
NS
LDL Cholesterol
(mmol/L)
4.32
3.85
-0.47
0.04
Cholesterol Ratio
5.22
4.77
-0.45
NS
Table 9. Comparison of physiological data upon referral to the social prescribing service and at
the 3-month follow-up (n=44). * Statistically significant change in paired data when p=<0.05.
46
Physical activity and smoking
63/105 (60%), of participants reported an increase their physical activity and 3/13 participants had
stopped smoking at the 3 months follow-up. One person declared smoking at 3 months follow-up,
when previously stating they were a non-smoker.
“It was the [the social prescribing advisor] I think, who first mentioned
this new treatment to help give up smoking. So that was part of that
consultation…and I opted to go on a Quit Smoking programme…So I met
with the nurse [who is] able to prescribe the drug, so a few days later I
was able to collect my first prescription from the pharmacy. I then saw
the Help2Quit nurse every three weeks, I think, for a period of about three
months.”
“I started going to the gym twice a week and, and as I say, the GP’s,
nobody had ever suggested it to me. This was all through the social
prescribing lady that I went down that route. I now go, well mostly three
times…but I’ve lost two stone in weight, I feel much healthier, happier.
That really sums it up.
Body Mass Index (BMI)
The changes in BMI (n=49) were analysed in more depth (Table 10). Overall there was a net
movement of weight loss, with 56% of participants experiencing some degree of weight loss,
compared to 4% of participants experiencing weight gain. This is an important result as being
overweight and obese is known to contribute to several long-term conditions, including cancer,
blood pressure, diabetes and CVD and a reduction in weight can therefore contribute to
preventing these conditions.
“I’ve lost one stone three pounds in six months, which is very, very
heart-warming”
27/49 (56%) people reported a weight loss at 3 months follow up.
9/49 (20%) reported a weight loss of 3kgs or more.
One overweight participant returned to normal weight,
Two participants moved from obese I to overweight.
Two people put on more than 3kgs in weight.
47
BMI category
Paired
Baseline (45)
3-month follow-
up Paired (49)
Normal
2 (4.4%)
3 (6.12%)
Overweight
20 (44.4%)
22 (44.9%)
Obese I
11 (24.4%)
10 (20.4%)
Obese II
5 (11.11%)
7 (14.3%)
Obese III
7 (15.6%)
7 (14.3%)
Table 10. Analysis of changes to BMI categories (n=49)
3.4.5 Health service usage
Improvements in patient activation are associated with reduction in health service usage data.25
All available data on health service usage for the participants was therefore analysed comparing
service usage in the 3 months prior to the first consultation with the social prescribing advisor and
over the 3 months between initial consultation and follow-up.
This data was then compared to a case-matched control group for participants referred for CVD
risk as data could be extracted from electronic medical records.
A case-matched control group was selected from anonymous patient records who had a CVD
Qrisk2 score of 10% or more. They were matched to by age and gender to the social prescribing
group. Control patients may have been invited to use the social prescribing service and not
attended or might not have been included in the initial retrospective list of invitations. Any patient
who had used the social prescribing service was excluded from the control group.
All patients in the control group also had a Pearson correlation for gender (p= 0.05) and age (p =
0.046) showed a positive similarity between the control group (N=85) and the paired pre/post
sample (N=105). Mean age for control was 63.3 years compared to 62.2 years (social prescribing
group). There were 45/85 males (53%) and 40/86 females (47%) in the control group, compared
to 48/105 males (46%) and 57/105 females (54%) in the experimental group.
25 Roberts et al (2018). Measuring patient activation: The utility of the Patient Activation Measure within a UK contextResults
from four exemplar studies and potential future applications. Patient Education and Counselling. 99(10); 1739-1746
48
A statistically significant reduction was seen in visits to the GP (reduced by 40%, p=0.00) for
people who used the social prescribing service. There was no statistically significant reduction in
visits to the GP in the control group. It is therefore highly likely that the social prescribing
service is having a significant reduction on the number of GP consultations, for
participants who were referred due to their risk of CVD.
Nurse and total visits also showed a significant reduction for participants using the social
prescribing service and for the control group. It is not clear why this is - the control group had a
larger starting amount of nurse appointments compared to the social prescribing group. Nurse
appointments may be high as CVD patients have regular checks with nurses to monitor blood
pressure and other risk indicators. Therefore, it is not possible to conclude that the social
prescribing service has affected the nurse appointments, it is likely that other factors have
contributed to the reduction in visits to the nurse.
Table 11. Changes to health service usage in the 3 months prior to first consultation with the
social prescribing advisor compared to service usage for three months prior to follow-up.
*Statistical significance is when p≤0.05
49
3.4.6 Working situation
People were asked to provide information about their work status over the three months prior to
meeting with the social prescribing advisor and then for the 3 months prior to follow-up (Table
13). Only a small data set of 18 was collected as some people did not fill in the questions provided
as they did not feel they were relevant to them, as they were not currently in work. With such a
small number of people it is unlikely that any changes would be picked up and indeed no
statistically significant changes found comparing hours worked, days ill, weeks unemployed
(Table 13).
Paired
Baseline
(n=18)
Follow up
Mean
(n=18)
Difference
Hours Worked
23.9
29.4
+5.5
Days Ill
0.39
0.14
-0.25
Weeks Unemployed
12.21
13
+0.79
Frequency
n= 105
(percent)
Frequency
n= 105
(percent)
Retired
53 (50.5)
54 (51.4)
+1
Employed
27 (25.7)
25 (23.8)
-2
Unemployed
16 9 (15.2)
17 (16.2)
+1
Disabled
5 (4.8)
3 (2.9)
-2
Housewife/Husband
2 (1.9)
1 (1)
-1
Sick leave
1 (1)
0 (0)
-1
Volunteering
1 (1)
3 (2.9)
+2
Missing data
0 (0)
2 (1.9)
+2
Table 12. Analysis of participants’ work-related activities
50
4.0 Conclusion
For the Shropshire Social Prescribing team, the journey from theoretical model to implementing
and growing the social prescribing service has been challenging, but also highly rewarding and a
positive learning experience.
The service design has adhered to best practice as set nationally by the Social
Prescribing Network and NHS England, whilst developing the service on a practice by
practice basis and only using existing resources. This required encouraging stakeholders
to come together, including the GP champion, GP practice manager, Operational Project
Lead, Data lead, and Lead Adviser role. Importantly this project has enabled greater
collaboration between the local authority and CCG.
The Shropshire social prescribing approach was highly aligned with the most
recent Public Health strategy26 as well as with potentially reducing the need for core
aspects of Adult Social Care services. The Care Act, 2014 explains that it is the
responsibility of the local authority to promote the wellbeing of individuals. Wellbeing is
comprised of personal dignity; physical, mental and emotional well-being; protection from
abuse and neglect; control over day-today life; participation in work, education, training or
recreation; social and economic wellbeing; domestic, family and personal relationships;
suitability of living conditions and the individuals’ contribution to society.
An agile management approach to service development was deliberately employed
and the local Help2Change team carefully tested things out, then paused and reflected
before proceeding. An expanding range of different sectors are now getting involved in
the social prescribing service and it has successfully expanded from an initial
demonstrator site in Oswestry and Ellesmere to covering 5 regions in Shropshire.
Between May 2017 May 2019, 515 referrals were made into the social prescribing
service via 4 services in Oswestry/Ellesmere, Albrighton, Bishop’s Castle, Bridgnorth and
4 GP practices in Shrewsbury, which incorporates 11 GP practices. 134 people were
recruited into the evaluation, with 3-month follow up data from 105 people.
Feedback from service users was very positive. Satisfaction ratings were 4.8/5 for
suitability of times, convenience of venue and feeling able to discuss concerns with
the social prescribing advisor. This demonstrated that participants were feeling heard
and supported, and that the service was meeting peoples’ needs by addressing them not
as a ‘condition’ or disability, but as a person, with their own set of social and emotional
wishes and wants.
The social prescribing service supported unmet needs beyond the expected remit,
due to the inclusion of a link workers in the service, which provided an
individualised element. The MYCaW concerns that participants reported ranged from
lifestyle advice through to social determinants of health and concerns related to adult
social care.
The patient reported outcome data demonstrated statistically significant
improvements in participants’ MYCaW concerns (p=0.001) and Wellbeing (p=0.001),
26 Department of Health and Social Care (2018). Prevention is better than cure. Our vision to help you live well for longer
51
activation levels (PAM) (p=0.000), and the De Jong Gierveld measures of loneliness
(p=0.05).
Score changes translated into improvements in weight, BMI, total cholesterol
(p=0.043), LDL cholesterol (p=0.04), blood pressure (p=0.007, diastolic), levels of
smoking and physical activity.
Reasons why the social prescribing service has triggered changes have been
captured through via qualitative interviews and the MYCaW tool. Participants particularly
valued the role of the social prescribing advisor. Not only was this due to the 1:1 time with
a social prescribing advisor, but their training in motivational interviewing amongst other
things, and the support an individual received to access an appropriate group when the
time was right.
Overall the full set of data captured provides a compelling reasoning for the
statistically significant (40%) reduction in GP appointments for participants at the 3-
month follow-up, compared to a case-matched control group of people who did not use
the social prescribing service.
Above all, the social prescribing service seeks to address real life social complexity
and inequalities by offering integrated, holistic solutions to multifaceted health and
social care issues.
5.0 Recommendations
Evaluation data from the social prescribing service has demonstrated a significant impact on
individual users and health service usage. Below are key aspects that were identified to support
the continuing development and improvement of the social prescribing service.
More involvement from general practice
1. It is recommended that the social prescribing team discuss the intention and
benefits of the social prescribing service with GPs, to develop more relationships
that will lead to an increase in referrals and integration of social prescribing into
the GP consultation.
Overall participants agreed with the ethos of social prescribing and the direction of healthcare
toward a more sustainable and preventative approach. Participants highlighted that they wanted
their GPs to be more involved in the service, including discussing social prescribing as an option
with their patients, e.g.
“I think you need to, to involve, if you’re talking about people’s overall
general welfare and health then you need to get the GPs more involved”;
“ [There was] no communication, no reference to social prescribing at all
during the session with the GP.”
52
The referral data showed a varying level of referrals from GP practices who are involved in the
social prescribing scheme. Partly this reflects the differing points in which they became involved
in the social prescribing service as it was rolled out across Shropshire. It also reflects how
engaged different practices and GPs are and what is already offered by the practice. Social
prescribing has been brought into general practice very quickly, with little underpinning
professional development support. Neither was it included in the medical curriculum or the GP
contract. This initiative also comes at a time of crisis within the GP profession and could be seen
as yet another change to make on top of the already mountainous workload. The Shropshire
social prescribing service does offer support to reduce workload on practices in start-up phase
via the social prescribing team.
Appropriate referral processes
2. It is recommended that referral and audit processes are reviewed to ensure that the
people who see the social prescribing advisor do have concerns that need addressing
and that they are clear on why they are being referred.
Most data demonstrated that people who are referred into the service had concerns that needs
supporting. A small number of individuals did not feel they had any concerns that needed support
and therefore were probably not considered in need of the social prescribing service.
A small number of people who attended the social prescribing service via the CVD audit were
also unsure about why they had been offered it. As such it is important that any minor
amendments to processes are made to ensure that people understand fully why they are being
referred to the social prescribing service. Furthermore, ensuring the social prescribing service
and the role of social prescribing advisor is explained in the same way by all social prescribing
advisors will support a greater community knowledge of the service.
3. We would recommend seeking out more ways to access those people who are lonely
and isolated, including young people (widening the service to people under 18 years
of age), who could be referred Department of Work and Pensions, or even through
colleges.
Managing the social prescribing advisor/service user relationship.
4. It is recommended that attention is given to informing service users if the social
prescribing advisor is going to change.
The relationship between a particular social prescribing advisor and service user has been
highlighted as a key aspect of the positive experience. Most participants were satisfied with the
length of time spent with the social prescribing advisor, however one expressed disappointment
when their original advisor had moved. Although the subsequent advisor was still very good, the
participant had established a rapport with the first advisor.
These visits took place during a period in which new advisors were being trained up and similar
disappointments were expressed about changes of GPs and other health professionals. These
comments confirm the importance that some participants attached to one-to one-relationships
53
they establish with professionals, the trust placed in these relationships and the potential impact
of person-centred care on patient outcomes. This also highlights the need to ensure continuation
of employment for link workers and to avoid short term contracting arrangements.
Additional training for social prescribing advisors
5. It is recommended that social prescribing advisors receive further training in areas
such as mental health issues and alcohol and substance abuse.
Social prescribing Advisors frequently deal with multiple, sometimes complex issues. Some
clients had a lot of things going on in their lives (e.g. debt problems, domestic problems.). While
Advisors needed to recognise the limits of their role, at least one Advisor felt that additional
training on specific topics such as anxiety, depression, and alcohol issues would be beneficial.
Evaluation
6. It is recommended that review of collecting physiological data such as weight, is
undertaken to address issues identified around lack of rooming or equipment, if future
evaluation is to be carried out.
The evaluation overall was successful but has presented several challenges to the social
prescribing team. Being able to translate changes in patient outcomes measures, into
physiological changes is also an important aspect of understanding how far reaching the impact
of the social prescribing service is. It is therefore important to address any practical barriers to
collecting this data.
7. Do it, without a doubt.”
Participants who were interviewed were asked if they had any recommendations to others
considering using the service, all but one was definite that others should try it, e.g.
“I’d say do it, without a doubt”
“Well I can’t thank them enough for what they did for me.”
“Things are ongoing but moving! And in the right direction! Great
feeling empowered and ready for battling!”
54
Appendix A - Referring medical practices
Medical Practice
Opportunistic
referral
CVD audit
Total people from
each practice
Cambrian
23
86
109
Plas Ffynnon
17
51
68
Albrighton
42
4
46
Bishops’ Castle
27
0
27
Ellesmere
20
0
20
Marden
40
0
40
Radbrook Green
11
0
11
Caxton
4
0
4
Claremont Bank
16
0
16
Severn Fields
14
0
14
Bridgnorth
56
0
56
Table 13. Breakdown of how people entered the social prescribing service per medical
practices in Shropshire.
55
Appendix B Organisations and services referred to by the Link
Workers
Organisation/Activity
Description
Age UK - Advocacy support & representation
Age UK - Benefit Advice
Age UK Dementia Respite Service
Age UK - Diamond Drop-in
Age UK - Help at Home
Age UK Living Well
Age UK Lunch Clubs
Age UK - Opel Day Centre Bridgnorth
Age UK - Opel Day Centre Ellesmere
Age UK - Opel Day Centre Oswestry
Age UK - Opel Day Centres Shrewsbury
Age UK - Volunteer Befriending
Alzheimer's Society Art Therapy
Alzheimer's Society - Dementia café
Alzheimer's Society - Home support
Alzheimer's Society - Peer Support Group
Alzheimer’s Society - Singing for The Brain
Bayston Hill Library - Personalised Library Induction
Personalised Library Induction regarding health
information and library activities
Carers Trust4All - Bridgnorth Carers Group
Carers Trust4All - Carer breaks
Carers Trust4All - Carers Group for Carers of Adults with a Learning Disability
Carers Trust4All - Carers Groups/Advice sessions
Christians Against Poverty Debt Counselling
Citizens Advice Shropshire - Advice and Information service for Debt
Citizen's Advice Shropshire - Benefit Check
Citizens Advice Shropshire General Advice
General Advice (e.g. Housing, Employment,
Health/Community Care, Relationships)
Citizens Advice Shropshire - My Money Matter Community Project
Citizens Advice Shropshire - Pensionwise
Guidance for over 50's
Citizens Advice Shropshire - SEND advice
Special educational needs and disability advice for
0-25 year olds
Codsall Leisure Centre (South Shropshire Council) - Forward to Health
12-week exercise scheme
Community Mental Health Team One-to-one Support
Designs In Mind - Arts based activity
For people with mental health issues
Designs In Mind - Mindfulness
Designs In Mind - Open Maker Night
Designs In Mind - Support into Employment
Diabetes UK Peer Support Group (Bishops Castle)
Dolly Mixtures Bishop’s Castle - Mixed ability ladies running group
Ellesmere Library Our Space - Books on Prescription
Ellesmere Library Our Space - Ellesmere Opportunities Group
Group for people with Learning Disabilities
Ellesmere Library Our Space - Family Knit
Ellesmere Library Our Space - Friendship Group
Older persons’ day respite service
Ellesmere Library Our Space Get Online
Ellesmere Library Our Space - Memory Cafe
Ellesmere Library Our Space - Reading Group
Ellesmere Library Our Space - Rhyme Time
Ellesmere Library Our Space - Time to Listen
Reading group
Ellesmere Library Our Space - Volunteer Opportunities
56
Enable - Supported Employment Service
For people with disabilities and mental health
illness
Energize - Elevate
Balance and strength classes for everyday life
Exercise on referral Made through GP
Extend - Extend
Low impact, gentle exercise to music
Green Oak Foundation
Counselling Therapy
Help2Change Help2Quit
Help2Change Help2Slim
Help2Change Managing Your Joint Pain
Ingeus - Healthier You (NHS National Diabetes Prevention Programme)
Library at The Lantern - Personalised Library Induction
Personalised Library Induction regarding health
information and library activities
Lifestyle Fitness - Exercise on Referral
Lifestyle Fitness - Get Active Feel Good
Marches EnergyEnergy Advice & Support
MHA - Shifnal, Albrighton & District Live at Home Scheme
MHA - Volunteering (Shifnal & Albrighton)
MIND - Crafty Afty
MIND - Drop-in
MIND - Reconnect programme
North Shropshire College - Assertiveness for Life course
North Shropshire College - Five Ways to Wellbeing course
North Shropshire College - Mindfulness course
Oswestry Leisure Centre - Exercise on Referral
Oswestry Leisure Centre - Healthy Lives
Oswestry Library - IT Sessions
Oswestry Library - Books on prescription
Oswestry Library - Home Library Service
Oswestry Library - Quick Reads
Oswestry Library Time To Listen
Pontesbury Library
Personalised Library Induction regarding health
information and library activities
Qube - Arts and creativity courses
Qube - Dial a Ride
Qube - Health and well-being courses
Qube - Shop Mobility
Qube - Social Group
Qube Volunteering
REMAP - Aids for disabled persons
REMAP - Volunteering
South Shropshire Housing Association Housing Advice
South Shropshire Housing Association Lunches 4 All
South Shropshire Housing Association Mobile Lunches
South Shropshire Housing Association Pedals for Health
Shrewsbury Library - Personalised Library Induction
Personalised Library Induction regarding health
information and library activities
Shrewsbury Town in the Community - Extra Time
Shrewsbury Town in the Community - Heads Up
Shrewsbury Town in the Community - Kick Cancer
Shrewsbury Town in the Community - Short breaks for parents of children
with disabilities
Shrewsbury Town in the Community - Walking Football
Shropshire Community Leisure Trust - Sports & Leisure Activities
Shropshire Outdoor Partnerships - Parish Paths Partnerships
57
Shropshire Outdoor Partnerships - Shropshire Wild Teams
Landscape management projects and other
outdoor activities
Shropshire Outdoor Partnerships - Volunteer Rangers
Shropshire Outdoor Partnerships - Walking 4 Health
Shropshire RCC - Active Buddies
Shropshire RCC - Albrighton Care & Share Group
For family carers and family members with mild
to moderate dementia
Shropshire RCC - FFMOT
Functional Fitness MOT
Shropshire RCC - Hearing Loss Support to hearing aid users
Shropshire RCC - Sight loss support
Shropshire Wildlife Trust - Feed The Birds Beneficiary
Shropshire Wildlife Trust - Feed The Birds Volunteer
STAR Housing - Sustain Housing Support Services
Housing support and benefit advice
Sustain Consortium (Care Plus Part) - Housing related support
Swan Mere Day Centre - Day Care provision
The Albrighton Trust - Angling, horticulture or woodcraft
Volunteering, or participating, in angling,
horticulture or woodcraft sessions at the Moat &
Gardens
The New Saints Football Club - Community Postural Stability Instruction
The New Saints Football Club - Exercise on Referral
The New Saints Football Club - Get Up and Go
Activity sessions for the over 60s
The New Saints Football Club - Otago
Balance and Strength Classes
The New Saints Football Club - Seated Exercise to Music
The New Saints Football Club - Walking Football
The New Saints Football Club - Zumba/Hoola Hooping Classes
Through the Doorway - Art 4 Well-being
Through the Doorway - Be Good to Yourself
Through the Doorway - Cooking 4 Life
Through the Doorway - Music for Well-being
Through the Doorway - Pilates
Through the Doorway - Tai Chi
Through the Doorway - Yoga
Table 14. The organisations and services referred to by the social prescribing advisors
58
END
59
... All included studies were conducted in high-income countries, with 51 studies originating from the UK and two from Australia [15,39]. There were 50 uncontrolled studies with a before-and-after design [12][13][14][15][16][17][18][19], one of these included a module with a controlled design for health care utilization outcomes [84]. Three studies included control groups: one randomized controlled trial [92], one quasi-experimental cluster randomized controlled trial [93], and one non-randomized controlled trial [94][95][96]. ...
... Most reports (n = 41, ~80%) had been published in the last five years, with about half of these dating back to the years 2019 and 2020 (n = 22). Fifteen SP evaluations focused on populations with special characteristics besides their existing psychosocial needs (Mental health issues: n = 6 [12,39,52,53,58,70,80,88], long-term conditions: n = 4 [49-51, 54, 57, 60, 61, 97], geriatric age group: n = 2 [19,73], work-related injuries: n = 1 [15], high risk for cardiovascular disease: n = 1 [84] and sensory impairment: n = 1 [87]).The remaining studies had included unselected/mixed populations or did not provide detailed information about the target group. Sample sizes were highly heterogeneous, ranging from n = 12 [87] to n = 10643 [64]. ...
... The Patient Activation Measure (PAM) and General Self-Efficacy Scale (GSE) were mainly used to report changes in self-efficacy [12,17,60,84]. We could compute the SMD for the GSE from Morton et al. [12], reporting a large positive effect in an unclear time frame (SMD = 0.85, 95% CI [0.65, 1.05]). ...
Article
Full-text available
Introduction: Social prescribing (SP) aims to provide targeted psychosocial support and close the gap between medical and non-medical services. This review assesses the effectiveness of community-based SP interventions. Methods: We performed a systematic review and qualitative synthesis of interventional studies of community referral interventions focused on facilitating psychosocial support. We considered health-related endpoints, other patient reported outcomes, or health care utilization. Six databases, grey literature, and additional trials registers were searched. Results were screened in a two-step process, followed by data extraction, each by two independent reviewers. If data permitted such, effect sizes were calculated. Risk of bias was assessed with the EPHPP and the Cochrane RoB2 tools. Results: We identified 68 reports from 53 different projects, three were controlled studies. Uncontrolled studies with shorter time frames frequently reported positive effects. This could largely not be seen in controlled settings and for longer follow-up periods. Designs, populations, and outcomes evaluated were heterogeneous with high risk of bias for most studies. Discussion and conclusion: Current evidence suggests positive effects of SP on a variety of relevant endpoints. Due to quality deficits in the available studies, scope for conclusions concerning clinical relevance and sustainability is limited. Further methodologically rigorous controlled trials are needed.
... Our work as researchers at the University of Westminster has entailed gathering quantitative data on social prescribing schemes and also eliciting multiple stakeholder perspectives of prescribing processes and outcomes. In one such study, a single arm mixed methods study of a Shropshire social prescribing scheme (Polley, Seers, & Fixsen, 2019), we conducted semi structured interviews with 12 service providers and 12 service users about their experiences of social prescribing. Topic guides rather than set questions were employed so that participants could feel free to relate their stories and unanticipated issues could emerge. ...
... GPs we interviewed agreed that social prescribing steers the patient away from being over medicalized and reminds doctors that there were other ways of working. One of the GPs, L., interviewed for the Shropshire study (Polley et al., 2019), described the types of patients he might refer to a social prescribing link worker: I'll tend to refer people with low level depression, anxiety, loneliness, isolation, people with chronic disease management problems to try and encourage them to take ownership in certain cases. But also, you do have a number of patients that are, frequent attenders with perhaps no confirmed diagnosis but they've had lots of tests, seen lots of specialists and just not getting anywhere. ...
Chapter
Full-text available
Social prescribing allows health professionals to refer at risk patients toward health and wellbeing interventions and activities in the local community. It is a key part of NHS (National Health Service) England health care policy, and schemes based on the social prescribing model have been developed in countries including Canada, New Zealand, the Netherlands and Singapore. In this chapter, we consider the role that social prescribing can play in reducing stress related problems and supporting and encouraging self-care and self-management of conditions for which conventional medicine may not be the only or the best option. Drawing on primary and secondary data sources, we examine the scope of social prescribing and professional and service users' perspectives concerning its strengths and limitations. Our findings suggest that link worker meetings within social prescribing schemes can motivate people to pursue activities with mental, physical and social benefits such as exercise, artistic pursuits and gardening. Problems within schemes included health provider engagement, recruiting those with low agency and communication between professionals and patients about social prescribing. Based on our findings, we propose a number of recommendations for enhancing social prescribing schemes. Professionals, including neurologists, we argue, can benefit from engaging in the concept and practice of social prescribing and referring patients and clients to social prescribing link workers where appropriate. Neurologists are also part of a larger team, as they work alongside allied health professionals such as occupational therapists and physiotherapists, some of whom are already performing aspects of the link worker role.
... While it is unrealistic to attempt to treat all mental health problems with psychedelic therapy, given the therapeutic potential of egodissolution and connectedness, equivalent non-psychedelic experiences could be emphasized in other modes of therapy as well as in daily life. Nature-relatedness achieved through contact with nature (Fretwell & Greig, 2019) and social prescribing (Kimberlee, 2013;Polley, Seers, & Fixsen, 2019) have both been found to be beneficial for mental health and psychological wellbeing. Mindfulness-based therapies like mindfulness-based cognitive therapy or acceptance and commitment therapy can be considered less intense equivalents of ego-dissolution insofar as they reduce self-focused cognition (Gu et al., 2015;Hayes, Strosahl, & Wilson, 1999). ...
Article
Full-text available
Background and aims Despite promising findings indicating the therapeutic potential of psychedelic experience across a variety of domains, the mechanisms and factors affecting its efficacy remain unclear. The present paper explores this by focusing on two psychedelic states which have been suggested as therapeutically significant in past literature: ego-dissolution and connectedness. The aim of the study is to investigate the impact of ego-dissolution and connectedness on the therapeutic effects of the psychedelic experience. Methods The investigation was carried out as a mixed methods systematic review, with the data from four databases analysed thematically and results presented through narrative synthesis. Results The analysis and synthesis of findings from 15 unique studies ( n = 2,182) indicated that both ego-dissolution and connectedness are associated with a higher chance of improvement following a psychedelic experience. However, there seem to be differences in the way the two experiences affect individuals psychologically. Ego-dissolution appears to trigger psychological change but does not typically exceed the psychedelic experience in its duration, while connectedness can be more sustained and is associated with several positive, potentially therapeutic feelings. Conclusions Moreover, the findings of this review have implications for further theory-building about the mechanisms which enable therapeutic effects in psychedelic experience. This in turn might lead to improved models for psychedelic therapy practice. Emphasis on ego-dissolution during the preparation phase and on connectedness during integration is one suggestion presented here, alongside overarching implications for the mental health debate and general practice.
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