''It sounded a lot simpler on the job description'': A qualitative study exploring the role of social prescribing link workers and their training and support needs (2020)

Social prescribing is an increasingly popular approach to promoting health and well-being, by addressing the wider determinants of health such as physical inactivity, social isolation and financial insecurity. Social prescribing link workers (SPs) connect people to local, non- clinical services. As part of the NHS Long Term Plan, NHS England aims to recruit 1,000 SPs across England by 2021. Understanding the role of SPs, including challenging aspects of the role and the types of training and support needed by SPs is crucial to optimising the effectiveness of social prescribing. Semi- structured qualitative interviews were conducted with nine SPs from five NHS and voluntary sector organisations in London to explore the role of SPs and identify SP training and support needs. Interviews were analysed thematically and three key themes emerged for which SPs needed particular support: defining and promoting their role; supporting clients with complex needs and coping with the emotional demands of their role. SP perceptions of training and future training needs is presented as a fourth theme.


| INTRODUC TI ON
Social prescribing is a novel approach to managing health and wellbeing in the UK. The aim of social prescribing is to improve health outcomes and reduce the burden on health services by addressing the social determinants of health, as well as empowering people to live more healthy lives (Kings Fund, 2017). Social prescribing may be carried out by any health professional. However increasingly, social prescribing link workers (SPs) are recruited from a variety of professional backgrounds and are employed to provide a holistic assessment and support clients to manage complex health and well-being needs. For example, a person with diabetes who is overweight and struggling with low mood could work with an SP to identify a range of factors affecting their health and well-being and co-produce a plan to address these. In this example, the SP may link the client to a local long-term condition support group and support them to attend a local exercise class. Although "social prescribing" is a relatively new concept in the UK, similar programmes can be seen internationally. Health Leads is a non-profit organisation in the US, which employs advocates to connect individuals with community organisations to address social issues, with the aim of improving health (Alderwick et al., 2018;Health Leads USA, n.d.) There is limited evidence for the effectiveness of social prescribing and it can be a challenging intervention to evaluate (Gottlieb et al., 2017;Husk et al., 2019). However, a number of early evaluations have shown positive effects on reducing the number of general practice (GP) and emergency department visits in places where social prescribing programmes have been implemented (Bickerdike et al., 2017;Carnes et al., 2017;Healthy dialogues, 2018). Despite the challenges in evaluating the effectiveness of social prescribing, it has been noted that the skills and experience of SPs is central to the success of any programme (Skivington et al., 2018). Social prescribers need an in-depth knowledge of community provision in the local area and must be trusted by community organisations they refer on to (Wildman et al., 2019). Community integration develops with experience and time spent in the role, adding to the importance of providing training and support to retain SPs.
In the UK, SPs can be employed by voluntary sector organisations and then commissioned to carry out work for the NHS or be recruited directly by the NHS and form part of primary care teams. SPs receive referrals from other health professionals such as GPs and self-referral is often available. In many areas SPs take part in multidisciplinary meetings in GP practices and have access to NHS patient records. As SPs work across health, social care and the voluntary sector, they have a vital role to play in the integration of health and social care (NHS England, 2019;Polley et al., 2017). Services vary nationally in the length and intensity of the support offered to clients ranging from telephone only support or sign posting to other services, to more holistic social prescribing (Kimberlee, 2015) which starts with a comprehensive assessment of need and may include faceto-face appointments offered over a number of weeks. There are different models of social prescribing ranging from simply signposting individuals to appropriate services (light) to working with clients over a number of sessions and weeks to empower them to work towards their health and well-being goals (holistic) (Kimberlee, 2015). Increasingly, it is noted that people who are employed in SP roles are using a holistic model with clients (Beardmore, 2019). Moffatt et al., (2017) explored the client perspective of social prescribing and found that people accessing social prescribing often had multiple health conditions, mental health difficulties and were socially isolated, creating complex caseloads of clients for SPs. As well as addressing complex client needs, SPs are expected to network with community organisations, look for gaps in community services and work with organisations to fill those gaps (Skivington et al., 2018). The role of SP is complex and demanding (Skivington et al., 2018), in order to fulfil the requirements of the role SPs must have a breadth of knowledge and skills for which appropriate training should be developed. One recent study explored the experiences of SPs working in the role and found that many SPs brought years of relevant experience, however, gaps in training were highlighted to help them develop in their roles and careers; including people management and collaborative working skills (Beardmore, 2019). The aim of this study was to explore the challenges of working as an SP and their experiences of training and support received as they develop in this new and evolving role.
• Research suggests that the initial training received by link workers may not adequately equip them for the role.

What does this study add?
• SPs reported the need for more comprehensive training, especially in mental health.
• Improvements in awareness of and understanding of SP roles among health professionals are needed to support SP role development and optimise the effectiveness of social prescribing.
• The development of local SP networks to provide peer-to-peer support could help SPs manage the emotional demands of their roles, particularly for SPs working in isolation.

| ME THODS
This study used an interpretative phenomenological approach to explore the lived experiences of individuals working as SPs (Smith et al., 2009). The primary researcher carried out in-depth semistructured interviews with SPs working in NHS and voluntary organisations in Greater London. The interviews lasted 30-45 min and took place in person or via telephone. All interviews were audio-recorded and conducted by JR.

| Recruitment and data collection
A topic guide was developed following a review of the literature and refined after the first two interviews. Questions about initial recruitment and training for the role, role challenges and experiences of support were included. Space was provided for the participant to explore specific questions in more detail or discuss anything relevant but not previously defined in the topic guide.

| Data analysis
Interviews were transcribed verbatim and analysed thematically using the stages described by Braun and Clarke (2006). Particular thoughts, insights or ideas were coded and these codes were then organised into themes. One transcript was coded separately by SB to enhance the rigour of the analysis and coding approaches were discussed and refined. See Table 2 for the coding structure with illustrative quotes. NVivo 11 software was used to support the analysis.

| Ethical approval
Ethical approval was gained from the London School of Hygiene and Tropical Medicine Ethics Committee and Health Research Authority (Project ID: 263,270) approval was gained for interviewing NHS employees. For all non-NHS-employed participants, there were no formal local ethical approval requirements, therefore permission to approach and interview participants was gained from their line manager. Participants were provided with a participant information leaflet at least 24 hr prior to the interview, fully detailing the study procedures and explaining all aspects of participation including their right to withdraw from the research and issues surrounding confidentiality and data protection. Participants signed a consent form before the time of the interview. As the participants were discussing potentially difficult workplace issues, any participant who raised concerns about their own well-being were signposted appropriately.

| FINDING S
Nine social prescribers were recruited to this study: seven women and two men, from three voluntary sector organisations and two NHS organisations in Greater London. Six SPs were employed by voluntary sector organisations, and three SPs were employed by NHS organisations. See Table 1 for details.
The job titles of the participants included social prescriber, social prescribing link worker, locality navigator, community navigator and stroke care advisor. Three key themes emerged from the interviews for which SPs required training and support: defining and promoting the role, supporting clients with complex physical and mental health needs and coping with the emotional demands of the role. A fourth theme is also presented in which SPs consider how well their training prepared them for the abovementioned challenges and what their future training needs may be; perceptions of training received and training needs. Quotes illustrating these themes are presented in Table 2.

| DEFINING AND PROMOTING THE ROLE
Participants often felt that their job scope and remit had been poorly defined from the outset and it had "sounded a lot simpler on the job description" (SP4). Participants also reported that their role was not well understood by external referrers such as GPs. It was reported that external referrers often had unrealistic expectations of what could be achieved by SPs, and in some cases were referring clients with complex needs that exceeded the remit of their role.
"I would definitely say it's a pattern for GPs to refer clients to you that they don't know what to do with… they know the person can't be helped, and even for the social prescriber it's going to be a long hard path, and really social prescribing is meant to be a low level intervention" SP7.
Challenges were experienced by the SPs in defining and promoting the service to potential referrers and NHS colleagues. In some cases SPs were tasked with setting up the service and deciding "how to promote your role, how to make people aware, how to articulate the role" (SP7) without support or guidance. One SP experienced frustration while attempting to articulate to their colleagues that social prescribing is not "only signposting" (SP7).

| SUPP ORTING CLIENTS WITH COMPLE X PHYS I C AL AND MENTAL HE ALTH NEEDS
One of the greatest challenges discussed by SPs was providing support to a caseload of clients with a range of complex physical, mental health and social needs. SPs reported that clients often disclosed serious mental health problems, including suicidal ideations. It was reported that the philosophy of social prescribing practice created opportunities for mental health to be discussed more openly: "I just find that sometimes, when you are working in a more holistic way, people are more open to bringing things up and I think that when you are suicidal you are desperate to tell somebody how you are feeling…our appointments are one hour long and someone can feel more comfortable and at ease talking to somebody to sort of raise their concerns and about suicide" SP7.
Participants reported that their way of working contrasted to that of GPs and other health professionals, who often have short appointment times or only allow for a single issue to be discussed, making it unlikely that a mental health issue will be raised. SPs working in NHS services often found it was challenging to meet the needs of clients who were physically disabled or housebound due to the lack of services available to assist them in leaving the house, which severely limited the services SPs were able to link to: "disabled people who cannot leave the house because they do not have a care worker…we just have no one to support them to go to these groups, I guess it's not that they don't want to attend activities, it's that they don't have the means to do it" (SP6).

| EMOTIONAL BURDEN AND COPING
SPs spoke of the emotional burden associated with working in the role, at times feeling unable to help within the limits of their personal resources and at risk of burn-out: "often you think you're managing fine and that you've done it, sorted it out yourself, but then it actually does take a toll physically, or on you" SP4.
SPs coped with the emotional burden in a variety of ways.
Participants felt that having a safe space to debrief their experiences was particularly important to support their health and well-being. SPs discussed one-to-one supervision and peer support as particularly valuable: "having a team of social prescribers… just to organise your thoughts with or have some reflective time with, you know, another social prescriber can be really valuable" (SP8).
Not all SPs worked in teams and getting appropriate professional and personal support when professionally isolated was reported as a challenge. Where SPs were unable to find support from another SP, they felt increased anxiety regarding their ability to fulfil their role and cope emotionally, as others' understanding of the role was perceived to be limited. The importance of support which was quick and easy to access on an informal basis was discussed by several SPs, which may also make working in isolation as an SP more challenging. SPs working in voluntary sector organisations in this study spoke of having organised mechanisms of peer or one-to-one "what I'm interested in is motivational training and I've been told it's not a priority. They thought that benefits was the priority" (SP6) A preference for face-to-face learning was expressed by participants. Online modules for important issues such as domestic violence were felt to be "a tick box kind of thing" (SP2) that did not equip the SP with the practical skills they needed to support clients who might be living in a high-risk situation. The need for training on issues such as housing and benefits, immigration, addiction and domestic violence was closely related to the levels of deprivation in the areas they worked. Many SPs in this study reported that high-quality mental health first aid and suicide awareness training were vital for the role and that this should be prioritised for face-to-face training:

| D ISCUSS I ON
In this study, we explored the main challenges of working as an SP and the experiences of training and support of SPs employed by NHS and voluntary sector organisations. This study supports findings from previous research describing the role of SP as a "big ask" (Skivington et al., 2018, p. 491). Participants in this study stated that the role exceeded their expectations in complexity and generally felt that training had inadequately prepared them for the role. A notable omission from the HEE initial e-learning training is mental health first aid or suicide awareness and prevention training. SPs in this study reported that supporting clients with mental health needs, particularly those experiencing suicidal thoughts, was the most challenging aspect of their role and it was reported that the number of people with complex or undiagnosed mental health issues was increasing on their caseloads. Mental health services have been chronically underfunded for a number of years (Docherty & Thornicroft, 2015). Despite more recent prioritisation of mental health in policy and funding, waiting times for mental health input continue to be unacceptably high in some areas (Baker, 2020).
Given that the need for mental health services has been rising (Baker, 2020), it is likely that people who would ordinarily have been managed by mental health services will continue to be referred to social prescribing services. Furthermore, given the holistic approach taken by SPs and longer appointment times available than to other health professionals, clients are more likely to disclose mental health issues or suicidal thoughts. To prevent distress for both clients and SPs, it is essential that SPs have the training to recognise when they are able to support clients with mental health needs through social prescribing and when more specialist input is required. Online training in suicide awareness and mental health first aid has been found to be almost as effective or as effective as a more blended approach to training (Reavley et al., 2018;Stallman, 2020), however, participant satisfaction was reportedly lower with online training (Stallman, 2020

| S TRENG TH S AND LIMITATI ON S
The sample size for this study was relatively small due to time constraints placed on data collection, however, efforts were made to ensure participants were recruited from a variety of NHS and voluntary sector organisations to explore a variety of SP experiences.
Participants had been in their roles for between 10 months and 2 years, which was an appropriate length of time for them to be able to reflect on their initial training and evaluate the impact of this training on their ability to carry out their role.
Interviews were limited to SPs working in the Greater London area, and further research with SPs working in other locations would be valuable to gain insight into any different challenges they may experience. The findings from this study, due to the small sample size and recruitment from an urban setting, are limited in transferability beyond urban areas, particularly outside of London.

| CON CLUS ION
The findings of this study support the assertion that working as a social prescribing link worker is a complex and demanding role. SPs are required to have in-depth knowledge of local services, which is built over time and makes retention in the role of high importance.
Steps have been taken to develop online resources to support SPs, however, there may be a need for more comprehensive mental health and suicide awareness training. SPs benefit from access to peer support to help them manage the emotional demands of the role and could benefit from the formation of local networks, especially for those SPs working in isolation. Where SPs are embedded in multidisciplinary health services, more guidance and training on the role of SPs could be made available for health professionals so they are able to support SPs to develop in their roles. Careful planning of the availability of training from all sectors is needed to ensure that SPs can work in an integrated way across health, social care and the voluntary sector.

ACK N OWLED G EM ENTS
I would like to acknowledge the contribution of Dr Dagmar Zeuner, Dr Mohan Sekeram and Barry Causer for providing me with links to my first participants and valuable practical support along the way.
Thank you to colleagues and managers of organisations who either gave their permission for me to interview their employees or introduced me to potential participants. Thanks to all the social prescribers for their time and contribution to the study.

CO N FLI C T S O F I NTE R E S T
No conflicts of interest declared by either author.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.