Social prescribing link workers—A qualitative Australian perspective

Abstract Social prescribing (or community referral) is a model of healthcare designed to address social needs that contribute to poor health. At the heart of social prescribing programs is the link worker, who liaises between clients, health professionals and community organisations. Social prescribing is newly emerging in Australia but there are already calls for a large‐scale roll out. This research, therefore, aimed to understand Australian link workers' role and skills required, to determine where such a workforce could be drawn from in Australia, and to identify what training and resources are needed to support this potential new workforce. To explore these questions, interviews were conducted with 15 link workers in Queensland, New South Wales and Victoria, and the transcripts were analysed using thematic analysis. Participants were predominantly female (87%); and primarily had qualifications in social work (47%) or nursing (27%). Three overarching themes were identified: (1) skills of successful social prescribing, identifying that link work requires multifaceted social and emotional skills; (2) workforce issues, presenting that link workers experienced challenges such as a lack of available support and training, lack of public awareness of social prescribing and a lack of sustained funding; and (3) job fulfilment, related to link workers' sense of reward and accomplishment from the job. We suggest that fostering job fulfilment in conjunction with the provision of increased support, training and security will reduce feelings of overwork and burnout among link workers and likely lead to longevity in the role. Social prescribing has the potential to be hugely beneficial to clients and the community and fulfilling for link workers, provided that sufficient advocacy and resources are put in place.


| SOCIAL PRE SCRIB ING LINK WORKER S -A QUALITATIVE AUS TR ALIAN PER S PEC TIVE
It is estimated that 10% of general practice (GP) patients account for 30%-50% of appointments, yet these 'frequent attenders' often do not feel satisfied with the services they receive (Vedsted & Christensen, 2005). This is partly due to social needs that are not readily met in medical services, such as loneliness and social isolation (Cruwys et al., 2018). Patients whose health is impacted by social factors are typically prescribed medication and/or given referrals for psychotherapy and counselling (Maughan et al., 2016). However, these treatment options are not ideal. Despite loneliness being associated with an increased risk of depression (Erzen & Çikrikci, 2018), there is no evidence that antidepressants are effective for loneliness.
Medications such as antidepressants nonetheless have high rates of over prescription in Australia (Wallis et al., 2021) with other referral avenues in psychology and counselling succumbing to critical short staffing and long wait times to access services (InPsych, 2021). A potential solution to these issues is social prescribing, a communitybased model of healthcare designed to address unmet social needs that contribute to poor health.
In social prescribing, clients are linked to a range of community services and social activities in order to address their social needs (GSPA, 2021;Kimberlee, 2013). Although there is no universal model (Kimberlee, 2013), social prescribing schemes commonly involve three components: (1) the individual is referred to the program, often by a GP or allied health professional; (2) the individual meets with a link worker (or 'navigator') to discuss their interests and needs and (3) the individual engages with a meaningful social activity within their local community GSPA, 2021). Although many health providers offer a type of 'light' social prescribing such as signposting of available activities with possible follow-up, high-intensity or 'holistic' social prescribing aims to address clients' social determinants of health more comprehensively (Kimberlee, 2013).
In Australia, holistic models of social prescribing are emerging in primary care, aged care and community services despite no national or state level oversight (Aggar et al., 2021). Those based in primary care share many features in common with the United Kingdom, with one or more link workers based internally within a primary care service. Community programs are otherwise based in neighbourhood or community centres, with external GPs, allied health, or community workers able to identify socially isolated persons and refer them to the social prescribing scheme. These community-based schemes, while focused on improving individual well-being, also work towards building and enhancing the capacity of local communities (Morris et al., 2022). Although there are currently few such social prescribing programs in Australia the potential for growth is evident (CSSC, 2021), with strong interest from consumers, GPs and allied health professionals (RACGP & CHF, 2019).
Further, the recent Queensland Parliamentary Inquiry into social isolation and loneliness recommended a large-scale roll out of social prescribing in Queensland to help address these significant social issues (CSSC, 2021).
The potential for a new workforce of social health care professionals would be invaluable to reduce service loads and to provide more relevant and specific care for people feeling lonely and isolated. Indeed, research from service users and link workers themselves make clear that they are critical to the success of social prescribing Zurynski et al., 2020). However, questions arise about where a new and potentially large workforce might come from, and what skills, qualifications and accreditation are warranted, particularly given the lack of clarity for qualifications required in the United Kingdom (Bickerdike et al., 2017). The fast and widespread roll out of social prescribing in the United Kingdom following the Government's 2018 loneliness strategy (Department for Digital Culture Media and Sport, 2018), while ambitious, failed to appropriately coordinate resources to account the complexities of link work. This resulted in some criticisms of social prescribing on the grounds of a lack of role delineation for link workers, which were at times done by volunteers, and a lack of relevant training for new link workers (Bickerdike et al., 2017;Fixsen et al., 2020;Islam, 2020). Although the Queensland parliamentary inquiry report recommended this workforce be sourced from social workers, they may be drawn from other fields, and we do not know the type of workforce currently operating in Australia. Further, it remains to be seen what training and support may be required What is known about this topic?
• A growing evidence base exists in relation to social prescribing link workers and the complexity of their roles.
• There is limited research on link workers experiences, particularly in relation to the resources required to continue their roles long term and the workforce capacity.
• There is also limited research on experiences of link workers outside of the United Kingdom where social prescribing is emerging.

What this paper adds?
• The present study is the first to investigate link workers' experiences in Australia and investigates how this workforce can be best utilised as social prescription grows in popularity.
• Results revealed that health workers are broadly trained in the skills needed to carry out successful link work, that there was a lack of support and training with high risks of burnout, and that despite these difficulties link workers felt a strong sense of reward and accomplishment in their work.
• This study makes recommendations on the types of support and training required to sustainably continue and expand social prescribing link work in Australia.
to upskill link workers to ensure an effective and safe workforce is developed for the future. Thus, the aims of this study are (i) to understand the experience of Australian link workers in relation to their role and skills required to identify where such a workforce could be drawn from and (ii) to understand link workers' experiences to determine what training and resources are needed to support this potential new social care workforce.

| Participants
Link workers at 10 social prescribing schemes found in Australia were approached to participate in the study. These 10 schemes were identified through chain referrals from other organisations and online searches. Due to a lack of link worker registration, the total number of link workers across these schemes could not be accurately determined. Most organisations employed one or two link workers, but some had over a dozen people doing link work as part of their job, such as nurse practitioners in some GP clinics. Overall, 15 link workers agreed to participate from eight social prescribing programs across Queensland, New South Wales and Victoria. Most participants (53%) were recruited from primary care-based schemes, and the remaining 47% were recruited from community-based schemes. All but two of the link workers were female (87%) and ages ranged from 24-61 1 (M = 40.12). Participants had worked in a social prescribing role between 3 months and 7 years, with most having tertiary qualifications in social work (47%), nursing (27%), business (7%), community development (7%) and counselling (7%). Those without tertiary qualifications instead had external training in counselling skills. Link workers primarily worked with communities experiencing disadvantage, despite three programs being established in more affluent areas.

| Ethics
Ethics approval for this research was granted by the University of Queensland Human Research Ethics Committee (2020001019).
All participants provided written and/or verbal consent before the interviews. They were reimbursed with $60 shopping vouchers to compensate for their time.

| Interviews and analysis
Semi-structured interviews were conducted with questions focused on link workers' perspectives of the skills they use to link clients to groups, strategies to overcome and address client barriers, the positive aspects and drawbacks of their roles and their identity as a link worker. The interview guide (see Data S1) was designed through discussion with the research team in consultation with a link worker employed in both community and primary care settings. Interviews were conducted between June 2020 and November 2021. Across this period, link workers experienced different levels of COVID-19 restrictions within each of their states and within each of their organisations.
Interviews were conducted via phone (87%) or in person by a qualitative researcher (LS) and all interviews were recorded and transcribed verbatim. Interviews averaged 30 mins and ranged from 22 to 39mins.
Thematic analysis using an iterative process was employed to examine the data using a combination of an experiential approach and a constructionist approach (Terry et al., 2017). This was considered appropriate for the study because the inductive approach allowed participants to explore what was of meaning to them during the interviews, while the constructionist approach allowed the researchers to ask about aspects of link workers' experience guided by our research questions. The analysis followed a well-established six-phase procedure de-

| RE SULTS
Link workers in the Australian context came from a broad range of professional backgrounds (see Participants) and it was clear that there was no strong sense of a link worker professional identity. Instead, link workers tended to identify as a member of their health or other professional role that was related to their qualification and training: My role title is a care coordinator. However, because I studied social work, I identify more in social work. (LW2, primary care) However, there were many common experiences of people doing link work. Three overarching themes were constructed from the data and are shown in the thematic map ( Figure 1). These referred to the role and skills used by link workers that they saw as necessary for successful linkage of clients to community groups; the broader workforce experiences such as a lack of role clarity, lack of advocacy for social prescribing and a need for sustained funding and resources for social prescribing programs; and job fulfilment and satisfaction gained from seeing clients and communities thrive.

| Interpersonal skills
The skills needed to create a sense of trust and safety were commonly mentioned as fundamental for successful social prescribing.
Rapport with clients allowed link workers to effectively communicate with clients and establish trust before pursuing new connections, and activities that might be outside their comfort zone: …the success of the program is really dependent on the relationship the wellbeing coordinator has with the client.
If they can develop a relationship of trust and rapport, that they feel they can engage in something and be taken on that journey, then they feel safe to be able to do that… (LW1, primary care) Establishing a strong rapport sometimes resulted in clients viewing link workers as a friend or a counsellor, meaning that setting clear boundaries with clients was an important part of setting expectations in the relationship. Some link workers described this as a challenging process:

| Thriving clients
Although link work was experienced as complex and difficult at times, link workers described it as satisfying and fulfilling. Positive client outcomes were impactful on all link workers interviewed who consistently described it as the most fulfilling aspect of link work.

| Thriving communities
Fostering relationships with the community included assisting with the formation of new community and interest groups, connecting with existing activities and group facilitators and increasing referral pathways to include broader community services outside health care settings.
The formation of these relationships made for easier access to groups and services, and fostered more supportive and accepting facilitators, which allowed clients to have a smoother transition to joining groups: For some, there was a sense of support and championing from the broader community to tackle loneliness, where they saw it as a community issue, rather than an individual one: So we're putting it on for the [clients], but we all get benefits from being together and seeing people thrive and seeing people do stuff that they never imagined that they could do. (LW15 community)

| DISCUSS ION
Social prescription has only recently begun in Australia with very few dedicated link workers across the country. However, the appe- identify what training and resources are needed to support this potential new workforce. Link workers described experiences that fell into three broad themes regarding the role and skills required for link work to be successful with clients, current issues arising from the workforce and sources of satisfaction and fulfilment from their role.

| The link work skillset
Our results revealed that Australian link workers were primarily women who identified with their professions in health and social care, such as nursing and social work. However, the breadth of experience was diverse with link workers also having training in business, counselling (formal and informal) and community development. The experience and skills gained from these previous occupations were important for carrying out link work that involved interpersonal communication, planning and networking and responding to clients' needs through counselling and advocacy . The skills identified for the role were similar to those found in international studies with link workers and clients (Frostick & Bertotti, 2021;Holding et al., 2020; and further highlighted the integral role of link workers providing advocacy and safety for clients to successfully participate in social programs that are not simply accomplished through signposting (Stuart et al., 2022). Our results indicate that, generally, health professionals are well suited to the link worker role, given much of their prior training equips them with suitable and transferrable skills needed.
Rather than restricting the link worker workforce to a single health profession such as social workers (CSSC, 2021), the flexibility of the social prescribing approach allows for this new workforce to be drawn from people with broader health training and skilled up to do important social health care.
To support this wider recruitment approach, access to training and guidelines in specific areas should be available for link workers to further their skills (Frostick & Bertotti, 2021 These results reiterate the difficulties of smaller and communitydriven models of social prescribing (Holding et al., 2020). Although there is a clear need for the community model to identify and assist socially isolated persons who do not regularly attend with a GP, further work is needed to increase the infrastructure and support available for those working in small teams. This includes sustained funding to ensure link workers are not working in silos by increasing funded positions to reduce workload and increase peer support and connection across sites. Not doing so will lead to increased burnout among link workers due to high workloads, which reliably predict emotional exhaustion and fatigue (Michielsen et al., 2004). Indeed, link workers indicated that the demand of their workloads was already causing feelings of exhaustion. Further, widespread education for consumers and referrers about what social prescribing is and its benefits would separately reduce the burden on link workers to educate others and the number of inappropriate referrals received (Islam, 2020). These modifications will also help partner organisations work together more effectively.

| Community health and connection
Despite the challenges identified, link workers were proud of their programs and the successes they could achieve alongside their clients and communities. Although this sense of fulfilment was mainly focused on positive outcomes for individual clients, link workers also expressed satisfaction about their contribution to developing community connections. Through their outreach, link workers had increased awareness of loneliness in the community and helped to mobilise community members and groups to champion this issue.
Of course, while several studies have investigated the challenges of link work, to our knowledge, this is the first study to reveal circumstances of fulfilment and accomplishment in link work roles. Indeed, our results found that feelings of fulfilment were strong and widespread across all link workers interviewed. It is possible that engaging with and fostering elements of satisfaction in link work roles are likely to reduce burnout risks associated with a lack of meaning and reward (Cartwright & Holmes, 2006). Further, the association between overwork and low reward are predictors for emotional exhaustion and cynicism. Therefore, helping to identify and promote these sources of fulfilment and personal accomplishment within the linker worker role, alongside providing proactive support and training, will be key to reducing future burnout and turnover, and decrease interrupted care for clients.
Importantly, while there have been positive outcomes for communities thus far, a wider roll out of link worker programs could put resource pressure on the community and volunteer sectors currently helping to champion social prescribing as has been found in the United Kingdom (Bertotti et al., 2018;Holding et al., 2020;The Health Foundation, 2015;Tierney et al., 2020). It is therefore important that these sectors are adequately funded so increases in referrals do not lead to overburden and long wait times for access to group programs.

| Research and policy implications
Social prescribing has the potential to increase the location and scope of health care beyond hospitals and health clinics to people's homes and communities (GSPA, 2021 Ending Loneliness Together, 2021; Kellezi, Frings, et al., 2019).
Strong quantitative long-term evaluations are necessary to further identify what parts of social prescribing work best and why to further shape and improve social prescribing practices (Husk et al., 2020).

| CON CLUS ION
Aligned with the Australian Federal Government's consumer-centred healthcare plan (CHF, 2018)

and the Productivity Commission Mental
Health reform (Productivity Commission, 2020), social prescribing has the potential to provide a 'holistic health service' where social, physical and mental health concerns can be addressed . This study provides the first investigation into the experiences of social prescribing link workers in Australia and revealed both areas of positivity and areas in urgent need of sustained support and development. Given the strong evidence linking loneliness and social isolation with mental and physical health conditions and morbidity (Holt-Lunstad & Steptoe, 2022), investment in social prescribing by all levels of Government is likely to produce cost savings for health and support thriving communities in Australia in the aftermath of the pandemic.

AUTH O R CO NTR I B UTI O N S
All authors contributed to the conceptualisation and design of the study. LS analysed the data with input on themes from GD, NM and SH. All authors contributed to the interpretation of themes for the discussion. LS and GD contributed to the first draft writing. All authors reviewed and edited the manuscript. All authors have read and agreed to the final version of the manuscript.

ACK N OWLED G EM ENTS
The authors acknowledge the link workers who participated in this research and thank them for sharing their insights and knowledge.

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 on request from the corresponding author. The data are not publicly available due to privacy restrictions.

E N D N OTE
1 One person chose to provide their age within a range and were excluded from the mean calculation.