Link worker perspectives of early implementation of social prescribing: a 'Researcher-in-Residence' study

Social prescribing (SP) is increasing in popularity in the UK and can enable healthcare providers to respond more effectively to a range of non-clinical needs. With the NHS commitment to establish an SP link worker in all GP practices, there is a rapid increase in the number of SP schemes across the country. There is currently insufficient evidence concerning the implementation and acceptability of SP schemes. In this paper, we report our analysis of the descriptions of the experiences of SP link workers, regarding the early implementation of SP link workers in two SP programmes in the South West. Data were gathered using the ‘Researcher in Residence’ (RiR) model, where the researcher was immersed in the environments in which the SP was managed and delivered. The RiR undertook

conversations with 11 SP link workers, 2 SP link worker managers, and 1 SP counsellor over six months. The RiR visited seven link workers at their GP practices (service 1) and four at their head office (service 2). The RiR met with the link worker managers at their offices, and the RiR spoke with the SP counsellor on the telephone. Data from these conversations were analysed using Thematic Analysis and six codes were constructed to advance our understanding of the components of early implementation of the SP programmes. Training (particularly around mental health), workforce support, location, and SP champions within GP practices were found to be key strategies of SP implementation, link worker involvement acting as a conduit for the impacts of these strategies. This paper suggests that the implementation of SP programmes can be improved by addressing each of these areas, alongside allowing link workers the flexibility and authority to respond to challenges as they emerge.    (Husk et al., 2019). As social prescribing comprises both a pathway and a series of relationships and these need to function to meet the patient need (any disruption to this series of interactions potentially limiting the ability of services to deliver effectively), embedded qualitative research is required which allows the detail and complexity of the functioning of these relationships to be explored in differing contexts.
In this paper, we report analysis of rich descriptions of the early implementation of link worker social prescribing, to assess how this series of relationships functions and the key barriers and facilitators experienced on the ground. While social prescribing programmes are tailored services to local contexts, the lessons learned around the functioning of relationships along the pathways would, we hope, have broader applicability and assist others in implementing new services proliferating with the rapid expansions through Primary Care Networks.

Researcher in Residence
We collected qualitative data relating to link worker experiences of implementing new social prescribing programmes, which were collecting using a 'researcher-inresidence' (RiR) approach to data collection as described by  The two organisations described here stated that it would be useful to investigate the early implementation of link workers in order to map their activities and to identify challenges which could then be addressed in real-time. The RiR undertook structured conversations with social prescribing link workers (see Figure 1) and link worker managers in two geographic areas delivering SP programmes in the South West of England (Service 1 and Service 2). This work was conducted after the link workers had been in post for 6 months, relating to their experiences of SP and their role in the pathway. Embedded counselling coordinators providing workforce support were also included.
Conversations were loosely directed by a topic guide and link workers were encouraged to digress beyond the conversation topic guide to surface issues that were pertinent to them.
Handwritten field notes were recorded by the RiR detailing the information shared by the link worker, throughout the conversation. Field notes can help the researcher record valuable contextual information (Phillippi & Lauderdale, 2018), therefore, the RiR was also able to record their observations such as their own experience of the setting (e.g. whether the link worker was able to display information about the SP service in the waiting room). The focus of these field notes was to describe what the link worker said to the RiR, in order to 12 capture the experiences and views of the link worker. This encouraged freedom of direction of the conversation, allowing rich descriptions to emerge from participants.

Ethics
Ethical approval for the synthesis of the two included service evaluations was obtained from the University's Faculty Ethics Committee and conforms to recognised standards concerning the ethics of research on humans, approval number: FREIC1920.40 Invitations to take part in these conversations were emailed to link workers by the link worker managers. And verbal, informed consent was taken immediately before each conversation.

Analysis and synthesis
We analysed collected qualitative implementation data using Thematic Analysis (TA) as described by Braun and Clarke (2006).
Here, the coding and the development of codes are driven by the content of the data, i.e. capturing and reporting what participants 'said', rather than seeking to interpret what was 'meant', and 'how' it was said. This study acknowledged that data were analysed from an experiential perspective, i.e., that the researcher 'learned' about the views and experiences of social prescribing, from their exposure to, and consultation with, participants, rather than interpreting the data of those 13 participants to elicit their 'reality', in a constructionist way. Our analysis iteratively examined data throughout the data gathering period. After each conversation with the link workers, link worker managers and the counselling coordinator, the RiR reviewed the field notes that were recorded during the conversation, and constructed codes that described the salient points of the conversation. This process was repeated after each conversation and as the data set increased, codes from each new conversation were compared with codes that had already been identified and examined for commonalities and differences in order to start to develop early, 'fledgeling' themes. We did not, however, develop these further into full TA themes as we wished to extract useful data that would remain specific in order to feedback to the SP services.
We took care to structure our data and analysis around concrete concepts that resonated with our participants. Initial codes were thus presented back to link workers, managers, and the counselling coordinator. Those who had been unable to take part were invited to contribute at this point if they felt that there were gaps in the data or if they felt that what was presented did not represent their experiences of social prescribing. Amendments were incorporated into the final dataset.

Service 1
The first SP scheme was delivered via a consortium of 6 VCSE In Service 1, interviews were conducted with seven SP link workers and one link worker manager. Where workers were based across multiple practices the most convenient for the link worker was selected. Meetings were held at individuals' place of work for two reasons; first, as outlined workers did not often return to a single base, it would have been time-consuming for them to meet as a group. Second, this process enabled the RiR to experience the environment in which each link worker practised first-hand and gain a sense of how integrated the link worker and the service was.

Service 2
Link workers in Service 2 were employed by a single Community Development Trust with an annual turnover of £1.2m and a trading surplus of over £150k which is used to support community projects. The local City Council are the Trust's major partner, and the Trust has a population coverage of approximately 46, 000. Whilst this cohort also delivered the SP service from GP practices they were, in contrast to Service 1, based at a single site with a shared office and were in close contact with colleagues regularly. The RiR was invited by the link workers and their manager to meet with them as a group of five at the Trust head office as that was deemed the most convenient. Service 2 also provides an in-house counselling service which operates from the main community hub and is available to both users of the SP service and the SP workforce; the counselling service manager was included but separate to the group conversation.

RESULTS
Following repeated engagement with the resulting data, we constructed the following codes to contribute to our understanding of the components of early implementation of 16 these programmes. Here, we describe the codes and report exemplar descriptions of where schemes were working 'well' and where there was a need for further development to allow the implementation to be successful.

Mental health severity (1)
Individuals reported a proliferation of referrals where those referred were experiencing moderate to severe mental health problems that were outside the remit of the link worker. "Many

Workforce support (3)
Frequently in discussions, individuals surfaced the importance of workforce support and supervision in the SP scheme. This reflected their experiences of working with a caseload that included mental health difficulties and enduring social and health problems. All link workers and the counselling coordinator talked about the need for comprehensive and wellembedded workforce support, including one-to-one clinical supervision that was a "confidential safe space" (RiR field notes, Link Worker 7, service 1).
There was considerable variability in the workforce support according to site. Where the SP scheme was managed by one organisation (Service 2), link workers experienced consistent 20 workforce support structure comprising of monthly manager supervision, informal peer supervision via the shared office base and group peer discussion at meetings. Where necessary, additional support was available from the in-house counselling service based at the Trust. Service 2 link workers reported feeling well supported.
In Service 1, where link workers were employed by six partners across a wide geographical area, there was greater variability in workforce support. While some felt well supported and able to access their own support structure (at times independently), "Link worker does feel supported in role, however, is supported by her own mechanisms for clinical supervision" (RiR field notes, Link Worker 4, Service 1); some reported feeling not wholly supported in some key aspects of their role, particularly around clinical Where link workers had reported a support structure this was often because they were able to access clinical supervision from their employing organisation (not the SP programme organisation), or through personal contacts with expertise in mental health supervision "Link worker attended supervision provided once but did not feel it was suitable for needs as it was general reflective practice, had sourced own support from psychologist friend." (RiR field notes, Link Worker 7, Service 1). This was starting to change at the time of writing 21 as the consortium's lead organisation had arranged clinical supervision for the link workers.

Location (4)
There were two main components to the fourth code: the role of GP practices (4a) and accessing SP activities (4b).

The individual as a conduit (6)
The experiences, skills, knowledge, and behaviour of the link workers crosscut the other codes and acted as a conduit for their impacts. The codes that emerged during the data collection and analysis were largely the result of external environmental factors. However, link workers were able to overcome these in novel and inventive ways. Where, for example, referrals were initially slow, strategies were developed which addressed rates such as a 'prescription pad', a bright, easy to complete and colourful pad that was put on the desk of each clinician, which subsequently increased referrals.
"Initially referrals were a bit slow but then the Link Worker developed an SP prescription pad that sits on the desk of all of 24 the clinicians." (RiR field notes, Link Worker 4, Service 1). This link worker was also involved in the rolling development and maintenance of community directories of activities and resources, in order to make referrals to providers and activities that had been quality assured by the service.
Where SP was working well and exceeded the capacity of the link worker, one individual had worked collaboratively with the practice to set up a weekly group meeting where those on the waiting list could meet until there was the capacity for their face-to-face meeting and referral onto individual activities.
As with the mental health code discussed above, the professional background of link workers influenced aspects of their approach to their role, and their confidence in developing and implementing novel solutions to the challenges that they faced.

Social prescribing implementation
As we argued at the outset, social prescribing is not a single complex intervention but a series of relationships all of which need to function to meet individuals' needs. We wanted to Last, and with greatest links to the existing literature, the impact that the skills, knowledge, characteristics, and approach 28 the link workers posses as individuals are difficult to exaggerate.
As noted in the NASSS implementation of digital technology health framework (Greenhalgh et al., 2018), allowing frontline staff the flexibility and authority to make minor adaptions can make marked impacts on the uptake and success of changes.

Strengths and limitations
The strength of our approach is that we adopted an innovative model of research, the RiR model. This embeds the researcher within services delivering programmes and allows real-time observation of the functioning and evolution of those services, alongside the challenges services that those services meet with.
The RiR model, furthermore, allows the researcher to feedback evaluation findings to services in order to optimise the delivery of the service.
The limitations of this approach are the potential challenge for the RiR of reporting evaluation outcomes that may indicate occasions when the service has not been functioning optimally, or where implementation has proved different. For the services described here, however, where the RiR identified aspects of the services which had faced challenges to implementation, the services reported that this was useful as it supported their anecdotal findings and supplied a rationale for further development of that component of the service. 29 In addition, our data do not allow us to make assertions as to whether services are effective or have an impact on health as is intended. We can certainly infer that if programmes are functioning well then, they have better reach, scope, and acceptability to those who they are looking to engage; but further quantitative work would be needed to definitively answer this question.

Recommendations
The evidence presented here implies that those looking to implement SP in new programmes, or at scale, would benefit Mangers of SP programmes should be aware of geographical variations in accessibility to activities and take active steps to improve access for referred individuals (e.g., by subsidising travel costs) or tailoring new and local solutions.

Conclusions
Social prescribing is proliferating, and all new Primary Care Networks will be recruiting new link worker roles in the immediate future. Implementation of programmes can be improved by focusing on fully embedding social prescribing services within GP practices, including securing link worker 31 access to all the practical resources that facilitate the work of the link worker, and ensuring their inclusion in practice/team meetings to support the maintenance of ongoing GP practice engagement with the social prescribing service. Crosscutting all the codes that have been described here, the link worker is a conduit for the impacts of external environmental factors and, therefore, understanding the role of the individual and allowing them the flexibility and authority to develop micro-solutions to problems as they emerge is paramount.