Voluntary Action North Lanarkshire · Web view2020. 10. 12. · This scoping study was undertaken...

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Social Prescribing

A Scoping Study for North Lanarkshire

Prepared by H. McIntosh

June 2020

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Contents

Executive summary 5

SECTION 1. Introduction 6

1.1 Purpose 6

1.2 Methods 6

1.3 Structure of this report 7

SECTION 2. The contextual landscape in North Lanarkshire 8

2.1 Demographics and health challenges 8

2.1.1 Population 8

2.1.2 Deprivation 8

2.1.3 Health inequalities 11

2.2 Strategic direction 16

SECTION 3. Social prescribing 24

3.1 Defining social prescribing 24

3.1.1 What is social prescribing? 24

3.1.2 Who is social prescribing for? 26

3.1.3 What does social prescribing offer? 27

3.1.4 How is social prescribing delivered? 29

3.2 Evidence base for social prescribing 35

3.2.1 Expectations 35

3.2.2 Benefits for people 37

3.2.3 Benefits for communities 41

3.2.4 Benefits for delivery partners 43

3.2.5 Cost and cost effectiveness 45

3.2.6 Effective principles for social prescribing 46

Section 4. North Lanarkshire’s foundations for social prescribing 51

4.1 Community and voluntary sector 51

4.1.1 Support infrastructure – Voluntary Action North Lanarkshire 51

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4.1.2 Range of services and activities 51

4.1.3 Locator 52

4.2 Partnership working with North Lanarkshire HSCP 54

4.2.1 Community Solutions Programme 54

4.2.2 Partnership for Change 56

4.3 Social prescribing initiatives 57

4.3.1 Well Connected 57

4.3.2 Making Life Easier 58

4.3.3 SPRING Social Prescribing Project 59

4.3.4 Other link worker roles 61

4.3.5 Commissioned services 64

4.4 Stakeholder perspectives 66

4.4.1 Statutory health and care provider perspectives 66

4.4.2 Community and voluntary sector provider perspectives 77

4.4.3 Public and service user perspectives 85

Section 5. Challenges and Opportunities 87

5.1 Strategic fit 87

5.2 Creating a coordinated and strategic approach 87

5.3 Funding sustainability 87

5.4 What social prescribing means 88

5.5 Raising awareness 88

5.6 Skills and competencies 89

5.7 Target groups 90

5.8 Enabling referral 91

5.9 Workforce 92

5.10 Public engagement 93

5.11 Outcomes, monitoring and evaluation 93

5.12 Digital connectivity 94

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5.13 Work best undertaken on a pan-Lanarkshire level 94

Section 6. Recommendations 96

References 98

AppendicesA. Informants

B. Interview and focus group guides

102

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Executive SummaryThis scoping study was undertaken for North Lanarkshire Health and Social Care

Partnership to inform discussion around development of a framework for social prescribing.

It explored current understanding, perspectives, practice, capacity and capabilities around

social prescribing in North Lanarkshire in relation to the strategic context and supporting

evidence base for the potential benefits of social prescribing and different delivery models.

The term social prescribing is used to describe a range of approaches for connecting people

to non-medical sources of support and resources within the community to help address

needs that are largely caused by social difficulties and thereby improve their health and well-

being. These supports and resources are mostly services and activities provided by the

community and voluntary sector.

Available data on deprivation and health inequalities in North Lanarkshire shows there is a

significant need to address the social determinants that influence people’s health and

wellbeing, which expanding access to social prescribing could help to support.

There are many different delivery models for social prescribing and considerable debate

continues over the adequacy of the supporting evidence base to inform service design,

implementation, or commissioning decisions. Decisions can however be guided by

accumulated practice-based learning on effective principles.

Several social prescribing initiatives are already operating in North Lanarkshire that could be

better aligned and development of a framework presents a timely opportunity to consider

improving alignment and co-ordination in how social prescribing is currently organised and

delivered. A more aligned and strategic approach would help to ensure that social

prescribing does not develop in a fragmented way and help to position new initiatives to best

advantage.

North Lanarkshire has a large, diverse and capable community and voluntary sector and a

shared commitment to collaborative, cross-sectoral partnership working with health and

social care. Expanding social prescribing activity in the statutory sector can reasonably be

expected to result in more referrals to community and voluntary sector services. The

greatest concern identified by this study is funding insecurity within the community and

voluntary sector, which has a vital role to play in any social prescribing initiative as the main

providers of community-based services and supports and sustainable funding models have

to be in place for social prescribing to work effectively.

Other factors identified by this study that may need to be considered in developing a

framework for social prescribing are discussed.

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SECTION 1. Introduction

1.1 Purpose

This scoping study was undertaken at the request of North Lanarkshire HSCP to inform

discussion around planned development of a framework for the implementation of effective

social prescribing across North Lanarkshire. The aim was to explore current understanding,

perspectives, practice, capacity and capabilities in relation to social prescribing in North

Lanarkshire taking account of the strategic context and wider evidence base for the potential

benefits of social prescribing and different delivery models.

1.2 Methods

The study was undertaken between October 2019 and March 2020 by a researcher

employed by the host organisation Voluntary Action North Lanarkshire. A mixed methods

approach was taken comprising:

Desk-based research to review strategy documents, published evidence reports and

other documentary and online sources.

Semi-structured individual interviews with staff occupying senior positions within Health

and Social Care North Lanarkshire and NHS Lanarkshire (selected by Kerri Todd,

Assistant Health Promotion Manager for NHS Lanarkshire).

Focus group and small group discussions with providers working in community and

voluntary sector organisations across North Lanarkshire.

Large group meeting discussions with attendees at various community and voluntary

sector network and North Lanarkshire locality events.

Initial exploration of public and service user engagement through Partnership for

Change.

Limitations: Consultation with a wider range of statutory sector providers was not possible

within the study timeframe so the perspectives of key groups including GPs and other front-

line staff have not been explored. Similarly, there was minimal engagement with service user

representatives.

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1.3 Structure of this report

Section 1 Introduction.

Section 2 Summarises selected population demographic and health inequalities data from

existing sources and extracted information from strategic plans to illustrate the potential for

social prescribing to address current needs and the approach’s alignment with current

strategic priorities in North Lanarkshire.

Section 3 Describes how social prescribing is variously defined and summarises the

evidence base.

Section 4 Presents a narrative account of the findings from stakeholder interviews, focus

group and informal discussions. Overinterpretation has been purposely avoided which is

appropriate to the level of analysis that was possible within the study timeframe, letting the

quotations speak for themselves.

Section 5 Discusses some challenges and development opportunities for effective and

sustainable social prescribing in North Lanarkshire.

Section 6 Offers recommendations arising from the scoping study to optimise social

prescribing practice in North Lanarkshire and inform future development.

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SECTION 2. The contextual landscape in North Lanarkshire

2.1 Demographics and health challenges

2.1.1 Population

North Lanarkshire has a population of 340,180 (2018), the fourth highest out of the 32

council areas in Scotland, having increased by 5.6% over the previous 10 years.1 Across the

six health and social care localities within North Lanarkshire the North locality has the largest

population (86,095) followed by Wishaw (58,343); Airdrie (57,576); Coatbridge (50,389);

Motherwell (45,504) and Bellshill (42,273).2 Approximately 2.1% of North Lanarkshire’s

population belong to a minority ethnic group.3

Projections based on 2016 data predict an

increase of 1% in North Lanarkshire’s

population by 2026. The average age of the

population is also projected to increase over

the same period with the largest percentage

increase (25.5%) expected in the 75 years

and over age group, continuing the aging

population trend observed between 1998 and

2018 (ibid footnote 2).

There were 151,744 households in North

Lanarkshire in 2018. Projections based on

2016 data, predict an increase of 5.3% to

158,375 by 2026. The number of ‘one adult’

households is projected to increase by 13.8% to 58,821 and remain the most common type,

accounting for 37.1% of the total; the number of one adult with dependent children

households is projected to increase by 9.3% to 13,636 (ibid footnote 2).

2.1.2 Deprivation

The Scottish Government uses the Scottish Index of Multiple Deprivation (SIMD) to identify

where in Scotland people are experiencing concentrations of deprivation.

1National Records of Scotland, North Lanarkshire Council Area Profile https://www.nrscotland.gov.uk/files/statistics/council-area-data-sheets/north-lanarkshire-council-profile.html#population_estimates2Locality profiles 2019 https://www.northlanarkshire.gov.uk/index.aspx?articleid=8881 3North Lanarkshire Equality Strategy 2019–2024 https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=23722&p=0

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https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=23722&p=0

https://www.northlanarkshire.gov.uk/index.aspx?articleid=8881

https://www.nrscotland.gov.uk/files/statistics/council-area-data-sheets/north-lanarkshire-council-profile.html#population_estimates

https://www.nrscotland.gov.uk/files/statistics/council-area-data-sheets/north-lanarkshire-council-profile.html#population_estimates

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SIMD 2020 ranked North Lanarkshire as the 6th most deprived council area in the country

based on local share of the 20% most deprived data zones in Scotland:

155 (35%) of North Lanarkshire’s 447 data zones are among the 20% most deprived

nationally, an increase from 144 (32%) since SIMD 2016).4

31 (7%) of North Lanarkshire’s data zones are among the 5% most deprived in Scotland

(an increase from 29 in SIMD 2016); and there are areas of deep-rooted deprivation

where data zones have consistently been among the 5% most deprived in Scotland

since SIMD 2004.2

Five of North Lanarkshire’s data zones among the 1% most deprived in Scotland, two of

these having moved into the worst 1% since SIMD 2016.3

The SIMD comprises more than 30 indicators of deprivation grouped together into domains

that provide insight on where people are experiencing disadvantage across seven different

aspects of their lives: income, employment, health, housing, education, access to services

and crime.

Income deprivation

Fifteen percent of North Lanarkshire’s population (50,897 people) is income deprived, a

reduction of 3% from SIMD 2016 but proportionally higher than the 12% across Scotland

as a whole.

Employment deprivation

While the number of working age people experiencing employment deprivation has fallen

since SIMD 2016 it remains at 11% in North Lanarkshire compared with the national

average of 9% (ibid footnote 5) 2015 data showed 7.84% of adults in North Lanarkshire claiming incapacity benefit or

severe disablement allowance compared with the national average of 6.16%; and 9.2%

claiming pension credits compared with 6.2% nationally (ibid footnote 3).

In 2016, the percentage of children in North Lanarkshire living in low income households

varied from 4% in Balloch West and Carrickstone, Cumbernauld to 43.4% in Craigneuk,

Wishaw (ibid footnote 3); with 18.8% overall living in low Income households compared

with the national average of 16.7%.5

4North Lanarkshire Council, Scottish Index of Multiple Deprivation 2020 Briefing Note https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=23859&p=0 5https://scotland.shinyapps.io/ScotPHO_profiles_tool/

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https://scotland.shinyapps.io/ScotPHO_profiles_tool/


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Housing deprivation

SIMD 2020 ranked 94 (21%) of North Lanarkshire’s data zones among the 20% most

deprived in Scotland for housing, which includes indicators for overcrowding and

absence of central heating.

Around 34% of households in North Lanarkshire are living in fuel poverty.6

Health deprivation

Areas that show income deprivation also show health deprivation.


health deprived in Scotland—the largest number of data zones in that category than for

any other SIMD domain (ibid footnote 5).

Lanarkshire is the 3rd most deprived health board area in Scotland based on local share

of the 20% most deprived data zones for income and health.7

Education deprivation


deprived in Scotland for education: 24 among the 1% most deprived nationally; and the

data zone ranked number 1 in Scotland for educational deprivation is in North

Lanarkshire.

Data from 2014–2015 showed that 73% of looked after children and young people in

North Lanarkshire left school aged 16 or under compared with 27% for other pupils (ibid

footnote 7).

Data from 2016–2017 showed North Lanarkshire had the highest rate of exclusion from

school for looked after children at 137.1 per 1000 pupils compared to the national

average of 79.9 per 1000.8

Access deprivation


deprived in Scotland for access to services, which includes indicators for travel time to

essential services including a GP, schools, retail centres and broadband access.

Only 1% of North Lanarkshire’s population live outwith the main urban areas (ibid

footnote 7).

6North Lanarkshire Partnership - Local Outcomes Improvement Plan https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=21277&p=07Introducing the Scottish Index of Multiple Deprivation 2020 https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=23823&p=08The Plan for North Lanarkshire

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Crime deprivation


deprived nationally based on indicators of recorded crime, and five within the 1% most

deprived.

2.1.3 Health inequalities

The Lanarkshire population health profile is poorer than the national average for many

indicators including smoking attributable deaths, deaths from alcohol conditions, and

children living in poverty.9 Many risk factors for poor health are closely linked to the social,

economic, and environmental conditions in which people live (Craig & Robinson 2019;

Health Foundation 2019). The greater the gap between the least and most deprived in

relation to these social determinants of health—like income, employment, education, living

environment and social capital—the greater the differences in health (WHO).10 Such health

inequalities are associated with differences in life expectancy and healthy life expectancy

meaning that people experiencing more deprivation not only die sooner but also spend more

of their shorter lives in poor health (Health Foundation 2019).

Life expectancy

In Scotland, improvement in life expectancy has stalled since around 2012.11 It has slowed

markedly in less deprived areas while mortality has been increasing in the most deprived

areas, indicating a widening of socioeconomic and associated health inequalities (Fenton et

al 2019).

In North Lanarkshire, life expectancy at birth (2016–2018) is lower for both males (75.2

years) and females (79.6 years) compared with the national average (77.1 years and

81.1 years, respectively) (ibid footnote 2).

In 2018, ischaemic heart disease then dementia and Alzheimer’s disease were the two

leading causes of death for both men (12.9% and 7.5%, respectively) and women (8.8%

and 14.3%, respectively) overall in North Lanarkshire and in Scotland as a whole (ibid

footnote 2).

Healthy life expectancy is also lower for people living in deprived areas in Scotland than for

those living in the least deprived areas12.

9Lanarkshire Primary Care Improvement Plan 2018 10WHO Social determinants of health: the solid facts 2nd edition 2013 http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf11Stalling life expectancy is a warning light for public health in Scotland http://www.healthscotland.scot/news/2019/february/stalling-life-expectancy-is-a-warning-light-for-public-health-in-scotland12ScotPHO Healthy life expectancy: key points https://www.scotpho.org.uk/population-dynamics/healthy-life-expectancy/key-points

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https://www.scotpho.org.uk/population-dynamics/healthy-life-expectancy/key-points

http://www.healthscotland.scot/news/2019/february/stalling-life-expectancy-is-a-warning-light-for-public-health-in-scotland

http://www.healthscotland.scot/news/2019/february/stalling-life-expectancy-is-a-warning-light-for-public-health-in-scotland

http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=2ahUKEwjpqLy6l9boAhXTUhUIHW_OAHEQFjABegQIChAE&url=http%3A%2F%2Fwww.southlanarkshire.gov.uk%2Fslhscp%2Fdownload%2Fdownloads%2Fid%2F141%2Flanarkshire_primary_care_improvement_plan_pcip.pdf&usg=AOvVaw1lUmv5KxOUqJDDC0QMjJMI

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30% of people in North Lanarkshire are living with one or more long-term health

conditions (ibid footnote 4).

25% of people over the age of 16 are limited in their day to day activities either a little or

a lot compared with the national average of 23%.

Premature death from all causes among people under 75 years of age—a national headline

indicator of health inequalities—was four times higher in the most deprived areas compared

to the least deprived areas in Scotland in 2018: the largest gap observed over the previous

10 years.13 In 2018 the mortality rate among 15 to 44 year-olds—a national indicator of

inequality in mortality—was eight times higher in the most deprived areas in Scotland (273.3

per 100,000 EASR14) compared to the least deprived (36.3 per 100,000) (ibid footnote 14).

In 2016, the rate of early deaths from all causes in the 15 to 44 years age group in North

Lanarkshire was 127.8 per 100,000 population compared with 105.8 per 100,000

nationally.

Disease burden

The Scottish Burden of Disease study (2016) highlighted the need to address the public

health priorities of mental health, alcohol, tobacco, drug problems, diet, healthy weight and

physical inactivity. It showed the disease burden15 in the most deprived areas was than

double that in the least deprived areas, and that it increased with each level of increasing

deprivation.16 The largest relative inequalities were for drug use disorders, alcohol

dependence, chronic liver disease, chronic obstructive pulmonary disease (COPD) and lung

cancer. When looked at by broad disease groups, the largest differences were for mental

health and substance use disorders, chronic respiratory diseases, and suicide and self-

harm-related injuries. Below are selected pertinent data for North Lanarkshire extracted from

the Locality Profiles (2019) and other sources as referenced.

Chronic liver disease, COPD and coronary heart disease

The prevalence of chronic liver disease in North Lanarkshire is 6.0 per 1000 population

(2018–2019) having increased on an annual basis since 2014–2015.

The rate of hospitalisation with COPD is higher in North Lanarkshire than for Scotland

overall at 360 patients per 100,000 population compared with 245.8 nationally (3-year

13Long-term monitoring of health inequalities, Scottish Government 2020 https://www.gov.scot/publications/long-term-monitoring-health-inequalities-january-2020-report/14European Adjusted Standardised Rate15Disease burden is measured in disability-adjusted life years (DALYs)= years of life lost due to premature mortality (YLL) + years lived with disability (YLD)16The Scottish Burden of Disease Study, 2016 https://www.scotpho.org.uk/media/1656/sbod2016-deprivation-report-aug18.pdf

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https://www.scotpho.org.uk/media/1656/sbod2016-deprivation-report-aug18.pdf

https://www.scotpho.org.uk/media/1656/sbod2016-deprivation-report-aug18.pdf

https://www.gov.scot/publications/long-term-monitoring-health-inequalities-january-2020-report/

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aggregate 2013/14 to 2015/16): local rates range from 85.7 patients per 100,000

population in Stepps in the North locality to 816.7 in Motherwell North.

All six North Lanarkshire localities show an upward trend for COPD/asthma prevalence

(2018–2019) with the highest rate of increase being in the Wishaw locality.

The rate of coronary heart disease (CHD) hospitalisations—a national morbidity

inequality indicator—is higher in North Lanarkshire than for Scotland overall at 460.5 per

100,000 population compared with 403.1 nationally (2014): local rates range from 216.3

patients per 100,000 population in Craigneuk, Airdrie to 686.5 in Petersburn, also in

Airdrie locality.

The death rate from CHD in those under the age of 75 years is higher in North

Lanarkshire than for Scotland overall at 65.92 per 100,000 population compared with

53.21 nationally (2015): local rates range from 7.82 per 100,000 population in Chapelhall

East, Airdrie to 170.65 in Kirkshaws, Coatbridge.

Alcohol and drugs

The rate of alcohol-related hospital admissions is higher in North Lanarkshire compared

with Scotland overall at 8.7 per 100,000 population compared with 6.6 nationally (2018–

19): at 12.5 per 1000 population, the rate for Coatbridge has increased by around 28%

over the last 5 years and has been consistently higher compared with North Lanarkshire

as a whole.

In 2016, alcohol-related hospital stays stood at 859.2 per 100,000 population compared

with 680.8 nationally: local rates range from 84.5 per 100,000 population in Craigneuk,

Airdrie to 2378.2 in Forgewood, Motherwell.

At 1.9 per 1000 population (2018–19) the rate of drug-related hospital admissions in

North Lanarkshire is equivalent to the national average: the rate in Motherwell (2.3

admissions per 1000) has however remained consistently higher since 2014–15; and

Coatbridge has the highest rate (2.6 per 1000 population) having increased over the last

4 years at a faster rate than in other localities.

Mental health

In Scotland in 2017, people aged 16 years and over in the most deprived areas were three

times more likely to have below average mental wellbeing—a national headline indicator of

health inequality—than those in the least deprived areas.17

In 2018–2019, 21.3% of the population of North Lanarkshire was prescribed drugs for

anxiety/depression/psychosis compared with the national average of 19.3%.18 17Long-term Monitoring of Health Inequalities 2018 file:///C:/Users/User/Downloads/00543867.pdf18 https://scotland.shinyapps.io/ScotPHO_profiles_tool/

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In 2016, the percentage population prescribed drugs for anxiety, depression and

psychosis ranged from 13.6% in Balloch West, Cumbernauld to 28.5% in Motherwell

South.19

The prevalence of psychosis in North Lanarkshire is 23.4 per 1000 population (2018–

2019): prevalence in the North locality (16.2 per 1000) is considerably lower than the

North Lanarkshire average and has been for the previous five years whereas in

Motherwell (26.7 per 1000), Bellshill (27.0 per 1000) and Airdrie (27.3 per 1000) it has

been consistently higher; prevalence has increased most rapidly in Airdrie particularly

over the last three years.

A national survey (2002) indicated that 45% of children and young people aged 5–17 years

who are looked after by a local authority in Scotland have a health mental disorder.20 North

Lanarkshire’s local outcomes improvement plan states that looked after children are

approximately four times more likely to have a mental disorder than children living in their

birth families (data source not cited).

Maternal health

In 2015, 83.6% of babies in North Lanarkshire were of healthy birthweight—a national

indicator of inequality—similar to the national average of 83.4%. Local rates ranged from

93.4% in Seafar, North locality to 76.3% in Calderbank and Brownsburn, Airdrie (ibid

footnote 3) Breastfeeding rates varied across the six localities from a low of 2.8% in Bellshill

Central to 31.3% in Ladywell, Motherwell compared with a council average of 15.2% and a

national average of 27.1% (ibid footnote 3).

Carers

The Carers (Scotland) Act 2016 defines a carer as an individual who provides or intends to

provide care for another individual (the cared-for person) and a young carer as someone

who is under 18 years old or still at school.

Scotland's 2011 Census determined that just over 10% of North Lanarkshire’s population

(34,000 people) was providing care compared with the national average of 9.3%.

Around 1 in 12 carers in North Lanarkshire are under the age of 24 and 1 in 5 are

retired.21

The Scottish Health Survey (2012–2013) found that the proportion of people who are carers

is similar between the least and most deprived areas in Scotland, but those in the most

19North Lanarkshire Health and population indicators across the six social work localities https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=22594&p=0 20Office for National Statistics, 200421North Lanarkshire Strategy for Adult Carers and Young Carers 2019–2024 https://mars.northlanarkshire.gov.uk/egenda/images/att92598.pdf

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https://mars.northlanarkshire.gov.uk/egenda/images/att92598.pdf

https://webarchive.nationalarchives.gov.uk/20151014063523/http:/www.ons.gov.uk/ons/rel/psychiatric-morbidity/mental-health-of-young-people-looked-after-by-local-authorities/2002-survey/index.html


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deprived areas provide the most hours of caring.22 Almost half (47%) of carers living in the

most deprived areas care for 35 hours a week or more compared with a quarter (24%) of

carers living in the least deprived areas. This disparity is also apparent among young carers

(defined as aged under 25 years): young people living in the 20% most deprived areas in

Scotland are more likely to be carers than those in the least deprived areas (3.1% versus

1.7%) and more likely to care for 35 hours a week or more (28% versus 17%).

North Lanarkshire placed second out of all Local Authority areas for the intensity of care

that carers provide, ranked according to the percentage of the population providing 35

hours of care each week (ibid footnote 23).

Around 30% of carers in North Lanarkshire (10,500 people) provide care for more than

50 hours each week, equating to around 3% of the population (ibid footnote 23).

As carers with greater caring responsibilities are drawn disproportionately from more

deprived areas, caring may stem from lack of choice and unfair circumstances and be

exacerbated by these existing inequalities. Further, the more care someone provides the

less likely they are to report ‘very good’ or ‘good’ health, and this is true for different age

groups (ibid footnote 18).

The Scottish Health Survey (2012–2013) found that those caring for 35 hours a week or

more are significantly more likely to have lower wellbeing scores and experience a

psychiatric disorder than other groups of carers and non-carers. Almost 4% of young carers

had a mental health condition compared with just over 1% for non-carers; and the proportion

with a long-term condition or disability (22%) was double the rate for non-carers (11%) (ibid

footnote 18). People who care for both older relatives and dependent children are more likely

than the general population to experience symptoms of mental ill-health, such as anxiety and

depression, and struggle financially, and the prevalence of mental ill-health increases with

the amount of care given.23 A health needs survey undertaken by North Lanarkshire Carers

Together (2013-2016) identified anxiety and stress as the most common health problems for

cares, affecting 75% (899/1197) of respondents; 49% reported depression or feeling sad

and 30% experienced isolation and feeling alone.24 Almost a third of respondents (27%)

reported that the financial impact of caring was affecting their health.

2.2 Strategic direction

22Scotland's Carers 2015 https://www.gov.scot/publications/scotlands-carers/pages/1/23Office for National Statistics 2019 https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/articles/morethanoneinfoursandwichcarersreportsymptomsofmentalillhealth/latest 24Carers Health Needs Report FMR Research 2017 http://www.carerstogether.org/wp-content/uploads/2017/08/NLCT-Carers-Health-Needs-Final-Report.pdf

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http://www.carerstogether.org/wp-content/uploads/2017/08/NLCT-Carers-Health-Needs-Final-Report.pdf

http://www.carerstogether.org/wp-content/uploads/2017/08/NLCT-Carers-Health-Needs-Final-Report.pdf

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/articles/morethanoneinfoursandwichcarersreportsymptomsofmentalillhealth/latest

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/articles/morethanoneinfoursandwichcarersreportsymptomsofmentalillhealth/latest

https://www.gov.scot/publications/scotlands-carers/pages/1/

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The Plan for North Lanarkshire

North Lanarkshire Partnership’s (NLP) long-term strategic Plan for North Lanarkshire

recognises there are still unacceptably high levels of deprivation and child poverty within

North Lanarkshire, and clear areas of inequity and inequality including an element of social

exclusion in some towns and communities.25

The Partnership’s work towards achieving its shared ambition—what ‘We Aspire’ to achieve

—is guided by the five priorities set out in the plan:

Improve economic opportunities and outcomes.

Support all children and young people to realise their full potential.

Improve the health and wellbeing of our communities.

Enhance participation, capacity, and empowerment across our communities.

Improve North Lanarkshire's resource base

The Ambition Statements attached to these priorities convey a shared commitment to

designing services around people, communities and shared resources; improving community

involvement in service developments and decisions that affect them; and developing

communities’ capacity to help themselves; along with giving people choice over supports

and services; promoting preventative approaches, early intervention, self-management and

independence, and encouraging health and wellbeing through social, cultural, and leisure

activities.

North Lanarkshire Equality strategy

North Lanarkshire Council’s (NLC) Equality Strategy (2019–2024) recognises that the

poverty, disadvantage and inequalities that exist for some people in North Lanarkshire can

be exacerbated if they have particular characteristics.26 The Council considers its

commitment to equality as being critical to achieving the best possible outcomes for all the

people of North Lanarkshire. The strategy’s objectives include ensuring provision of local

services that are appropriate and accessible to the diverse needs of all residents and service

users.

Health and Social Care North Lanarkshire Strategic Plan

HSCNL’s ten-year strategic plan (2016–2026) has the overarching ambition to set in motion

an approach to delivering health and social care that will lead over time to achieving national

25 The Plan for North Lanarkshire https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=22960&p=026 Equality strategy https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=23722&p=0

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outcomes for health and wellbeing; children, young people and families; and community

justice.27

The North Lanarkshire Integration Joint Board (IJB) will focus on six strategic priorities over

the lifetime of the plan:

Addressing inequalities

Prevention and early intervention

Person-centred support

Effective, safe, timely and quality care

Maximising all our assets

Making the whole system work efficiently

A three-year (2020–2023) Strategic Commissioning Plan28 sets out six Ambition Statements,

to:

Do the right thing first time

Provide a range of community services to support people to live well in connected

communities

Focus on what matters to people (outcomes)

Be at the forefront of technical and sustainable solutions

Promote prevention and early intervention

Ensure North Lanarkshire is the best place to work, volunteer and care

These ambitions were informed by the community-driven priorities that people should be in

control of the care they receive; and be supported to maintain independence, self-manage

their care needs, and avoid preventable conditions.

Goals to work towards achieving these ambitions over the coming three years include:

Increased focus on addressing inequalities, and prevention and anticipatory care

approaches

Further develop ways to ensure cross-sector service providers are accessible at the first

point of contact, the underlying principle being there should be ‘no wrong door’

Develop whole system pathways for long terms conditions management

Further develop and promote Making Life Easier

Support communities to build connections

Develop opportunities for volunteering

The locality approach to planning and delivering health and social care in North Lanarkshire

enables services to be tailored to different needs in local areas, and the assets that already

27 HSCNL Strategic Plan 2016–2026 http://www.hscnorthlan.scot/wp-content/uploads/2016/05/nlc_strat_doc_v13.pdf28 HSCNL Draft Strategic Commissioning Plan 2020–2023 https://www.hscnorthlan.scot/wp-content/uploads/2020/02/Draft-Strategic-Commissioning-Plan-20-23-for-feedback.pdf

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exist within local communities to be taken into account in the development of local supports

and services.

Partnership working with the third sector is integral to delivering the locality approach:

accordingly, a commitment to investment in the third sector is embodied in the goal to

continue to invest in and develop the Community Solutions Programme commissioning

strategy over the coming three years. The Community Solutions Programme (formerly called

Community Capacity Building and Carer Support) is described as the third sector branch of

HSCNL. Community Solutions funds community and voluntary sector organisations to

deliver community-based services and activities that promote health and wellbeing. The

programme’s current five-year strategy (2018/23) (sic)29 and commissioning plan focus on

personal outcomes achievement for service users based on its overarching strategic

priorities to address inequalities and reduce loneliness and isolation. (Community Solutions

is described in more detail in section 4.2.1.)

HSCNL’s strategic work programme for the next three years also includes delivering

HSCNL’s Participation and Engagement Strategy, the Primary Care Improvement Plan and

the Mental Health and Wellbeing Strategy for Lanarkshire; and implementing North

Lanarkshire’s Children’s Services Plan, NHS Lanarkshire’s Child and Young People’s Health

Plan, and the Carers Act.

Participation and Engagement Strategy

HSCNL’s Participation and Engagement Strategy is a key strand of work in support of the

overall Strategic Plan. It sets out how the Partnership will ensure effective engagement with

stakeholders in the communities it serves including the third and independent sector, carers

and people who use services.30 The intention is to build on local knowledge and experience

to ensure that services are tailored to community needs and make the most of existing

community assets.

Primary Care Improvement Plan

Lanarkshire’s Primary Care Improvement Plan (PCIP) supports the delivery of the General

Medical Services (GMS) contract (2018) that aims to refocus the role of GPs as expert

medical generalists working with a wider team to provide more healthcare in the community

and ensure that people are seen by the right person, in the right place, at the right time.31

29 North Lanarkshire Community Capacity Building and Carer Support Strategy 2018/2330 HSCNL Participation and Engagement Strategy 2017–2020 https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=20509&p=031 Lanarkshire Primary Care Improvement Plan (PCIP) GMS Contract 2018 https://www.nhslanarkshire.scot.nhs.uk/download/primary-care-improvement-plan/?wpdmdl=6482&ind=1565002490589

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The Plan recognises the need to address health inequalities in Lanarkshire and the key role

of primary care services in improving health and wellbeing for individuals in local

communities through actions that include referral and signposting to a range of social

supports that can facilitate changes in life circumstances and lifestyles, and help build

community resilience

GP Community Link Workers (CLW) is one of the six key priorities that GP practices or

clusters will deliver for patients under the new GP contract. Recruitment of nine CLWs to

work within GP surgeries across North Lanarkshire was underway at the time of writing. (GP

Community Link Workers is described in more detail in section 4.3.4.)

Mental Health and Wellbeing Strategy

Lanarkshire’s Mental Health and Wellbeing Strategy (2019-2024) acknowledges that mental

health outcomes are not distributed evenly across the population: and that recognition of the

strong relationship between social inequalities and poor mental health together with

collaborative working across organisational boundaries will be required to achieve its vision

for a Lanarkshire where everyone can have good mental wellbeing.32

Outcome-focused action plans for North Lanarkshire and South Lanarkshire have an

overarching focus on reducing inequalities. Within these plans there are actions around

development and accessibility of community assets and non-clinical sources of support;

providing support for people who face barriers to accessing community supports; building

capacity within the third sector; and harnessing the contribution of the community and

voluntary sectors to bring in additional resources. Promoting early intervention and

maximising community assets through the development of a social prescribing framework for

young people is among the actions for delivering on mental health and wellbeing in this

population, possibly through extending the Well Connected model. (Well Connected is

described in more detail in section 4.3.1.)

Children’s Services and Children and Young People’s Health plans

Children’s Services and Children and Young People’s Health plans are currently being

developed (as noted in HSCNL’s Strategic Commissioning Plan for 2020–2023).

NLP’s Children’s Services Plan for 2017–2020 set out the outcomes that North Lanarkshire

Children’s Services Partnership planned to deliver for children, young people and families,

32 Getting it Right for Every Person (GIRFEP) A Mental Health and Wellbeing Strategy for Lanarkshire (2019–24) https://www.nhslanarkshire.scot.nhs.uk/download/mental-health-wellbeing-strategy-2019-2024/

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which included outcomes around prevention, and promoting mental health, wellbeing and

resilience.33

Recognition that statutory, independent and voluntary sector agencies working with children,

young people and families can deliver more by working in partnership than by working alone

was central to the development of Lanarkshire’s Children and Young People’s Health Plan

for 2018–2020.34 The plan set out overarching aims to focus on reducing health inequalities

through prevention, early intervention and partnership working; improve health and wellbeing

outcomes by supporting children and young people to adopt healthier lifestyles; improve

outcomes and experiences for children and young people with additional support needs; and

build solutions with and around this population to ensure they are central to decisions that

affect their health and wellbeing.

North Lanarkshire Strategy for Adult and Young Carers

North Lanarkshire’s strategy for adult and young carers (2019–2024) sets out the plan of

action for implementing statutory duties under the Carers (Scotland) Act 2016.35

HSCNL has taken the approach of commissioning local third sector carer organisations to

deliver a range of community-based support services for unpaid adult and young carers in

North Lanarkshire. In 2019, the contract to deliver these services was awarded to three

organisations:

Lanarkshire Carers Centre—direct support for adult carers

Action for Children—Young Carer’s Support Service

North Lanarkshire Carers Together—adult carers campaigning, information and

representation Services

The contract was awarded for an initial period of four years with an option to extend for two

years and a further one year.

The strategy’s action plan for adult carers includes enabling primary and community health

staff to identify and signpost carers to suitable community supports, and encouraging carer

participation in community-based activities, leisure and employment opportunities so that

carers can establish connections and supports to enhance their lives, have the same choice

33 North Lanarkshire Partnership Children’s Services Plan April 2017–March 2020 https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=20987&p=0 34 Children and Young People’s Health Plan Lanarkshire 2018-2020 https://www.nhslanarkshire.scot.nhs.uk/download/child-and-young-peoples-health-plan-2018-2020/?wpdmdl=6757&ind=156767258935335 North Lanarkshire strategy for adult and young carers 2019–2024 https://mars.northlanarkshire.gov.uk/egenda/images/att92598.pdf

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and control as any other citizen, and feel less isolated and more able to continue in their

caring role.

Actions for young carers include supporting young people to overcome barriers to accessing

social, sporting and cultural activities, and signposting young carers and their families to

other organisations within the third sector so that young carers are enabled to have a normal

social life and fulfil their potential, and feel better about themselves and experience less

stress and isolation.

Community and Voluntary Sector Strategy for North Lanarkshire

The objectives within North Lanarkshire’s Community and Voluntary Sector Strategic Plan

(2020–2023) include strengthening communication and collaboration within the sector, its

partnership engagement, and the sustainability of its resource base to ensure the sector is

able to respond effectively to local needs.36

Voluntary Action North Lanarkshire (VANL), the third sector interface for the North

Lanarkshire local authority area has developed a linked organisational strategic plan aligned

to this whole sector strategy. Both this strategy and VANL’s linked strategic plan have been

developed in response to identified community and voluntary sector’s priorities and support

needs in North Lanarkshire.

Voluntary Action North Lanarkshire Strategic Plan

VANL’s strategic plan for 2020–2023 sets out how the organisation will support the

community and voluntary sector in North Lanarkshire in line with its mission to foster

dynamic, inclusive communities through promoting and supporting volunteering and

development of the voluntary and community sector in order to improve quality of life and

wellbeing for the people of North Lanarkshire.37

The focus of the plan’s objectives is to help the sector fulfil its resource requirements, and

provide guidance, support and training on organisational development priorities, so that it is

better able to respond more effectively to local needs; support effective communication and

collaboration across sectors and with local citizens; and support the sector’s contribution to

delivering the Plan for North Lanarkshire.

The ways in which these objectives will be met include supporting community and voluntary

sector organisations to diversify their sources of income; promoting volunteering and

employer-supported volunteering; working with the sector and statutory partners to improve

36 Community and Voluntary Sector Strategy for North Lanarkshire April 2020–March 2023 (Draft three)37 Voluntary Action North Lanarkshire Strategic Plan 2020—2023

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support for the community and voluntary sector paid and volunteer workforce, local grant

funding, procurement and access to community resources.

VANL receives core funding to deliver this plan from North Lanarkshire Council and has

recently agreed a three-year Service Level Agreement with the Council, although the level of

continued funding may change depending on the Council’s financial situation.

Community and Voluntary Sector Children and Young People’s Strategy

North Lanarkshire’s Community and Voluntary Sector Children, Young People and Families

Strategy (2020–2023) sets out how the sector will work collectively and with the public sector

and business sector to improve the lives of children, young people and families in North

Lanarkshire.38 In so doing, the strategy aims to contribute to the achievement of the

ambitions and intended outcomes of other key partnership strategies including the Children’s

Services Plan and Child and Young People’s Health Plan, the Community Solutions

Strategy, Lanarkshire’s Mental Health and Wellbeing Strategy, and the Plan for North

Lanarkshire.

The Strategy’s objectives are to support the sector to improve the effectiveness of its

services and support for children, young people and families, inform and influence relevant

wider policies and services, and evaluate and communicate more effectively the contribution

it makes to improving peoples’ lives; and to strengthen understanding and appreciation of

the sector’s contribution within the statutory sector and more widely.

The ways in which these objectives will be met include strengthening the design and delivery

of community and voluntary sector support and services through user engagement, sharing

of information and training; governance, organisational development and workforce (paid

and voluntary) development support; and facilitating innovation and piloting new approaches.

38 North Lanarkshire Community and Voluntary Sector Children, Young People and Families Strategy 2020–2023 (Draft 5)

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Section 3. Social prescribing

3.1 Defining social prescribing

3.1.1 What is social prescribing?

The term social prescribing is used to describe a range of approaches for connecting people

to non-medical sources of support and resources within the community to help address

needs that are largely caused by social difficulties and thereby improve their health and well-

being.

The rationale for social prescribing lies in the longstanding recognition that addressing the

social determinants that influence people’s health and their ability to live healthier, happier

lives is just as important as providing good healthcare. And that this requires solutions that

have their basis in the social model of health with its focus on promoting wellness rather than

the healthcare-oriented medical model with its emphasis on illness and treatment.

The supports and resources that social prescribing connects people to are generally,

although not exclusively, services and activities provided by the community and voluntary

sector that have a positive influence on wellbeing. Social prescribing, therefore, aims to

complement, rather than replace, mainstream healthcare provision by harnessing strengths

and assets within the community that are better able to address people’s social, emotional

and practical needs (Paterson 2019, Davison et al 2019, Year of Care 2011).

Initiatives described as social prescribing range from simply making information about

community-based resources generally available to people, through progressive levels of

individualised signposting and supported referral, to provision of one-to-one support,

possibly from a dedicated link worker, for people who need more help to access what they

need. The schematic shown in Figure 1, which was used in a survey to gather information in

order to map social prescribing activity in Dundee, illustrates this conceptualisation of social

prescribing as a spectrum of approaches.

Figure 1. Social Prescribing as a spectrum of approaches: mapping activity in Dundee39

39 Dundee Strategic Social Prescribing Group 2019, https://www.dundeecity.gov.uk/sites/default/files/publications/socialprescribingsurveyreport-april2019.pdf

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Consequently, the term social prescribing is often used interchangeably with terms like

signposting, community referral and link working depending on how it is understood and put

into practice (Health Scotland 2016, Drinkwater et al 2019). Others however stress that

social prescribing is more than a process of signposting and referral to community provision

because a vital aspect of social prescribing is the ongoing support and engagement that

people receive while taking part in it (Paterson 2019). Some go as far as to assert that

signposting is not social prescribing (Elemental 2018) or that it complements social

prescribing and should be viewed in terms of ‘as well as’ and not ‘instead of’ social

prescribing (NHS England 2019).

Language and meaning

The term ‘social prescribing’ is well-established particularly in the heath sector and in use

nationally in Scotland but it is not universally well liked or understood (Dundee Strategic

Social Prescribing Group 2019, Elemental 2018). The term has been described as an

oxymoron with its medicalised language of prescribing placing the person in the role of

patient or passive recipient contradicting the approach’s core principles of individual

engagement, choice and control (Davison et al 2019, Health Scotland 2016, Health

Education England 2016). Some feel that this language, therefore, does not easily support a

rebalancing of the relationship between patients and healthcare providers, and that talking

about a ‘prescription’ might constrain what a social prescribing service can provide (Dundee

Strategic Social Prescribing Group 2019, Davison et al 2019, Health Scotland 2016, Health

Education England 2016). Others, on the other hand, feel that ‘prescribing’ lends weight to

the credibility of the approach as having clinical value and could support compliance (sic)

(Dundee Strategic Social Prescribing Group 2019, Davison et al 2019). There is anecdotal

evidence that for social workers the term social prescribing can be especially objectionable

and misunderstood to undermine the social work profession.40

How the term ‘prescription’ is understood in the context of social prescribing also varies: for

some it is the healthcare or other professional who issues the social prescription through the

act of signposting or referral either directly to a community-based service or to an

intermediary link worker (Drinkwater et al 2019, Paterson 2019, Volunteer Scotland 2015,

Langford et al 2013) whereas others, including the UK Social Prescribing Network41

emphasise that it is the individual who decides, possibly with support from a link worker,

which services or activities can improve their personal situation and thereby designs their

own social prescription (Davison et al 2019).

40 Social prescribing - use what you have: Social Workers BMJ Open 2019 https://www.bmj.com/content/364/bmj.l1285/rr-0 41 https://www.socialprescribingnetwork.com/

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Branding

Many social prescribing initiatives purposely eschew this terminology in favour of branding

local delivery using language that is more accessible to the community (Moffatt et al 2017)

such as Healthy Connections, in Dumfries and Galloway—where community engagement

informed the service brand and marketing (Claire Thirwall, Health and Wellbeing Specialist,

Dumfries and Galloway Council, Personal Communication, 20 Feb 2020). Some of the many

other examples are: Community Connect (Bexley), Ways to Wellness (Newcastle upon

Tyne), Connect Well (Essex), and indeed, Well Connected in Lanarkshire (see section

4.3.1).

3.1.2 Who is social prescribing for?

Social prescribing can support people experiencing a wide range of social, emotional, and

practical difficulties that affect their health and wellbeing. It may be used to enable people to

self-manage existing health conditions or find solutions to practical problems; or, as a

preventive approach to promoting wellness through, for example, helping people to make

lifestyle changes, build social networks, increase self-efficacy and strengthen resilience

(NHS England 2019, King’s Fund 2017, Langford et al 2013, Davison et al 2019, Kinsella

2015).

Some social prescribing initiatives target specific groups such as people experiencing mild to

moderate mental health problems or people living with long-term conditions such as

diabetes; some proactively seek out prospective service users such as ‘hard to reach’

groups or ‘high resource use’ individuals. Many initiatives have been set-up to serve

deprived communities most affected by health inequalities. If social prescribing is to help

tackle health inequalities it needs to be accessible and its interventions relevant to people

experiencing greatest social and economic disadvantage; and also to recognise that those

who may need it most may be the hardest to engage (ERS 2013, Liverpool CCG 2017,

Health Scotland 2016).

Commonly identified groups who could benefit from social prescribing include:

people with poor mental health

people living with long-term physical illness

people who are socially isolated or lonely

people experiencing social welfare problems

people who have complex social needs

people who frequently attend primary or secondary healthcare services

people not benefiting from clinical treatment or whose condition has no medical solution

people seeking ways to take greater control of their own health and happiness.

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Children, young people and families

Most work around social prescribing to date has concentrated on adults (Hayes et al 2020).

Consideration of social prescribing for children and young people is a more recent

development and grouping this population with adults and the elderly when designing and

implementing social prescribing could be a barrier to success (Healthy London Partnership

2018, Jani et al 2019). A recent survey undertaken by the Healthy London Partnership as

part of a coproduction exercise to develop social prescribing for children, young people and

their parents and carers (Healthy London Partnership 2018) identified the following issues

that respondents most wanted support with:

Children and young people Parents and carers Coping with stress and anxiety

Sex and relationships

Exercise

Sleep

Long-term conditions

Coping with stress and anxiety

Education

Child behaviour

Self-confidence and self-esteem

3.1.3 What does social prescribing offer?

Social prescribing can offer a wide range of interventions that can help address many kinds

of non-clinical problems that affect health and wellbeing (Public Health England 2019,

Drinkwater et al 2019, Health Scotland 2016, Kinsella 2015, Volunteer Scotland 2015).

Mostly these are services and activities that local community and voluntary sector

organisations and community groups offer, usually at low or no cost to the individual. The

types of support that can be offered will, therefore, depend on what is available within a local

community.

As with all local services, what social prescribing initiatives offer should reflect the needs of

the community they serve, meaning that this may look different in each local community

(Public Health England 2019, Elemental 2018). Also, as a person-centred approach that

aims to give people a choice in which interventions can improve their personal situation,

social prescribing ideally has to offer a diverse range of options.

Interventions commonly associated with social prescribing are often grouped under broad

categories like these:

Physical activity and leisure (such as exercise classes, walking groups, ‘green gyms’)

Arts and culture (such as art classes, bibliotherapy, choirs)

Healthy eating (such as cookery classes)

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Befriending and peer-support (such as local volunteer-led schemes)

Learning (such as digital literacy sessions and self-help resources)

Employment (such as job coaching)

Volunteering (such as volunteering to help run a community group activity)

Welfare rights (such as debt and housing advice and advocacy services).

Social prescribing initiatives designed to help specific target groups may encourage the

uptake of certain interventions that have been shown to be effective in addressing problems

that those groups often encounter.

Categorisation of social prescribing interventions according to a hierarchy of need, as

illustrated in Figure 2, illustrates that people’s basic needs—like safety, financial security and

housing—need to be addressed before other interventions targeting physical activity,

connectedness or creativity can be expected to work. (UCL Laws 2017)

Figure 2. Categories of local community services in social prescribing (Elemental 2018)

3.1.4 How is social prescribing delivered?

There is no universal agreement on the operational definition of social prescribing, and it can

mean different things to different people (Polley et al 2017b, Kinsella 2015). There are,

therefore, many different models for the delivery of social prescribing that vary in their

setting, the people they serve, the way they connect people to sources of support, the

supports on offer, the intensity and duration of support provided, and the intended outcomes

(Husk et al 2019, Drinkwater et al 2019, Health Scotland 2016). There is, therefore, no ‘one

size fits all’ model for social prescribing and variation in how it is delivered can reflect ‘fit’

according to needs and availability of community-based supports, which is locally different.

(Husk et al 2019, Health Education England 2016).

NHS Lanarkshire – a stepped model Health Scotland’s guidance on social prescribing for mental health featured a conceptual

stepped model for the delivery of social prescribing, as shown in Figure 3, as an example of

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how NHS Lanarkshire had identified different levels of support for different client groups (sic)

dependent on need (Health Scotland 2016). This model recognises that the most suitable

level of support will depend on the complexity of need in the target group, and that each

individual will have different support needs and their level of need may change over time.

Individuals can, therefore, move between the tiers in this model: some people will require

minimal support to access the services and advice they need, for example, while others who

need high or medium level support to engage with social prescribing opportunities initially

may subsequently require lower level support to sustain their engagement and achieve their

longer-term goals.

Figure 3. Conceptual

model of delivery for social

prescribing, NHS

Lanarkshire 201542

Ways of connecting people to sources of support

Models of delivery for social prescribing generally incorporate processes of signposting and

referral to connect people to community-based sources of support. As these terms are often

used interchangeably it is useful to note the advice that referral should not be confused with

signposting, which is when a person is provided with information about another service and

has to initiate contact themselves, whereas a referral is a request from one part of a system

to another part of the system on behalf of the person (Polley et al 2017b).

Signposting

Social prescribing as signposting only may do little more than inform people of local sources

of support that might help them to address their wellbeing needs, leaving them to their own

devices to contact and engage with the services available (Kimberlee 2015). More

comprehensive models can however incorporate signposting and active signposting to

mutually agreed sources of support for those who are confident and skilled enough to find

their own way to services after a brief intervention, as in the stepped model shown in Figure

3.

42 Source: Social prescribing for mental health: guidance paper, Health Scotland 2016

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Referral pathways

Referral is a key element of most delivery models for social prescribing and common among

these are models designed as a means of enabling GPs and other primary care

professionals to refer patients to local, non-clinical sources of support (King’s Fund 2017,

CordisBright 2019, Public Health Wales 2018, Paterson 2019). Depending on the model, this

can be a direct referral to a community-based provider or referral to an intermediary link

worker. Delivery models can incorporate referral from other agencies: NHS England, for

example, defines social prescribing as enabling all local agencies including general practice,

local authorities, pharmacies, multi-disciplinary teams, hospital discharge teams, allied

health professionals, fire service, police, job centres, social care services, housing

associations and voluntary, community and social enterprise organisations to refer people to

a link worker (NHS England 2019). Some delivery models also accommodate self-referral

and referrals from carers or family (NHS England 2019, Paterson 2019, Davison et al 2019).

Referral pathways can also extend to referrals between community-based providers and

referrals back to statutory care providers when an individual’s identified needs require it

(CordisBright 2019).

Link worker models connecting communities and healthcare services

In the context of healthcare, connecting people to community-based supports through a link

worker has emerged as a core delivery model for social prescribing and the link worker role

is widely considered to be essential to success (CordisBright 2019, Polley et al 2017b,

Davison et al 2019, King’s Fund 2017, Elemental 2018, Year of Care 2011). The UK and

Ireland Social Prescribing Network, for example, specifically defines social prescribing as a

means of enabling GPs and other frontline healthcare professionals to refer patients to a link

worker who provides them with a face-to-face conversation during which they can learn

about opportunities to improve their health and wellbeing.43

A link worker is a non-clinically trained person whose role is to enable and support

individuals to assess their needs, co-produce solutions, and connect them with suitable local

services and activities that can improve their health, wellbeing or personal situation (Polley

et al 2017b, Davison et al 2019, Bertotti et al 2019). The link worker role is designated by

various titles such as community connector, community navigator, care navigator,

community care co-ordinator, social prescribing coordinator or simply social prescriber. This

role requires relationship building to create a genuine partnership with the people they

support and engage with referring professionals and local community-based providers,

43 https://www.socialprescribingnetwork.com/

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hence link workers are generally recruited for their communication skills, empathy and ability

to support people (NHS England 2019).

Link worker models largely embody a holistic approach to social prescribing in which the link

worker engages with an individual for as long as is necessary to fully understand their

needs, help them design solutions, support them through engagement with suitable local

services and activities and review their progress towards improvement in wellbeing

(Kimberlee 2015, Polley et al 2017b, CordisBright 2019). A key aspect is that the link worker

has more time to spend with individuals than say the typical ten minute GP appointment,

which means that people are given time to talk in detail about their situation and what

matters to them and time to develop the trust necessary to do so. The level and duration of

engagement with the link worker will vary depending on an individual’s support needs,

confidence and capacity to act independently.

In practice, social prescribing initiatives operating on a link worker model may offer

individuals a set number of one-to-one sessions initially, typically between 6 and 12, and can

provide open-ended support, continuing to work with individuals for two years of more (NHS

England 2019, Moffatt et al 2017).

There are two distinct types of link worker model according to whether the link worker is

situated within a healthcare or community and voluntary sector organisation. The former is

exemplified by the Scottish Government funded Community Link Worker programme

currently being implemented through the new GP contract in which link workers are being

situated within GP practices. As described in Section 4.3.4 of this report, the specifics of that

delivery model will be designed locally to suit local need, demand and resources. Some of

the claimed advantages of basing link workers in a healthcare setting are that it allows

healthcare professionals who would be referrers to get to know the facilitator and better

understand what their role is and that it gives a visual reminder to make referrals; and that

the visible association with the health sector adds credibility, creating trust among staff and

patients that supports initial engagement with service users (Davison et al 2019, EVOC

2017).

The SPRING Social Prescribing Project, described in section 4.3.3, currently being delivered

in North Lanarkshire is an example of a delivery model where the link workers situated within

local community ‘anchor’ organisations receive referrals from local GP practices. Link

workers being an integral part of a community-led anchor organisation is considered critical

to the project’s success because it ensures they are well linked-in to community provision

and have the support of an experienced organisation that is trusted and respected locally.

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Ways to Wellness in Newcastle-upon-Tyne,

described as one of the first initiatives to deliver

social prescribing on a large and prolonged scale

in the UK, is another example.44 The Ways to

Wellness ‘hub’ delivery model that enables GP

practices to refer patients to link workers situated

within community organisations was designed

following extensive consultation with patients and

healthcare professionals (Moffatt et al 2017) In this

model, illustrated in Figure 4, a community

organisation or Lead Non-traditional Provider

(NTP) in each locality receives referrals and

develops relationships with other local NTPs who

provide services and activities that can meet

referred individuals’ needs and preferences,

allowing for variability in each locality (Year of

Care 2011).

The model also explicitly recognises that public

access to NTPs continues to exist alongside

additional referrals from social prescribing.

Funding models

Funding for social prescribing in the UK has come from a wide range of public, private and

third sector sources, including Clinical Commissioning Groups (in England), primary care,

public health, local authorities and charitable funders notably the National Lottery

Community Fund (Polley et al 2017b, Jani et al 2020, Paterson 2019, CordisBright 2019).

The models deployed are context dependent and there is no ‘one size fits all’ (Jani et al

2020). In the case of link worker models, where a link worker is based is not always

indicative of who employs them or how their position is funded (Polley et al 2017b).

Learning from National Community Fund funded initiatives highlighted the need for a

systematic approach to funding that nurtures and enables collaboration between statutory

and community providers: that social prescribing works best when organisations are willing

to work with each other towards shared goals and funding does not create perverse

incentives and competition (Davison et al 2019). The approach should also ensure that

44 https://waystowellness.org.uk/

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Figure 4. Ways to Wellness delivery model (two NTPs are shown for illustration—there can be many)
























































https://waystowellness.org.uk/

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money reaches all parts of the system so the volume of demand is not simply transferred

from healthcare to the voluntary sector.

The recent Scottish Government Health and Sport Committee inquiry into social prescribing

in relation to physical activity noted that although the services to which health professionals

refer patients are nearly always provided by the community and voluntary sector, social

prescribing schemes do not fund those services or offer resource to help with their capacity

to deliver what is required.45 The Committee recommended that social prescriptions are

treated on an equal basis to medical prescriptions when issued by health and social care

professionals—a recommendation Scottish Government is supportive of in principle but

remains to be explored.46

NHS England has suggested different ways that local commissioners there can provide

funding to ensure that local voluntary organisations, community groups and social

enterprises are locally sustainable and can plan ahead, such as: developing a shared

investment fund bringing together all local partners including the private sector;

commissioning existing staffed community and voluntary sector organisations and providing

small grants for volunteer-led community groups; micro-commissioning new groups where

there are gaps in community provision; enabling people to use personal health budgets to

pay for community and voluntary sector supports; and exploring social investment

opportunities and outcome-based commissioning (NHS England 2019).

45 Social Prescribing: physical activity is an investment not a cost. Heath and Sport Committee 2019 https://sp-bpr-en-prod-cdnep.azureedge.net/published/HS/2019/12/4/Social-Prescribing--physical-activity-is-an-investment--not-a-cost/HSS052019R14.pdf46https://www.parliament.scot/S5_HealthandSportCommittee/General%20Documents/ 20200204_HS_Ltr_IN_CabSec.pdf

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3.2 Evidence base for social prescribing

3.2.1 Expectations

The concept of social prescribing is not new but there is renewed interest in its potential to

contribute to national health and wellbeing and support delivery on a range of strategic

agendas around health and social care integration, population health and health inequalities.

Social prescribing has become part of the wider agenda of shifting the balance of care from

hospitals and GP practices towards community-based interventions more aligned to the

social model of health (Paterson 2019, Davison et al 2019). Social prescribing recognises

that the community and voluntary sector can be a largely untapped asset that can deliver

further integration between health and social care in the creation of a more responsive and

efficient local health economy.

Interest in social prescribing within the NHS has gathered pace in recent years due to

increasing demands on healthcare services and the cost implications for service provision;

as well as the growing recognition that statutory healthcare providers are unable to address

many of the social reasons why people seek help from the NHS (Polley et al 2017b, Popay

et al 2007). Social prescribing is particularly seen as a way to extend the range of options

available to GPs and other primary care practitioners to provide individualised care for

people whose needs are related to social difficulties (Polley et al 2017b, Brandling & House

2009). Primary care is for most people their most frequent point of contact with the NHS and

around 20% of patients in the UK consult their GP for what are primarily social problems. An

estimated 30% of GP consultations and half of regular attendances are for common mental

health problems, mainly stress, anxiety and depression, and many of these consultations

arise because of social difficulties including financial and debt problems, housing problems,

unemployment and loneliness (Kinsella 2015). Within Lanarkshire there is an immediate

challenge around the sustainability of several GP practices as well as a wider issue of

general sustainability.47

The potential to reduce demand on secondary care services also appears to be an important

driver of interest in social prescribing as a means of addressing inequalities and enabling

more people to manage their own health and live well over the longer term (King’s Fund

2017). People living in the most deprived areas in Scotland, for example, can account for

twice as many emergency department attendances than those in the least deprived areas,

which could be for a number of reasons including poorer health and more complex social

47 Lanarkshire Primary Care Improvement Plan GMS Contract 2018 https://www.nhslanarkshire.scot.nhs.uk/download/primary-care-improvement-plan/?wpdmdl=6482&ind=1565002490589

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needs; and the likelihood of hospital admission following emergency department attendance

also increases with deprivation.48

It is anticipated that shifting the balance of care towards community-based interventions

more aligned to the social model of health will lead to less and more cost-effective use of

NHS and social care resources. The patient pathways for people with long-term conditions

shown in Figure 5 illustrates this conceptual association between such a shift in balance

towards enabling self-care with support from community and voluntary sector providers and

reductions in the cost of NHS care (Year of Care 2011). This schematic underpins the Ways

of Wellness social prescribing link worker model described in section 3.1.4.

Figure 5. Pathways

between medical and

social models of health for

people with long term

conditions (Year of Care

2011)

There is an expectation that cross-sectoral working to deliver social prescribing will

strengthen connections between mainstream services and community resources, help

identify and address gaps in local services and thereby lead to widening of the local provider

base.

Consequently, the anticipated benefits from social prescribing encompass a wide range of

improved outcomes for individuals, communities, service providers and the health and social

care system as a whole.

48 Understanding emergency care in NHS Scotland NHS NSS ISD 2015 https://www.isdscotland.org/Health-Topics/Emergency-Care/Publications/2015-09-29/2015-09-29-EmergencyCare-Report.pdf?597780943

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3.2.2 Benefits for people

Non-clinical interventions

Many studies reporting on the benefits of social prescribing for people assess particular

types of non-clinical interventions commonly accessed through social prescribing, such as

physical exercise or the arts, rather than delivery models or particular approaches to social

prescribing (CordisBright 2019, Paterson 2019). Most of these studies report positive

outcomes for participants no matter what the intervention is, including self-reported

increases in motivation, confidence, self-esteem, and feelings of control; improvements in

physical and mental wellbeing and quality of life; and reductions in social isolation and

feelings of loneliness over the shorter-term (Fancourt & Finn 2019, Chatterjee et al 2018,

Price et al 2017). Evidence of lasting effects is sparse because such data are rarely

collected. The concern for those looking to implement evidence-based practice in promoting

certain types of interventions over others is that the quality of many of these studies is

questionable and publication bias49 highly likely; which, together with the wide variety of

interventions, participants and reasons for referral across studies, makes it difficult to draw

clear conclusions about effectiveness or who could benefit most or from which types of

interventions. It has to be borne in mind also that social prescribing as a person-centred

approach is about giving people choice to decide what which services or activities can

improve their own personal situation.

Evidence from studies of particular support services or activities interventions also provide

no insight on the effectiveness of social prescribing as a systems approach.

Link worker models

Studies of social prescribing delivered through link worker initiatives in the UK involving

referral from primary care have reported improvements in patient outcomes including

knowledge, skills and confidence in managing their own health, quality of life, and measures

of emotional, mental and general wellbeing. Reviews of such studies however have failed to

reach firm conclusions about the benefits of social prescribing for health and wellbeing

because the evidence from different studies is mixed or conflicting and generally of poor

quality (Mason et al 2019, Bickerdike et al 2017, Polley et al 2017a). A recent realist review50

of social prescribing as a referral pathway from primary care to non-medical community-

based activities also found the evidence base overall insufficient to make general inferences

about the effectiveness of any particular model of social prescribing referral or supported

uptake (Husk et al 2019). Hence the evidence for social prescribing as means of enabling

49 Studies showing positive results are more likely to be published that those that do not.50 Realist review is a method for synthesising evidence from studies of complex social interventions in order to discern what works for whom, in what circumstances.

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primary care professionals to refer patients to local non-medical sources of support leading

to positive health and wellbeing outcomes is widely considered to still be emerging

(Drinkwater et al 2019, King’s Fund 2017).

The realist review was able to discern that:

Patients are more likely to agree to a social prescribing referral if they believe it will be of

benefit and it is presented in a way that matches their needs and expectations

Patients are more likely to attend an activity if it is accessible and transit to the first

session is supported

Activity leaders’ knowledge and skills, and changes in the patient’s condition or

symptoms can influence adherence to activity programmes.

In a qualitative study patients living with long-term conditions in a socioeconomically

deprived area of North East England felt a greater sense of control and self-confidence

following referral by their GP practice to a link worker within the Ways to Wellness social

prescribing service (section 3.1.4) (Moffatt et al 2017). This study also found evidence of

positive effects on health and wellbeing as a result of changes in health-related behaviours,

improvement in long-term condition management, increased resilience and reduced social

isolation. A follow-up study found these patients continuing to make improvements across

various aspects of their lives up to two years after their initial engagement with the service

although many had also experienced setbacks requiring continued support to overcome

problems due to multi-morbidity, family circumstances and socioeconomic factors (Wildman

et al 2019). The findings elucidated the importance of a strong and supportive relationship

with an easily accessible link worker in promoting sustained behaviour change; and that

service users who have complex health and social needs may require link worker support

over the longer term.

Evidence from studies comparing social prescribing via a link worker with usual practice is

scarce. An evaluation of the National Links Worker Programme pilot in Glasgow Deep End51

general practices, which is among the most robust in terms of its methodology, found no

difference in patient outcomes or self-reported healthcare utilisation at nine months

comparing referral to a link worker with usual care in comparison practices that did not

deliver the programme (Mercer et al 2017). It found no difference in health-related quality of

life between patients who engaged with a link worker (rather than just being referred) and

the comparison group, although patients who saw a link worker at least twice showed more

improvement in anxiety symptoms, depressive symptoms, and self-reported exercise levels.

51 This was a collaboration of general practices serving the 100 most deprived populations in Scotland.

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A key limitation of the evaluation design however was its inability to balance patient

characteristics at baseline in the groups being compared because the intervention practices

had the freedom to decide which of their patients should be referred to the link worker. As a

result, estimates of the effects (or lack of effects) on patient outcomes could not be

ascertained with confidence.

Welfare rights advisors as link workers

A report that summarised the evidence base for co-locating socio-legal welfare rights

advisors in healthcare settings in the UK found some evidence of positive health outcomes

for clients, such as reduced stress and anxiety, but a lack of high quality studies able to

demonstrate reliable quantitative estimates of effect (UCL Laws 2017). The report identified

several gaps in the evidence base, noting that longer term benefits may take several years

to emerge and accumulate over multiple support episodes over time; and a need to develop

empirical evidence to understand what works, for whom and in what circumstances in order

to inform expansion of the model. Among the key messages from a workshop for which this

review was undertaken was taking care to avoid over-promising on impact, acknowledging

that people’s lives remain hard even after housing or debt issues are resolved and providing

support at one stage in their life acts as no guarantee for the lifetime resolution of problems.

Children and young people

A recent review of the evidence base for the social prescribing link worker model to improve

the mental health and wellbeing of children and young people failed to identify any relevant

studies despite a thorough search of the published and grey literature (Hayes et al 2020).

The lack of evidence could be due to the fact that social prescribing for children and young

people is still in its infancy compared with social prescribing for adults; or the complexities of

adapting social prescribing approaches designed for adults to the needs of children and

young people, particularly around parent or guardian involvement and consent.

A national audit of children and young people’s mental health and wellbeing services in

Scotland highlighted a reluctance on the part of some GPs and CAMHS professionals to

signpost (sic) young people to voluntary sector services, which the report suggested may be

due to a lack of awareness of what is available, and can leave children and young people

without support and unclear about what options might be available to them (Audit Scotland

2018).52

Volunteers

52 Children and Young People’s Mental Health. Audit Scotland 2018 https://www.audit-scotland.gov.uk/uploads/docs/report/2018/nr_180913_mental_health.pdf

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Volunteering is often one of the opportunities on offer through social prescribing schemes

and it is not uncommon for social prescribing service users to get involved in volunteering

once their own needs had been addressed. Volunteers can also be involved in the delivery

of social prescribing services either as link workers or, more usually, providers of additional

support to service users. There is evidence from various studies linking volunteering with

health and wellbeing benefits such as reductions in anxiety and symptoms of depression,

and demonstrating, for example, greater life satisfaction, more happiness and better physical

and mental health among volunteers compared with non-volunteers (Volunteer Scotland

2015).

Volunteers recruited as social prescribing link workers (Community Navigators) within GP

surgeries in Brighton and Hove reported benefits to themselves including personal

satisfaction, gaining confidence, knowledge, skills and experience, and feeling more

connected to their community and people within it (Farenden et al 2015). Some also gained

employment in the health sector as a result of their link worker experience hence the role

was considered to be an effective volunteer opportunity to support people into employment

and encourage new people into the health sector workforce. Volunteers recruited to provide

extra support and motivation to individuals using social prescribing services that considered

it essential to have paid advisors in the link worker role have also reported that volunteering

in this supporting role provided them with an important stepping stone back into work

(Dayson & Bennet 2016).

Work-related outcomes

On reviewing the published and grey literature the Work Foundation found little reference to

social prescribing as a means to achieve work-related outcomes (Steadman et al 2017). Using

case studies of four link worker social prescribing services in England, including Ways to

Wellness (section 3.1.4), the Foundation identified that work-related outcomes were seen as

valuable but the social prescribing services had no clear pathways to work-related supports.

All four services collected some form of outcomes data, most commonly health service

usage and client health and wellbeing outcomes, but none collected data on work outcomes.

The Foundation concluded that employment needs to become a more considered part of

social prescribing; that link workers may need guidance and training on the role that good

work can have in achieving broader recovery outcomes and should, therefore, be

encouraged to explore the availability of employment supports in the local community.

A recent evidence review on supporting disadvantaged young people to achieve

employment outcomes found the evidence base was not strong enough to draw robust

conclusions on what works; but noted a broad consensus in the literature that effective

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support for young people furthest from the labour market is underpinned by intensive

advisory support and personalised information, advice and guidance: pointing in particular to

the provision of one-to-one advisory support, and continuity of adviser throughout an

intervention period (Newton et al 2020). This review also found a strong consensus that

integrated, comprehensive and holistic approaches to tackle unemployment locally are better

than just focusing on skill acquisition.

3.2.3 Benefits for communities

There is a tendency in the literature on social prescribing to conflate benefits for

communities and benefits for the community and voluntary sector or community groups.

There is also a tendency to infer benefits for whole communities from improvements in

personal outcomes for individuals: the What Works Centre for Wellbeing points out that

community wellbeing is more than the sum of people’s individual wellbeing and is complex to

define.53

Social prescribing has been credited with helping to build social capital by increasing

community involvement through connecting people locally to community organisations and

each other as well as providing opportunities for people supported through social prescribing

to becoming volunteers themselves (Paterson 2019, Polley et al 2017b). Among NHS

England’s criteria for what good social prescribing looks like for communities is that they are

stronger and more tolerant, because people from all backgrounds are supported to be

involved in community groups, and there are more people who volunteer and give their time

back to others (NHS England 2019). There is some evidence for the potential of social

prescribing to engage with diverse and harder-to-reach groups but the evidence on benefits

at community level from its potential to strengthen social capital is not well-developed

(Paterson 2019, Skivington & Smith 2018).

Increasing social capital and ‘impact of programme ethos on community’ were medium to

long-term outcomes for the Glasgow ‘Deep End’ general practices Links Worker Programme

pilot but evidence from early evaluation cast doubt on whether these outcomes would be

fully realised in practice (Smith & Skivington 2016).

Social Return on Investment

Social Return on Investment (SROI) is about social value rather than money (in seeking to

improve wellbeing and reduce inequality and environmental degradation SROI uses

53 What works for community wellbeing: a public debate (2019) https://whatworkswellbeing.org/wp-content/uploads/2020/01/www_comm-deabte-A4-4.pdf

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monetary values to represent a range of social, economic and environmental outcomes as a

widely accessible way to convey value).54

An evidence review of social prescribing services in the UK involving patient referral from

primary care professionals to a link worker reported identifying four studies that estimated

SROI but only reported one study’s estimate—that for every pound of investment in the

Weston-super-Mare Healthy Connections service project, £2.73 of social value was created

(Polley et al 2017a). The review referenced only one of the other three studies, which

showed that for every pound of investment in Bristol’s Wellspring Healthy Living Centre's

Social Prescribing Wellbeing Programme, £2.90 of social value was created. The studies

reviewed were reportedly difficult to compare because they used inconsistent combinations

of potential benefits.

A study in Scotland that forecast the SROI for co-locating welfare advice workers in medical

practices based on three medical practices in Edinburgh and Dundee predicted that every £1

invested over a one-year period (2015 to 2016) would generate around £39 (range £27 to

£50) of social value (Carrick et al 2016).

Reducing health inequalities

Evidence on reducing health inequalities within communities suggests that interventions that

improve accessibility to appropriate services, prioritise disadvantaged groups and provide

intensive individualised support are more likely to be effective (Health Scotland 2016, Lorenc

et al 2013, Macintyre 2007). Conversely, services that only provide information, rely on

people taking the initiative to opt-in, or present cost or other barriers to accessibility are less

likely to reduce health inequalities. Consequently, it is believed that social prescribing

models based solely around signposting or unsupported referral to other services are

unlikely to reduce health inequalities and may even result in widening inequalities because

those who are more socially disadvantaged are less likely to take up the opportunities on

offer without additional support.

3.2.4 Benefits for delivery partners

Social prescribing as a means of connecting people to community-based supports to help

improve their health and wellbeing lends itself to cross-sectoral partnership working between

statutory health and social care providers and the community and voluntary sector as

providers of services and activities in the community.

Statutory sector

54 The SROI Network 2012 http://www.socialvalueuk.org/app/uploads/2016/03/The%20Guide%20to%20Social%20Return%20on%20Investment%202015.pdf

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The evidence base for the benefits of social prescribing for statutory care providers focusses

on outcomes relating to primary and secondary healthcare services.

A widely-cited review of UK studies that assessed the impact on healthcare demand

associated with social prescribing services involving patient referral to a link worker in

primary care found evidence an average reduction in patient demand for GP services of 28%

(range 2% to 70% across 7 studies). The Royal College of General Practitioners (RCGP)

believe the findings from this review could suggest promising outcomes for GP workload

through social prescribing, which NHS England has identified as one of 10 high impact

actions with the potential to increase capacity and reduce workload in general practice

(RCGP 2018). A RCGP survey55 of GP perceptions on the anticipated impact of these

actions on their workload found that 59% of the 143 GPs in England who responded thought

that social prescribing would decrease their workload while 13% felt it would increase it

(RCGP 2018).

The same review also found evidence of an average fall in Accident and Emergency (A&E)

attendance of 24% (range 8% to 26.8% across 5 five studies); and a fall in emergency

hospital admissions of between 6% and 33.6% (across 3 studies) in the months following a

social prescribing referral (Polley et al 2017a). One study reported a significant reduction in

secondary care referrals whereas another study showed referrals to secondary mental

health care more than doubled for patients with psychosocial problems.

The review concluded that although the evidence for social prescribing was broadly

supportive of the potential to reduce demand on primary and secondary care the quality of

the evidence was weak and it would be premature to conclude that a proof of concept for

demand reduction had been established (Polley et al 2017a). The RCGP report states there

is limited robust evidence around social prescribing and the GPs surveyed often expressed

higher scepticism about actions where strong evidence is lacking, emphasising the

importance of communicating evidence of impact and sharing case studies (RCGP 2018).

A recent Public Health England review that assessed UK studies involving referral to a social

prescribing link worker in primary care and looked at contact with primary healthcare

services as an outcome (such as the frequency of GP consultations) similarly found

inconsistent results across seven studies of generally low quality, and concluded there was

no clear evidence of effectiveness (Mason et al 2019).

Evidence mapping by the Public Health Wales Observatory also failed to identify sufficient

evidence from published research or experience of implementing social prescribing

initiatives, in terms of quality and the outcomes reported, to answer the question of whether

55 RCGP survey conducted December 2017 to January 2018

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social prescribing reduces demand for mainstream primary and community care (Price et al

2017).

Social prescribing initiatives in secondary care settings are not as common as in primary

care. An recent project that aimed to contribute to knowledge about the best way to utilise

social prescribing in secondary care ran a six-month pilot of a voluntary sector led social

prescribing service in one London Hospital in an area that already had a well-embedded

social prescribing service in primary care (Family Action 2018). The service offered up to

eight sessions with a link worker who provided practical and emotional support with non-

clinical needs such as finances, housing, and carers support and facilitated referrals to

appropriate community organisations. The service model aimed to achieve healthcare

system outcomes including reduced discharge delays, reduced readmissions, reduced

demand on hospital staff, and improved integration with primary care but this could not be

assessed within the short timescale. Fewer referrals to the service than anticipated was

thought to be due to it not being available on the hospital management system for secondary

care staff to refer easily, and the length of time required to embed a service within secondary

care pathways.

Community and voluntary sector

Community and voluntary sector organisations have a vital role to play in any social

prescribing initiative as the main providers of community-based services and supports; and

in some delivery models also providing a link worker function. A range of potential benefits to

the sector from involvement in social prescribing have been suggested, such as

strengthening relationships with statutory services, reaching more and new clients, building

community assets, securing sustainable funding, and increased resilience (Davison et al

2019, CordisBright 2019). Evidence on the extent to which these benefits are realised is

limited as most studies and evaluations of social prescribing initiatives do not appear to

assess them.

The views of community organisations receiving referrals through the Glasgow Deep End

general practices Links Worker Programme pilot provided some evidence of benefits from

working collaboratively (Smith & Skivington 2016, Skivington & Smith 2018). Evaluation

showed evidence of progress towards increasing and strengthening cross-sectoral

relationships, albeit largely between the link workers and individuals within community

organisations rather than between GP practices and community organisations as a whole.

Community organisations saw the link workers as being able to facilitate a community

organisation presence within GP practices, and their potential to educate practice staff about

the community resources available locally. There was also evidence of improvement in the

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appropriateness of referrals, in that community organisations felt that the patients referred

through the link workers were more appropriate for their service than the referrals they had

received from GP practices before the link worker model was implemented. Hypothetically,

some community organisations considered that they might be in a better position to apply for

funding because of increased referrals from the Links Worker Programme.

Evidence of impact on the scope and capacities of community resources to support people

to live well, which was a medium-term outcome for the Deep End Links Worker Programme,

was limited—for example, a few community organisations being supported by link workers to

develop their capacity through funding applications and shared events.

3.2.5 Cost and cost effectiveness

A systematic review of social prescribing initiatives in the UK involving referral to a link

worker in primary care found insufficient evidence to reliably judge value for money

(Bickerdike et al 2017). A review that identified eight UK studies involving referral to a link

worker in primary care that reported some kind of cost analysis (having found no studies of

cost effectiveness or cost utility) concluded that the evidence that social prescribing delivers

cost savings to the health service over and above operating costs was encouraging but by

no means proven or fully quantified (Polley et al 2017a). A previous review by the King’s

Fund concluded there was a need for more evidence about the cost-effectiveness of roles

like link workers; and questions remained around the scale at which such roles need to be

developed to release cost savings elsewhere in the system (Gilburt 2016). The evaluation

that compared Glasgow Deep End general practices implementing the National Links

Worker Programme with practices that did not deliver the programme concluded that

evaluation of longer term outcomes over 23 years, with linked health and social care

utilisation data drawn from robust sources, would be required to assess whether or not the

programme was cost effective (Mercer et al 2017).

The assessment of the evidence base for co-locating socio-legal welfare advisors in

healthcare settings in the UK noted that although service evaluations consistently report

direct financial gains to advice recipients that outweighed the costs of providing the service,

there was an evidence gap around robust economic analysis of cost-benefits and

efficiencies for health services (UCL Law 2017).

3.2.6 Effective principles

The Social Prescribing Network emphasises that successful social prescribing schemes are

locally designed to suit the people they are aimed at, which means embedding core

principles into the design rather than using one standardised model.56 A recent review 56 https://www.socialprescribingnetwork.com/

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concluded that the evidence regarding the elements of practice that make for effective social

prescribing is limited to evaluations of local initiatives and evidence from experience

(CordisBright 2019).

In 2016, Health Scotland identified key facilitative factors for effective social prescribing for

mental health (Health Scotland 2016), including:

Engaging the individual in identifying the support required, based on their needs

Engaging local partners and stakeholders in the design of local approaches, maximising

the contribution that each can make, including statutory and community and voluntary

sector agencies and communities

Building relationships and trust within the local partnership to support planning, delivery

and evaluation

Embedding the approach within wider pathways and routes of referral

Supporting capacity building within all sectors, so that staff and volunteers feel able to

support social prescribing

Equality proofing local approaches to ensure they do not widen health inequalities

Monitoring and evaluating local approaches in order to build the evidence base for what

works.

As noted in section 3.1.4, the link worker role has come to be widely considered as essential

to the successful delivery of social prescribing in healthcare settings.

A contemporary guide commissioned by NHS England, coproduced by people with practical

experiences of designing, commissioning, delivering, and evaluating social prescribing

schemes in the UK, describes essential ingredients that successful schemes have in

common (Polley et al 2017b). NHS England also engaged a wide range of stakeholders to

identify key elements of what makes a good social prescribing scheme and what needs to be

in place locally (NHS England 2019). These together provide a good representation of key

factors identified by others, and include:

Collaborative commissioning and partnership working: all partners work together in local

areas to build on existing community assets, co-producing and co-commissioning local

social prescribing schemes; the community and voluntary sector is involved from the

start; local organisations with deep-rooted community networks need to be

commissioned to provide social prescribing services

Funding commitment to ensure funding to support and maintain the link worker position;

it is important that money follows the patient, and that the community-based

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organisations receiving referrals can plan ahead and sustain their income and service

provision

Buy-in from referring healthcare professionals: educating healthcare professionals, and

other referrers, on aspects of social prescribing is very important

Easy referral from a wide range of local agencies in order to coordinate support around

the person and encourage partnership working; referral criteria need to be designed to fit

the target people for the social prescribing scheme, and need working out with all

partners to ensure transparency

Statutory bodies should work with partners to create reasonable and safe referrals,

based on what matters to people, whilst minimising bureaucratic controls and working to

overcome an overly risk-averse approach to local community development

Informed decision-making before referral to social prescribing is important to ensure

people can exercise choice, they know what to expect, and that it is right for them

Communication between sectors: commissioners need to be clear about intended

outcomes for the service they are commissioning (in terms of who the service is

targeting); and it is important for the referrer to know if the person referred receives the

support they need

A service delivery steering group involving all stakeholders is also considered important and

the earlier they come together and work in partnership the better chance of success for the

social prescribing scheme.

The developers of the Ways to Wellness ‘hub’ delivery model (section 3.1.4) that enables

GP practices to refer patients to link workers situated within community organisations added

‘a visible base in each locality’ as a key principle, to increase healthcare practitioners’

awareness of community and voluntary sector provider organisations. This model is similar

in this way to the SPRING Social Prescribing Project (section 4.3.3) currently being delivered

in North Lanarkshire whose developers recognised that situating link workers within well-

established local community-led health organisations, to ensure they are well-linked-in to

community provision and well supported, as critical to its success.

Learning from community and voluntary sector experience echoes many of the

aforementioned principles and offers further insight on effective practice from the perspective

of vital delivery partners for social prescribing.

In 2015, Volunteer Scotland, in partnership with Scottish Government’s Health Directorate,

explored third sector perspectives on barriers and enablers to introducing social prescribing

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in a primary care setting (Volunteer Scotland 2015). Learning from that exercise included the

following points on effective practice:

Social prescribing works best where all those involved have a good understanding of

what it is, what it can offer and who it can benefit

Unlocking the full potential of social prescribing will only work if productive partnerships

and alliances are formed and key sector partners are connected

Social prescribing is not a quick fix or a bolt-on and it takes time to introduce an effective

and sustainable model

To really work in partnership may require giving away some power to other players

Good partnership working is crucial if healthcare practitioners are to know what

community-based services are able to provide and deliver

To be effective, social prescribing very much depends on primary care staff having a

good knowledge of what services are available in the community: the asset mapping of

local groups and services into electronic directories can help to establish uniform access.

Good communication and guidance is needed from all sector partners as to what

patients can expect from social prescribing and how they can benefit from it: it’s

important that patients see the support that they receive as part of their care package

and not separate

A recent report from the National Lottery Community Fund offers learning from funded

projects piloting or scaling social prescribing, or providing services as part of existing

schemes, to help others thinking of designing, improving or expanding social prescribing

initiatives (Davison et al 2019). This largely relates to link worker models, with the link worker

role seen to have an essential position at the heart of social prescribing (acknowledging that

community and voluntary sector organisations often provide the link worker function).

Learning from this work echoes that of others in that:

All stakeholders including commissioners, referrers and delivery partners need to have a

common understanding of key terms and principles

Social prescribing schemes need to be joined up and key partners need to be on board

from the start

Understanding the local context is important in preventing barriers to an effective and

joined up social prescribing service

Partners should cooperate at strategic and operational levels and recognise, from the

planning stage through to final delivery, what each has to offer the others

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Standards and quality assurance for community-based services can improve confidence

in social prescribing

Making a referral should be as simple as possible

Referrals to community-based services must be appropriate and at a level that is

sustainable

Both the link worker role and the delivery of community-based services must be

adequately funded for social prescribing to flourish

Social prescribing works best when organisations are willing to work with each other

towards shared goals and to share learning, and when funding does not create perverse

incentives and competition

Showing how social prescribing contributes to preventing ill health and improving health

and wellbeing is essential to gaining credibility, buy-in and sustainable funding.

A scoping exercise involving surveys of third sector providers and third sector interfaces

undertaken by Voluntary Health Scotland to help inform the development of the national GP

Community Link Worker programme (Voluntary Health Scotland 2017), suggested from its

findings that the most effective way of using the third sector would be to:

Actively involve the sector in the design and planning of services, recognising and

drawing on its areas of expertise.

Provide a greater range of mainstream service delivery opportunities through contracts

and Service Level Agreements.

Further develop its contribution to specialist service delivery, wherever it has a

recognised specialism.

Its recommendations included that:

Cross-sectoral approaches to workforce development and planning should be

significantly strengthened to maximise the sharing of knowledge skills and experience

The major contribution of volunteers should be further developed, recognising that they

are not a ‘cost free’ resource

The focus of investment should be on models that build and sustain community capacity

Community Link Worker programmes should aim to commission third sector

organisations for a minimum period of three years to ensure quality, partnership and

workforce development, and meaningful evaluation

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A report that describes social enterprises’ views on what would improve social prescribing

activity in Scotland and how its impact could be maximised (senSCOT 2018) identified four

overarching principles:

Strong partnership working

Value community and existing resources

Widen understanding of need

Realistic resourcing of social prescribing

Strong partnership working reiterated the need for a shared understanding of social

prescribing to harness collective action; and recognising the contribution that all partners

bring, including the local community, and the barriers they face. Valuing communities and

existing resources included making connections between existing services and activities;

and investing in community capacity building. Widening understanding of need included

identifying and addressing gaps in service design and planning; and openness to

considering all types of activities. Realistic resourcing reiterated investing resources to

ensure capacity exists to meet the higher levels of demand for community-based supports

that more social prescribing may bring; and embedding sustainability by ensuring that

funding follows the individual. It also brought out the need to improve recording of outcomes

to create evidence of the difference it makes, adding that this is needed to tackle potential

bad press on alternative spending of NHS money.

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Section 4. North Lanarkshire’s foundations for social prescribing

4.1 Community and voluntary sector

4.1.1 Support infrastructure – Voluntary Action North Lanarkshire

North Lanarkshire has a capable community and voluntary sector infrastructure organisation

in Voluntary Action North Lanarkshire (VANL). As the third sector interface for the North

Lanarkshire local authority area, VANL receives core funding from the Scottish Government

and North Lanarkshire Council to support community and voluntary sector leadership and

collaboration, individual organisations and volunteering. VANL provides a single point of

access for advice and support for the community and voluntary sector and has a strategic

role in enabling the sector’s involvement in community planning and integration, responding

to local needs and delivering outcomes. VANL’s Chief Executive Officer is a non-voting

advisory member of North Lanarkshire’s Integration Joint Board (IJB), which has

responsibility for planning, commissioning and overseeing the delivery of community health

and social care services across North Lanarkshire’s six localities.57

4.1.2 Range of services and activities

North Lanarkshire’s community and voluntary sector encompasses over 1800 diverse

groups and organisations contributing to the wellbeing of people and communities, including:

Local community groups, many run entirely by volunteers and often not registered as a

charity

Small, medium and larger charities, some of which are local branches of national

charities, usually employing staff and assisted by volunteers

Social enterprises including housing associations and co-operatives.

North Lanarkshire has 450 voluntary sector charities registered on the Office of the Scottish

Charity Regular (OSCR) Scottish Charity Register, which in terms of the number per 1000

population (1.3) is fewer than in any other local authority area (2018).58 Just over half (55%)

of these charities are small organisations (annual income less than £25K) yet they account

for only 0.7% of the overall annual income (2017/2018) whereas the largest organisations

(annual income greater than £1M) that make up only 5% of the sector in this sample account

for 87% of its annual income.

57 https://www.hscnorthlan.scot/ 58 SCVO State of the Sector 2020

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https://app.powerbi.com/view?r=eyJrIjoiNDY5YTg2MGItMjg1MC00ZDBkLThlMzYtYjc4MDhhNTJkYTZhIiwidCI6ImMyOTQ5NGY5LTNhY2EtNGE3MS05NWUyLWM4ODBjNWE1ZThmOSIsImMiOjh9

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Almost half (48%) of the registered charities are social care organisations, with culture and

sport next accounting for 13%, followed by organisations categorised as providing

community, economic and social development activities (10%) and health (5%) with various

other activities making up the remainder.

Many community and voluntary sector organisations rely on volunteers in order to deliver

supports. Less than a third (30%) of charities on the Scottish Charity Register employ paid

staff and 4 out of 5 (83%) paid staff are employed by the largest 5% with annual turnovers of

over £1M. Over half of all paid staff in this sample are employed by social care and health

organisations (ibid footnote 59).

There is a strong volunteering culture in North Lanarkshire where an estimated 27% of

adults (around 75,000 people) volunteer formally through an organisation or community

group, similar to the national average of 28%.59 Participation in the Saltire Awards also

indicates a positive youth (aged 11–25 years) volunteering culture in North Lanarkshire.60 In

2016, volunteers living in North Lanarkshire provided an estimated 7 million hours of help to

others and contributed around £102M to the local economy (ibid footnote 60). Data from

2014 indicated that over a quarter (27%) of people who volunteer have a disability or long-

term condition.61

4.1.3 Locator

Locator is North Lanarkshire’s online repository and search tool that anyone can use to find

information about community-based supports in the area. Locator is maintained by VANL

and lists details provided by local voluntary organisations including community groups,

activity groups, peer support groups and advisory organisations (at present there are no

listings for social enterprises).

59 Scottish Household Survey 2017 https://www.volunteerscotland.net/for-organisations/research-and-xxxxxx`evaluation/data-and-graphs/local-area-profiles/north-lanarkshire/60 North Lanarkshire Community and Voluntary Sector Children, Young People and Families Strategy 2020–2023 (Draft 5)61 North Lanarkshire Equality Strategy 2019–2024 https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=23430&p=0

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Locator currently lists 528 entries offering a wide range of activities and supports under the

following categories:

Activity for Carers

Activity Group

Advocacy

Arts and Crafts

Befriending

Bereavement Support

Bookbug

Cafe

Call Line

Cancer Support

Carer Support

Coffee\Drop In

Community Council

Community Transport

Complementary Therapies

Credit Union

Dance

Dementia Support

Faith

Fitness

Friendship Group

Green Health

Handy Person Service

Healthy Living

Healthy Start Vitamins

Home Care

Hospice

Housing\Residents Association

Information and Advice

Learning Opportunities

Lunch

Mental Health Support

Meals on Wheels

Music

Palliative Care

Parent and Toddler

Shop Mobility

Singing

Social Group

Stroke Club

Support Group

Thematic Frameworks

Visual Impairment Support

Individuals and organisations can search Locator by type of

support or activity or using key words and limit their search

by postcode and radius. Locator also has a map function to

show the geographical availability of the listed types of

services and activities across North Lanarkshire. VANL can

provide training on how to use Locator if needed.

In the period from 1st April 2019 to 5th March 2020 almost

8,500 users spent over 11,000 sessions accessing

information across over 41,000 page-views on Locator

(Douglas Milne, Organisational Development Advisor, VANL,

Personal Communication 6th March 2020).

Locator’s content relies on organisations providing VANL with details about their services

and activities and informing VANL of any changes so information can be kept up to date.

This can be challenging for community and voluntary organisations operating under capacity

constraints, and particularly smaller community groups who more often depend on short-

term activity-based funding.

Locator has undergone improvements since it was constructed in 2014 and is currently

undergoing further development funded through the Community Solutions Programme

(section 4.2.1) under its enabling services function.

Locator is listed on North Lanarkshire Council’s Making Life Easier resource (section 4.3.2).

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4.2 Partnership working with Health and Social Care North Lanarkshire

4.2.1 Community Solutions Programme

Health and Social Care North Lanarkshire (HSCNL) recognises that an assets-based

approach to community capacity building and co-production at locality level can result in

better outcomes for people, especially at the prevention and anticipatory care end of the

care pathway, and that the community and voluntary sector is best placed to implement it.

Community Solutions62 is a strategic investment programme described as the third sector

branch of HSCNL. As a partnership initiative, Community Solutions was developed jointly

with HSCNL for the community and voluntary sector to take a co-ordinated approach in its

strategic contribution to ensuring every person in North Lanarkshire receives the right

support in the right place at the right time. The Programme has been in place since 2013.

Community Solutions currently receives annual core funding from HSCNL’s integrated

budget allocated through the IJB, which together with additional funding from other sources

is managed through VANL as the Programme host. In the year 2018–2019, the Programme

used its £1.14M core funding to leverage £485,000 in additional funding and gain in-kind

contributions of approximately £63,000.63

The Community Solutions Programme model embodies co-production

within its four pillars of Locality Development; Community Support;

Carer Support; and Enabling Services. Local consortia involving

community and voluntary sector organisations, service users and

statutory partners are hosted by a voluntary organisation in each of

North Lanarkshire’s six localities. The Consortia work to understand the

needs within their local community and, in partnership with community representatives and

other partners, co-commission local services to meet those needs. They also ensure that the

whole of the community and voluntary sector in North Lanarkshire is represented on all

Locality Planning Groups.

Community Solutions project funding is allocated in line with the Programme’s 5-year

strategy64 and commissioning plan and is governed through a ‘triple lock’ structure involving

the North Lanarkshire Wide Consortium in local solutions co-design at level 1; scrutiny and

review by a Governance Subgroup of the IJB at level 2; and approval from the HSCNL

Senior Leadership Team at level 3. The level of funding ranges from investments of up to

62 Previously called the Community Capacity Building and Carer Support (CCB&CS) Programme 63 Community Solutions End of Year Report 2018/201964 North Lanarkshire Community Capacity Building and Carer Support Strategy 2018/23

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£75,000 in initiatives categorised under nine thematic strategic priorities to micro-funding

distributed via the locality Consortia from an annual Locality Activity Fund of £30,000 per

locality. In 2018—2019, in addition to the funding of thematic priorities more than 60

community-based groups and organisations across North Lanarkshire received funding

through the Locality Activity Fund.

The Community Solutions Programme focusses on personal outcomes achievement for

service users based on its overarching strategic priorities—addressing inequalities and

reducing loneliness and isolation—and implements a common monitoring and evaluation

framework. Projects report against agreed programme outcomes for adults, children and

young people, and carers. The Programme Manager provides the Senior Leadership Team

with regular performance updates and reports annually to the IJB.

In October 2019, VANL embarked on the development of an improved Monitoring,

Evaluation and Learning Framework for the Community Solutions Programme in order

to strengthen the collection and use of data to measure progress, demonstrate impact,

inform decision making and enhance learning for improvement in line with HSCNL’s

emerging priorities. A report on this work will be available in June 2020.

Improvement Service review

In March 2019 the Improvement Service supported a review of the Programme in which

stakeholder opinion was sought on key aspects of its approach in relation to outcomes-

focussed partnership working. Stakeholders, including statutory and community and

voluntary sector partners, were sent an electronic checklist of statements and the

Improvement Service analysed the data collected on respondents’ agreement with those

statements. The review identified three areas of strength, based on statements with the

highest agreement scores, as follows:

Strategic planning—based on agreement with the statement that the Programme’s

strategy demonstrates an understanding of local needs and opportunities.

Focus on outcomes—based on agreement with the statement that the Programme’s

outcomes link to the nine national outcomes.

Reporting impact—based on agreement with the statement that by working together, the

Programme has delivered improvements which would not have been delivered by

individual organisations.

Free text comments highlighted strong stakeholder confidence in the Programme’s structure

and governance procedures.

Four areas for improvement were identified and actions agreed, as follows:

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Improve the use of localised data in identifying key challenges and needs for localities—

actions included working with HSCNL on ways to use third sector data to build a more a

holistic picture of community needs.

Consider how the process of funding can be improved to support more effective strategic

planning—actions included reviewing the governance process, looking at longer term

funding and working to realign more strategic third sector investment through the

Community Solutions Programme.

Identify more innovative and accessible ways to share information including performance

governance, key messages and Programme branding—actions included a rebranding

exercise from which the then CCB&CS Programme was re-named Community Solutions.

Explore how the Programme can better market and celebrate its achievements across

North Lanarkshire—actions included developing a communications strategy and

investing in a dedicated communications officer.

4.2.2 Partnership for Change

Partnership for Change is a service user and carer led organisation founded by four

voluntary sector organisations (Voice of Experience Forum; Lanarkshire Links; North

Lanarkshire Disability Forum; North Lanarkshire Carers Together) to provide a platform for

service users and carers to engage with the changes taking place across health and social

care services. Partnership for Change works to ensure meaningful service user and carer

engagement and participation in shaping joint priorities for community care within the

integration of health and social care agenda across North Lanarkshire.65 Partnership for

Change holds quarterly assimilation meetings for service users, carers and providers from all

sectors where information is shared and engagement sought on current integration initiatives

that affect health and social care provision in North Lanarkshire. A partnership working

agreement between Partnership for Change and Community Solutions ensures best use of

shared resources, efficient communication around developments in health and social care

integration, and maximum service user and carer engagement at all levels. The Partnership

for Change lead sits on the Community Solutions Programme Governance Subgroup and

consortia members attend assimilation meetings.

65 https://www.alliance-scotland.org.uk/blog/our_members/partnership-for-change/

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4.3 Social prescribing initiatives

4.3.1 Well Connected

Well Connected is described as Lanarkshire’s social prescribing programme for mental

health and wellbeing.66 The programme was launched in 2012 and involves a range of

partners including NHS Lanarkshire, North Lanarkshire and South Lanarkshire councils and

the third sector. Well Connected is designed to help people who may be experiencing

symptoms of stress or low mood, and anyone who wants to feel better in themselves and in

their life, connect with a range of non-medical support services and activities in their local

communities that can benefit their wellbeing. The programme currently provides information

in a booklet format (one for North Lanarkshire67 and one for South Lanarkshire) that

individuals and those who support them can use to help access the eight types of

opportunities that it offers:

The initial drivers for Well Connected were the desire to support people who were presenting

at primary care with low level mental health problems and being prescribed antidepressants,

and the need to be using existing community assets more effectively68 The programme’s

assets-based approach in recognising and harnessing existing knowledge, skills and

expertise within services already in place across Lanarkshire has enabled implementation at

minimal additional cost.69 Learning from a pilot project helped inform development of the

programme’s support pathways and the services listed were originally selected to align with

the Five Ways to Wellbeing (Connect; Be Active; Keep Learning; Help others; Take notice).

A number of additional sources of information that lie outside the eight core areas, or

domains, have been added to the Well Connected listings over the years such as NHS

Lanarkshire’s stop smoking services, North Lanarkshire Council’s Making Life Easier

66 http://www.elament.org.uk/self-help-resources/well-connected-programme.aspx67 http://www.elament.org.uk/media/1904/wellc-nth-bklt-jul2018-screen2.pdf 68 Elspeth Russell, Assistant Health Promotion Manager, NHS Lanarkshire, July 2017 in The Social Prescribing Project [SPRING] Business Plan Appendices 2017.69 http://www.healthscotland.scot/media/2077/well-connected-lanarkshire-case-study.pdf

55

Physical Activity and Leisure

Stress Control Classes Arts and Culture

Healthy Reading and Self-Help Information

Benefits, Welfare and Debt Advice Learning VolunteeringEmployment

http://www.healthscotland.scot/media/2077/well-connected-lanarkshire-case-study.pdf

http://www.elament.org.uk/media/1904/wellc-nth-bklt-jul2018-screen2.pdf

http://www.elament.org.uk/self-help-resources/well-connected-programme.aspx

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(section 4.3.2) and the Scottish Association for Mental Health (SAMH) Well-informed

Information Service in North Lanarkshire.

Through Well Connected, people can find information for themselves or be signposted by a

care provider to the relevant listed services; and in promoting the SAMH Well-informed

Information Service it offers a route to information about other resources that are available

locally and access to a Community Link Worker for people who may need more intensive

support to engage with local services and participate in activities.

The collection and use of data for evaluation is currently being looked at with support from

the Department of Public Health for NHS Lanarkshire.70 Gathering data on numbers of

people accessing the listed services through Well Connected has not been possible to date

with a few exceptions such as North Lanarkshire leisure services that can report on numbers

of referrals received through Well Connected. A Well Connected app is currently being

developed to enhance user accessibility that will also improve the programme’s ability to use

data analytics to evaluate the programme’s effectiveness in promoting access (ibid footnote

71). Data on service user outcomes is also limited, again with some exceptions such as for

stress control classes, which is a service delivered in-house by NHS Lanarkshire that

measures change in participants wellbeing scores.71

4.3.2 Making Life Easier

Making Life Easier is an online service provided by ADL Smartcare for North Lanarkshire

Council.72 It offers information, advice and direct access to services for people living in North

Lanarkshire with long term conditions or a disability or who are experiencing difficulties with

everyday activities as they get older.73 The website provides information on national support

organisations and local self-help groups, and a link to the Locator tool (section 4.1.3) to help

people find other local community-based support groups and activities. In addition to general

advice on various aspects of health and wellbeing, and hints and tips on how to carry out

everyday activities independently, Making Life Easier also offers people the opportunity to

complete a guided self-assessment in order to access personalised professional advice and

direct access to statutory services and supports including equipment. The collection of

personal data is covered by the General Data Protection Regulation (GDPR).

4.3.3 SPRING Social Prescribing Project

The SPRING Social Prescribing Project is the largest coordinated project of its kind, bringing

together 30 community-led health organisations including 10 delivery partners in Scotland of 70 Susan McMorrin, Senior Health Promotion Officer, Personal Communication, 17 March 202071 Flash report obtained from Susan McMorrin72 https://www.makinglifeeasier.org.uk/73 https://www.northlanarkshire.gov.uk/CHttpHandler.ashx?id=4156&p=0

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which three are based in Lanarkshire: Health Valleys (Lanark) and the Healthy and Happy

Community Trust (Rutherglen) in South Lanarkshire; and Getting Better Together (Shotts) in

North Lanarkshire. The project is being delivered in partnership between Scottish

Communities for Health and Wellbeing (SCHW) and the Healthy Living Centre Alliance

(HLCA) in Northern Ireland with funding from the National Lottery Community Fund. The

Fund is providing £3m to fund the ten delivery partners in Scotland with £40,000 per year for

at least three years to develop the project and host Social Prescribers.

The SPRING project defines social prescribing as: a way to link medical care to (typically)

non-clinical, locally delivered support services. The SPRING social prescribing approach is a

link worker model in which local GP practices who agree to participate refer patients to

Social Prescribers based within well-established local community-led health organisations—

the anchor organisations. The Social Prescribers are tasked with engaging GP practices in

their local area, which for Getting Better Together is the Greater Shotts area. The project has

standardised referral criteria (informed by a pilot project in Northern Ireland) targeting people

(aged 18 and over) thought most likely to benefit from a social prescription such as patients

(or carers) experiencing social isolation, loneliness or low level mental health problems, and

other factors including physical inactivity, chronic conditions, inconclusive diagnoses or poor

results with mainstream treatments, and frequent attendance at primary care services.

The Social Prescriber works with each individual referred to co-create their social

prescription and a personal ‘health pathway’ that gives them control over their journey;

connects them with suitable services and opportunities in the community and gives them the

support they need to access services, engage with groups and join-in activities to help them

achieve their health and wellbeing goals. The project draws on a range of local supports and

activities and offers each individual 12 interventions. Funding to cover the costs of

interventions follows the patient (anchor organisation hold the budget for their area and

when people engage in activities run by other organisations the associated budget passes to

that provider) and the project provides each local delivery partner with £5000 pa for local

capacity building to fill identified gaps in local activities and supports.

The project’s overall goal is that at least 8,000 people will co-create a social prescription and

engage in at least one contact intervention in order to deliver a total of 96,000 interventions

overall in the first 3 years: that equates to 2000 interventions for 160 separate individuals per

year for each local delivery partner. By working at this scale SPRING aims to gather enough

robust evidence of the impact of social prescribing to influence policy decisions and change

the way that healthcare budgets are set in order to shift the focus towards preventive spend

on health and wellbeing in the community. The role of the project’s Strategic Advisory Panel,

whose membership includes operational, finance, policy and political representation, is to

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champion the project within governments and the NHS in order to influence long-term

cultural change in the way health generation and improvement is delivered nationally. The

aim over the duration of the project is to secure policy commitments to fund social

prescribing longer term and role the model out across both regions.

SPRING uses the Elemental Core digital platform provided by Elemental Software74 to

facilitate project management and impact assessment (the project’s funding includes

£40,000 per annum for the online system). The system enables Social Prescribers to receive

referrals from GP practices in real time; and clinicians and Social Prescribers to monitor and

track referrals, log progress, build a case file and aggregate reports. Its features include a

social prescription generator for referring individuals to community based interventions, a

calendar that generates bookings with providers that is integrated with the participant’s

personal calendar, an attendance tracker, impact measurement using the Warwick-

Edinburgh Mental Well-being Scale and the Outcomes Star (Wellbeing Star) to track

improvement in health and wellbeing, and a cost-saving analysis tool.

The project incorporates formative evaluation being undertaken by external consultants

(CavanaghKelly) using a theory based approach.75 Information will be collected through

Elemental and other methods including surveys, case studies and qualitative feedback

gathered from focus groups, regional managers meetings and the Strategic Advisory Panel.

The evaluation framework includes measures of impact for people, healthcare, communities

and government.76

There is an optional break clause at the end of year three (2021) in the project’s five-year

plan (2019–2023) to allow the partnership and funders to consider the year three evaluation

report and decide on that basis if and how the project would continue into years four and

five. The year one evaluation is currently in draft form and should be available in June 2020

(John Cassidy, Chair, SCHW, Personal Communication, 11 March 2020).

74 https://elementalsoftware.co/75 The project budget includes £38,000 for evaluation76 Approach to evaluation framework, January 2019, obtained from June Vallance, GBT

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4.3.4 Other link worker roles

In addition to the SPRING project Social Prescribers there are several other link worker roles

and initiatives currently operating in North Lanarkshire performing functions recognisable as

social prescribing, some of which are described here.

SAMH GP Link Workers and Community Link Workers

Six SAMH GP Link Workers are based in GP practices in North Lanarkshire’s six localities.

They offer a person-centred response to patients’ mental health needs by working

collaboratively with individuals to identify their needs and connect them with suitable

community resources. They also work to develop links with the community in order to create

opportunities for patients locally. The support is generally provided over four 30-minute

sessions.

SAMH Community Link Workers offer support in the community for up to six weeks to help

motivate and support individuals who need it to engage with local opportunities and activities

and encourage self-management. They also work to map the availability of local

opportunities and resources. The Community Link Workers receive referrals from various

agencies as well as self-referrals and can refer individuals on to peer support and more

intensive support services provided by SAMH. As individuals are not followed up once

contact with the Link Worker has ended the extent to which community engagement is

sustained or personal objectives achieved is not known (SAMH Community Link Worker,

Personal Communication,13 December 2019).

Support in the Right Direction Community Connectors

The Scottish Government’s Support in the Right Direction (SiRD) programme funds local

projects across 31 local authority areas through its delivery partner Inspiring Scotland to

deliver independent support to individuals, families and carers accessing the social care

system. North Lanarkshire Disability Forum receives SiRD funding governed through the

Community Solutions Programme (section 4.2.1) for the employment of two full-time

Community Connectors who offer a service to people in North Lanarkshire who are not yet

eligible for self-directed support. The Community Connectors offer one-to-one support to

help people decide what their needs are and connect them to appropriate services and

supports in their local community. The Community Connectors also work to promote their

service to potential users and referrers in the North Lanarkshire area and build connections

with local community support providers. The project has funding for three years (2019–2021)

with a budget that includes funding for advocacy support provided through Equals Advocacy.

The programme’s success is being evaluated nationally using a theory based approach and

all funded projects are required to report on how their project outcomes contribute to the

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programme’s high-level outcomes.77 The service was initiated in September 2018 with the

first six months to March 2019 start-up period including recruitment and development of the

Community Connector role. In the six months from April to September 2019 the Community

Connectors supported 56 people, 21 of whom also benefited from advocacy support (SRiD

Activity and Outcomes Report 1April 2019–30 September 2019).

Hospital Discharge Community Liaison Coordinators

Through the Hospital Discharge Support Programme, two Community Liaison Coordinators

based in Monklands and Wishaw General Hospitals provide a link between acute settings

and supports provided by third sector organisations in the community. The Community

Liaison Service is available to all North Lanarkshire residents (aged 16 years and over) in

hospitals and NHS sites and accepts referrals from health and social care professionals as

well as self-referrals from patients, families and carers. The Community Liaison Coordinators

meet with service users to discuss their support needs and offer tailored information,

signposting and referrals to suitable community supports. This can include self-

management, welfare rights, future planning, support for carers, social opportunities, leisure

and physical activities, and how to provide feedback on services received. The service is

funded through the Community Solutions Programme and has been since 2015. It was

introduced as a test of change to support discharge and prevent people returning to hospital

by enabling them to access non-statutory support where required in order to live full and

meaningful lives. In the year 2018–19, the service supported 503 people on discharge from

hospital with 353 referrals made to community organisations in addition to 175 carer

signposts and 107 direct referrals to carer support services (Community Solutions

Programme end of year report 2018/2019).

Coordinators for Carers

Carers Together Carer Co-ordinators work across all GP practices in North Lanarkshire to

identify and engage with ‘hidden’ carers and young carers, facilitate access to the GP Carers

Register, and offer signposting and referral to appropriate support services as well as being

a reference point for professionals within the practices.

North Lanarkshire Carers Together also has Carer Information Workers described on the

organisations website as link workers who offer information and signposting to help carers

access local and national supports to help them in their caring role including information on

carers’ rights. The Carer Information Workers also attend local community events to help

identify hidden carers and promote the work of North Lanarkshire Carers Together, and work

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in partnership with statutory and voluntary sector staff to ensure carers get the best

information possible.

GP Community Link Workers

The Scottish Government has committed to funding a national Community Link Worker

(CLW) programme for this parliamentary period (up to 2021) with a commitment to recruit at

least 250 CLWs across Scotland during that time.78 Community Link Workers is

consequently one of the six key priorities that GP practices or clusters will deliver for patients

under the new GP contract.79 The Memorandum of Understanding aligned to this contract

defines the CLW as ‘a generalist practitioner based in or aligned to a GP practice or cluster

who works directly with patients to help them navigate and engage with wider services, often

serving a socio-economically deprived community or assisting patients who need support

because of (for example) the complexity of their conditions or rurality’.80 The service will be

designed, commissioned and delivered locally by HSCPs in collaboration with local GPs and

community based services including the third sector so that service configuration may vary

dependent upon local geography, demographics, needs, demand and resources. NHS

Scotland's Public Health Network (ScotPHN) is supporting Health & Social Care

Partnerships (HSCP) and their partners to develop and implement Community Link Workers

locally with information and guidance on recruitment and selection, induction and core

training, data and information sharing agreements, the role of HSCP’s, standards and

governance, and monitoring and evaluation.81

Recruitment of 18 generalist CLWs to work within GP surgeries across Lanarkshire

commenced in December 2019, nine of whom will be appointed for North Lanarkshire; a

programme co-ordinator is already in post within the Primary Care Improvement Team

together with two regional co-ordinators to take responsibility for coordinating the service in

North Lanarkshire and South Lanarkshire. At the time of writing, work was underway to

progress implementation in Lanarkshire82 involving development of the work programme and

service model including referral pathways, community resource mapping and induction

training for the CLWs (Carla Maxwell, Community Link Worker Programme Coordinator,

NHS Lanarkshire, Personal Communication, 17 February 2020).

78https://vhscotland.org.uk/wp-content/uploads/2017/06/Scottish-Government-Briefing-on-Community- Link-Workeres-30-May-2017.pdf79https://www.scotphn.net/wp-content/uploads/2018/08/Paper-1-Policy-Context.pdf 80 Memorandum of Understanding 201781ScotPHN CLW Support, Information & Guidance https://www.scotphn.net/resources/community-link-workers-support-information-guidance/clw-support-information-guidance-2/ 82http://www.southlanarkshire.gov.uk/slhscp/download/downloads/id/218/ south_lanarkshire_integrated_joint_board_meeting_papers_18_february_2020.pdf

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Specialist link workers (SLW) who can offer specialist advice and casework on a range of

social welfare and financial problems and, when necessary, connect patients to sources of

support in their community, is another element of non-clinical support that HSCPs can

embed in general practice under the MOU requirement to provide CLWs.83 In this model,

which is already being implemented in some GP practices in Scotland, SLWs are employed

and managed by the third sector or local authority advice services accredited under the

Scottish National Standards for Information and Advice Providers, registered with, and

regulated by, this will be implemented in Lanarkshire with procurement of SLWs through

Citizen’s Advice.

A data and measurement plan (2020—2021) is being developed to evaluate the impact of

link worker roles within the CLW programme in Lanarkshire based on the theory of change

for the national CLW programme developed by Health Scotland (Helen Alexander,

Evaluation Manager, NHS Lanarkshire, Personal Communication, 17th January 2020). The

plan, in draft form at the time of writing, defines process and outcome measure in relation to

the generic (Wellbeing and Social Prescribing) Link Worker role and the Financial Link

Worker role. Data collection will be ongoing and enable presentation by area for North

Lanarkshire and South Lanarkshire and by locality, GP Cluster and GP practice.84

4.3.5 Commissioned services

Routes to Work Specialist Health Case Workers

Routes to Work Ltd is a third sector charitable organisation and a well-established Arms-

Length External Organisation of North Lanarkshire Council that supports local people to

progress to and access employment as a means of sustainably improving the quality of life

for individuals, families, and communities in North Lanarkshire. A review of Routes to Work

that examined the benefits from operating at arm’s length found that its charitable status was

highly valued by clients and its perceived separation from the council means that many

clients feel more comfortable accessing its services.85

Routes to Work established a specialist team in 2018–19 to work in line with Scottish

Government’s No One Left Behind plan by focussing on the areas of health, justice and

housing and homelessness. In relation to health, a Specialist Health Case Worker offers a

person-centred service for people facing significant barriers to work in terms of health and

deprivation to enable them to improve their health and wellbeing and progress towards

83 Specialist Link Workers (Welfare Rights Advice) in General Practice 2018 https://www.improvementservice.org.uk/__data/assets/pdf_file/0017/9710/hscp-briefing-welfare-advisors-general-practice-mar18.pdf84 NHSL Draft Link Worker Measurement Plan 28/01/2020 85 ALEO Review of Routes to Work Ltd. 2019 https://mars.northlanarkshire.gov.uk/egenda/images/att91717.pdf

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employment. As well as self-referrals and internal referrals from justice and housing

specialist service colleagues, the service takes referrals from various external agencies

including social work and community mental health services, including referrals from SAMH

GP Link Workers (Specialist Health Case Worker, Routes to Work, Personal Communication

16 December 2019). Case workers have regular meetings with each client to understand

their needs and provide tailored support including referral to justice and housing specialist

service colleagues and external agencies within the service’s provider framework, as well as

ongoing encouragement to sustain engagement to help them achieve their personal goals.

Every individual’s progress is monitored using a Hanlon Software Solutions information

management system to collect data including demographic and other individual

characteristics, referral source, barriers to employment, engagement with supports and

progression towards achieving personal outcomes; service performance reports can be also

generated from this database. A key distinction between the specialist health case worker

service and Routes to Work’s standard support service is its focus on addressing the

complex social needs of people who are ‘furthest distanced from work’ due to living in

situations that are detrimental to their physical, mental and emotional health; and this is

reflected in lower performance targets for getting individuals into employment in favour of

evidencing what the individual has achieved in terms of ‘the distance travelled’.

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4.4 Stakeholder perspectives

4.4.1 Statutory providers

Social prescribing as a concept

Understanding of social prescribing within the statutory sector in North Lanarkshire is

generally viewed as being uneven.

“If you’re talking about the senior leadership team and the core team in North Lanarkshire Partnership...I think there’s a reasonable level of knowledge – in very basic terms – around what social prescribing is.” (Interviewee 6)

“…generally, throughout all of the services, I’d say it was fairly mixed” (Interviewee 5)

“I don’t think it is particulary well understood on the local authority side, and within the health side I think its patchy” (Interviewee 1)

Familiarity with the concept of social prescribing is seen as broadly associated with particular

areas of work and especially mental health care, which is consistent with the earlier adoption

of the biopsychosocial model of mental health more generally. In primary care, it was felt

there was reasonable acceptance of the concept among GPs but also accounts of

unfamiliarity within wider primary healthcare teams. NHS health improvement practitioners’

greater understanding of social prescribing was often mentioned.

“Social prescribing is pretty well embedded within the mental health side of things, we are well used to the concept of working with all sorts of things…we have always thought of a biopsychosocial model as being our way of thinking about things” (Interviewee 3)

“I think the ideas are well received by GPs, the GPs certainly that I talk to are comfortable with the concept” (Interviewee 3)

I’ve been asking if people thought [non-clinical interventions to reduce the use of medication in general practice] can be achieved…but even the question, people looked at me as if I’m mad; I do think there’s a huge disconnect between the—not the health improvement side of the NHS—but other aspects of health provision and social prescribing” (Interviewee 1)

The agency of individuals however also transcends professional categories; that is, those

who adopt a social perspective and the ethos of social prescribing in the way they work

through personal conviction whatever their professional role.

“If people doing my role were a health professional…with a particular skill set and a particular way of training they might not see it the same way, and I know my colleagues who are also social workers that do the same job as me, I don’t think they’ve got into this at all" (Interviewee 1)


Many of the expressed views on the term ‘social prescribing’ chime with those already

documented by others as described in section 3.1.1. By seeming to place people in the role

of passive recipients of a service, the medicalised language of prescribing could be seen as

misrepresenting the fundamental principle of social prescribing to increase people’s control

over their own health and lives and rebalance the relationship between statutory providers

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and service users. It was also clear that there is more to this than just arguing over

semantics.

“Sometimes we get ourselves caught in the language of things that make it sound as though it’s a ‘servicey’ response when it isn’t, and it shouldn’t be; and we perpetuate the sense that people need something given to them…” (Interviewee 2)

“…is it prescribing? It’s a passive thing, its power relationships, prescribing suggests I tell you to do something, I prescribe it for you; but that’s not the relationship that we want to generate …it’s difficult to get the right term, but we do need to think about it.” (Interviewee 3)

Failing to clarify meaning for everyone involved was identified as a real risk that could hinder

efforts to achieve a shared understanding and a rebalancing of the relationship between

patients and healthcare providers.

“…prescribing, people probably think of drugs or medication, so if you’ve not got the [prescription] pad and you’re not being prescribed to do it, what’s people’s understanding of that?” (Interviewee 4)

“…if we’re valuing communities, essentially if we’re saying ‘how do we help communities be strong, be supportive of each other, be able to recognise what contribution everybody has to make – by us using professional language, does that help or hinder that?” (Interviewee 2)

On the other hand, advantages to professional language were noted in relation to buy-in

from health and care professionals that could influence progress towards its wider adoption;

and underlining integration authority responsibility to ensure sustainable funding.

“But you need to have something [a name] that’s going to have buy-in from the professions and at the moment ‘social prescribing’ does have buy-in from the professions; if you told them ‘you’re not allowed to prescribe anymore, you have to assist people to connect’…it might just stop you being able to make the progress you want to make” (Interviewee 3)

“One of the important reasons to use that medicalised language is that it protects the funding round it because it’s got that pseudo-sense of ‘we’re doing this because it helps people’s health and wellbeing, which will help on pressures on other parts of the system, so that’s quite a legitimate reason to use some of that language, to protect the sense that that’s not somebody else’s responsibility, that’s our responsibility to fund and see that as a whole” (Interviewee 2)

Creating shared understanding

Lanarkshire’s Well Connected programme (section 4.3.1) exemplifies the local branding of a

social prescribing initiative using language that is more accessible to the community, which

has also made the service more familiar among care providers.

“…when we say social prescribing people probably stop and think ‘what is that?’; if you say ‘Well Connected’ people might realise ‘Oh, that’s what they mean about physical activity, the library and looking after your wellbeing” (Interviewee 4)

“…if you then talk about Well Connected people probably understand that a lot more because it’s more understandable in the name Well Connected – you’re Well Connected…I presume that’s why they went with a local name, to try and make it a bit more understandable and accessible for people” (Interviewee 4)

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But local branding does not in itself guarantee familiarity across all parts of the health

service.

“Say you were- to speak to our health improvement teams, right away they’ll know what Well Connected is; if you were maybe to ask some of our social work teams, mental health teams, I think they would know quite quickly, but some of our other teams I’m not quite sure, I don’t know if it would be as quick for them” (Interviewee 4)

Informal knowledge transfer in the course of everyday collaborative working was identified

as a contributory factor to creating shared understanding of social prescribing: mechanisms

included engagement with the Health Improvement colleagues, cross-sectoral relationships

and shared learning within speciality and interdisciplinary teams.

“As far as my staff go, within my own service, I think there is a fairly high level of understanding of what it’s about…it’s just their knowledge of what’s happening round about them…there’s a bit about working with the professionals they work beside, health improvement staff etcetera, voluntary organisations they’ll come across, and it grows from there and we have team meetings and they share that” (Interviewee 5)

“…what [our local Health Improvement Advisers have] said to me is social prescribing is not just going to swimming or going to the gym, there are all sort of other things that people could do, green gyms, join all sorts of community groups, gardening groups and all sorts of things…so I’d be somebody who had a relatively narrow perspective on social prescribing in general but I’m sure lots of people are similar to me; I’m convinced now that that’s not the case – the broader we can be the better” (Interviewee 1)

Raising awareness

That a need exists to raise awareness within the statutory sector about what social

prescribing is, what it can offer and who it can benefit, was not contested but there are prior

considerations around how and when that is done.

“There is [more to be done about raising awareness]; there’s a tension in it about how we do that because if we file it all as social prescribing are we perpetuating that whole problem of professionalising it?” (Interviewee 2)

“…but we can’t promote it if we don’t fund it, or if it’s not funded in a range of ways, because if it doesn’t exist why would you promote it?” (Interviewee 2)

“…yea, I think there is [more to be done about raising awareness] but [social prescribing’s] not available is the problem…I don’t think we are equipped to do it the way we ought to.” (Interviewee 5)

There is also some work to be done around changing attitudes to the value of social

prescribing and whose responsibility is it to take account of the wider determinants of health

in the care they provide.

“There are the doubters out there…I think they would be marginally on top because you’ve got the traditionalists that believe in traditional models and some people just aren’t at that place where they can accept there’s another alternative…but I think it’s marginal and we’re getting there…” (Interviewee 5)

“…how do we get our wider teams to think about what’s out there for people…because people say that’s not my role, not my job” (Interviewee 4)

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The challenge this presents in the face of rising demands and competing priorities combined

with fiscal constraints is clear and should not be overlooked in the judgement of ostensible

negative attitudes to social prescribing.

“…that bit about the constant pull to the immediacy of the crisis…the ability to then say ‘no, we want to take a step back and do something that would stop so many people going to the hospital in the first place’ is really hard” (Interviewee 3)

“[There are] all sorts of pressures at this time of year on A&E and that just takes a grip of everybody and when you have that dynamic everybody’s perspective changes so you cease to think about ‘why are all these people at the hospital in the first place… maybe if people took a bit more care of their own health they might not have that particular issue that’s bringing them to the door of A&E’ so the two things are going on in people’s minds at the same time: I don’t think there’s a scepticism of the value of the social prescribing approach…it’s more that they would always privilege the traditional medical model, I’m convinced of that” (Interviewee 1)

“It’s about winning people’s minds over and saying ‘Right, ok, I see the validity in that’: that’s where the doubters are…particularly when you’re working at the clinical coal face you’re running hard to stand still and trying to get the work done.” (Interviewee 5)

There was some concern raised about the risk of wider opposition, which underlines the

importance of a shared understanding of social prescribing among all stakeholders.

“What worries me slightly is…I think we run into some opposition from the partnership, so from the Union side of things I have heard that sense of ‘if we start putting resource across into the independent and third sector then that’s a form of privatisation; we’re taking work away from the statutory side and putting it into these slightly loose arrangements where people maybe won’t have the same terms and conditions’…so it’s akin to privatisation would be the opposition to it.” (Interviewee 3)

Strategic thinking

North Lanarkshire’s partnership strategic plans and the processes through which they have

been developed reflect deliberative thinking about embedding core principle associated with

social prescribing, although seldom referred to using that term; and this is viewed positively.

“We’ve got really strong discussions happening about it on the GP side [going through the process of primary care improvement implementation and planning]…and as we get into those discussions its very natural to get into ‘and are there things that could be done in the non-statutory side to support and help people at an earlier stage before they need the requirement for statutory…’, in those strategic discussions it’s definitely there.” (Interviewee 3)

“One of the things I’m quite encouraged by is that we’ve tried to simplify [the Strategic Commissioning Plan] and make the message more straight forward and make it clearer what it is we’re intending to do…prevention and early intervention is right up there in terms of what people see as important, and how do we focus on doing that” (Interviewee 2)

“The structure around [the Plan for North Lanarkshire] is trying to embed the sense that this is everybody’s responsibility and we need to be more joined-up and we need to be thinking about the whole population and our collective diminishing resources…how do we increasingly make use of the resource that we’ve got across the piece rather just in their split up silos: now, the rhetoric of that is really good but actually doing it is much harder than it seems, not because people are not willing but because that’s not the way we’ve traditionally done things, and that feels like it’s a really positive evolution and will continue.” (Interviewee 2)

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Investment dilemmas and decisions

When it comes to service delivery, decisions about funding social prescribing are

nevertheless strongly influenced by current resource constraints. Relative to pressing

demands on clinical care provision, social interventions are more likely to be low on the list

of priorities, which may to some extent reflect how they are perceived.

“The timing of doing the Strategic Commissioning Plan would say yes [social prescribing] does [feature in strategic or planning level discussions around service delivery] because we’ve really recognised that significantly within the drafting to date; and the most recent Mental Health and Wellbeing Strategy, social prescribing, the approach to recovery, is embedded in that, so yes people do talk about it and do recognise the importance of it. The crunch comes when you’re talking about limited resources, that’s where there becomes a more difficult debate” (Interviewee 2)

“…the problem and issue is everything’s a priority; if you’ve got high waiting lists and government pressures…our hospitals just now are in a very tense situation so the priorities will always go to the acute and the unwell and its always been finding that balance…” (Interviewee 4)

“When it comes to hard financial discussions its hugely difficult…that is a problem for us, there is a sense that some of this is a bit woolly and a bit soft and therefore it can be a bit of a soft target when it’s compared to some of the hard stuff that needs to be done”. (Interviewee 3)

One interviewee contested the lack of financial resources argument, with emphasis on the

words ‘decide’ and ‘priorities’:

“…the other myth of course is that there’s no money: a lot of our resources [allocation] you can’t pull out of…but there is always a margin and that margin is larger than many people think…that’s a lot of money around which we have to make decisions…people talk about a lack of resources [but] we decide what we spend money on and we spend money on priorities” (Interviewee 6)

Funding insecurity for the community and voluntary sector is recognisably a risk that

threatens to diminish the local provider base and undermine the notable advances North

Lanarkshire has already made through productive partnership working with the sector in the

development and delivery of the Community Solutions Programme.

“If you look at North Lanarkshire compared with other areas we have invested significantly [in our third sector through Community Solutions] however we’ve never been able to give that guarantee of ‘this is us, we’ve got two-year, three-year funding to take the work forward’ there’s always that…its unsettled, its unsure” (Interviewee 4)

“We’ve lost so many staff from our third sector organisations because we can’t give them the guarantee of one, two or three-year funding…extremely frustrating” (Interviewee 4)

It is also recognised that sustainable funding for community and voluntary sector providers is

the bedrock of a sustainable model for social prescribing.

“The other huge thing is that so many of the [community-based supports] that are on offer are on offer based on short term funding and with limited capacity or availability; and, it’s back to the money thing, about how do we shift this onto a more sustainable basis.” (Interviewee 3)

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Wider healthcare system challenges

System-wide barriers and decisions enacted in the wider healthcare policy arena add further

complexity to the local decision-making environment, which can get in the way of developing

and embedding a locally appropriate, joined-up and effective social prescribing service.

“One of the interesting things about the way that we operate in a whole system is sometimes the Scottish Government decide to give money that actually makes that quite hard as well, the fact that some of the GP or primary care changes is coming with a very ’here’s this money and that’s how you’ve to use it’…you think, if we’d had a chance to do it a different way we might not have just gone completely down that route; so some of those tensions are very real and complex; because on the same hand the Scottish Government will be promoting third sector involvement and community empowerment so I just suppose it’s a demonstration of how complex the whole thing is. (Interviewee 2)

“You think about that [Scottish Government rolling out the national GP Link Workers Programme], where’s the capacity? So these workers are there and that’s great but the foundation below that…so if I’m one of those link workers and I’m referring to you as a third sector organisation, as a local group, you don’t have the capacity for all of this because you’ve not had that funding” (Interviewee 4)

Or is it complicated throughout the whole system that’s what I mean, like from Scottish Government right to communities, and Council’s layer in there and health boards layer in there and it makes it just hard to see how to do it; it’s not really solution focussed is it!” (Interviewee 2)

System-wide barriers are seen to impinge on local financial decisions and control over

financial resources in ways that have to be negotiated.

“Our systems are not easily designed around longer-term solutions…like not moving to longer term financial planning is a tension, not because people aren’t willing to do it, it’s because structurally there’s a sense that you do year on year planning because it’s based on Scottish Government settlement and stuff like that…there is a difficulty there” (Interviewee 2)

“The problem with this is the big-ticket items for health and social care partnerships are always around service delivery and particularly those areas that are national priorities and targets…” (Interviewee 6)

“That’s actually a huge problem across our whole public sector because the Christie Commission etcetera set out the benefits we would have by taking a preventative approach yet our entire system is calibrated towards dealing with fixing the bits that are broken rather than taking a preventative approach. I can’t see how you would do that without separating the money somewhere, you need to have a set of money that’s for fixing the broken bits and a different set of money that’s for taking a proactive and preventative approach. Social prescribing kind of fits in between those though, it’s neither one nor the other…on the fringes of fixing things but it’s not quite prevention although some of it will be: it’s an interesting debate…” (Interviewee 3)

Relationships, reliance and trust in the community and voluntary sector

Achievements in building working relationships with the community and voluntary sector in

North Lanarkshire are viewed positively and there is trust expressed in the sector as a

dependable delivery partner as well as an unequivocal recognition of dependence on it.

“We’ve just done a load of engagement session round our strategic plan and at every single session and locality it was spoken about the work of the third sector and the relationship between our third sector and statutory organisations and over the years this is coming so much closer than what it was before” (Interviewee 4)

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“In terms of our long standing relationship with VANL, third sector, I think our recognition of the role that they have and the structure around their engagement with communities is one of the things that has worked well in North Lanarkshire; and things like local people coming together with support through VANL to make decisions…local people identifying [what the issues are] and doing something about it” (Interviewee 2)

“Yes [there is trust the community and voluntary sector as reliable providers]. I think it’s more of necessity; the independent sector [sic] now provide services that either didn’t exist or that people needed or [that] used to be provided by statutory services. Aye, there’s a very strong relationship of trust. And VANL…they’re key partners in everything we do.” (Interviewee 1)

“I think [statutory providers] do [trust the community and voluntary sector to be reliable providers]…and there’s a number of things that voluntary organisations can do that we can’t so there is a dependency and we definitely need them as partners, and trusting that will continue because…we couldn’t survive to support people out there if we didn’t continue to fund them: aye, there will always be a place for voluntary organisations, always. (Interviewee 5)

Evidence for investment and evidence of success

The difficulties inherent in establishing the evidence for the benefits of social prescribing

hinders evidence-based decision-making about investing in it; and expectations differ on the

level and type of evidence that would be sufficiently convincing.

“One of the other aspects particularly of social prescribing and taking a more preventative and proactive approach is how can you say for certain that what you’ve done there has this effect over here, you can’t say for absolute certain…or how do you know what you’ve done here has offset a range of things that haven’t happened, that’s even harder to show that; so inherently I think the things [for which] you can say ‘that money has bought that many clinical appointments or residential home placements or individualised support that has resulted in this number of people being supported’ that’s easier to understand; but this bit of work which might have touched 50,000 people, which might have helped the general wellbeing in this community, is harder to quantify” (Interviewee 2)

“…particularly GPs, I think it’s important that they can see there being evidence it can promote health change and health benefits; I think GPs tend, for good reason, to be much more empirically driven and look for hard evidence for things” (Interviewee 1)

This is also evident in relation to evidence of economic value:

“I do wonder if what you really need…is would you need an NHS economist to say this is a cost effective way to deliver a health service; it would give it a credibility as well” (Interviewee 1)

“…because of the pressing issues we have round resources, delivery plans, the enormity of the problem…if your core services are potentially going to be cut and you [want to] invest in something that’s going to show some profit or return in ‘x’ number of years, people will have doubts and that’s essentially where we are” (Interviewee 5)

I think what we do is we actually force people to take a very good idea but the only way it gets heard is if you tell people it’s going to save money: ‘I can’t go to SLT who are looking at financial savings and a whole pile of other things and say please start doing this because it’s better’, which is the right thing to do, what they have to say is ‘if I get a little bit of money this year you will save so much more down the line’ (Interviewee 6)

The stakeholders questioned also expressed a range of views on what persuasive evidence

of success would look like. Benefits for people were notably seen as being paramount:

“The most important thing is that the person themselves has got a feel-good factor” (Interviewee 5)

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“There’s some people like me who would think, if you’re going to a GP for antidepressants the fact that at the end of the day your social circle has improved and you’re less lonely or whatever is a good thing…ideally they would be able to reduce your medication…but even if that’s not the case at least someone’s outcomes have improved” (Interviewee 1)

“…if my patient’s telling me ‘I went along to that community group and I feel so much better, I’ve made friends, it’s nice to know I’m not alone’ and they go off and they’re empowered…for me, that would be the biggest influence; [narrative] feedback you get from patients or from staff about a patient’s state of wellbeing and reduction in need for medical intervention…on a [GP] practice level, is probably one of the most powerful things” (Interviewee 6)

Benefits for healthcare providers included a change in attitudes towards social prescribing as

well as anticipated benefits commonly mentioned in the literature such as having more

options and reducing workload.

“The big thing for me is that we all have that knowledge and we all believe it’s got a place…you need to believe that it does make a difference, that it’s important” (Interviewee 4)

“…and softer things like a GP having at their fingertips the ability to access a variety of resources easily, so it’s easier to refer someone into a social prescribing route than to write a prescription or refer to another professional” (Interviewee 3)

“If we manage patients differently than what we’re doing just now, and the outcomes are evident then the clinician or social care worker would see the benefit of it, and if it is assisting them with managing their case load, managing that person, then I think that would be the convincing factor for them” (Interviewee 5)

In relation to benefits for the healthcare system, there were divergent views on the absolute

need for quantitative evidence of reduced demand at the system-level.

“In a really simplistic sense, from a system point of view, social prescribing would be effective if there was less pressure on referral for more specialist services…so if you think about CAMHS and supporting young people with mental health difficulties, if a wider range of options is available for people at an earlier stage in terms of young people and their families feeling connected and valued in their community and valued as people then the logic would be that the number of people that experience psychological difficulty should reduce but the people that have got a need for specialist mental services for children [those] services will always be there, and if you get the people that really need it at the time then that would be a really good outcome. That’s ultimately the measure we would be looking for in the system we work in to make sure that response across the board demonstrates how it joins up and impacts positively” (Interviewee 2)

“When I look at the number of people who are referred for psychological therapy or CAMHS over the last 10 years I see a steady increase – success would be that that starts to flatten or drop; because there are such good alternatives out there…; I’m sure there will be other things you could look at…fewer people needing rehab for long term conditions, so a drop in the physiotherapy waiting list…” (Interviewee 3)

“At strategic level…you want something that works…the narrative stuff, for me, is probably the first thing, if you’re going to wait for a change in antidepressant prescribing you’re going to wait long and weary, if you’re going to wait for a change in hospital admissions you’re going to wait even longer…if we’re looking for that kind of evidence there are so many confounding factors [so] narratives, individual cases, individual success stories, very simple things…here’s a number of patient who were referred by their GP and four weeks later they’re still going to a particular class, a particular group…[evidence that] people are buying-in. How [should we] measure that? We don’t measure the number of consultations they have with their GPs, we don’t measure how many of them get admitted to hospital, we measure how many turn up and who turns up often; so in terms of evidence I think it’s very much keep it simple” (Interviewee 6)

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What else we can or need to do to support social prescribing in North Lanarkshire

The stakeholders interviewed have confidence in HSCNL’s strategic direction but are alert to

the importance of making sure there is close alignment between delivery plans for its

statutory services and the Community Solutions Programme.

“Having this central to our Strategic Commissioning Plan is helpful, it’s a good symbol that it’s there” (Interviewee 3)

“It’s not just about the funding, it’s about breathing space and I don’t think any of us ever gets breathing space to look and see are [our strategies] aligned, do they sit ‘like that’ as you want them to sit as our delivery vehicle…there’s that time [the Community Solutions Programme Manager] and others need to stop and breathe and say ‘what’s happening over the next three years, are our programmes fit to deliver what they need to deliver over the next three years’. We just need to make sure we are going together.” (Interviewee 4)

The success and durability of Community Solutions is a credit to the leadership and

determination within the NHS, Council and Third Sector Interface in North Lanarkshire right

from its origins in the Change Fund, and it’s governance arrangements are highly regarded,

but ways have to be found to maintain that infrastructure and its financial sustainability in an

uncertain health economy.

“…the strength is there but to maintain strength you need funding, we need to know they’ve got bills to pay, they don’t get their lets, venues, everything free…” (Interviewee 4)

“…moving to three-year funding commitments, and doing a three-year Commissioning Plan steps us towards that” (Interviewee 2)

The implications of lack of oversight to ensure coherence and avoid duplication across all

social prescribing initiatives in North Lanarkshire that are funded and governed outwith

Community Solutions, including the various link worker roles, and how that might be done,

also warrants consideration.

“…and actually by funding them in that way…that part does that and this part does this, do you divide and weaken…or do you take all those bits and create a big monster of a thing that just becomes a bureaucracy in a different way…I don’t know the answer to that, it’s really a big tension” (Interviewee 2)

“In terms of the prevention and anticipatory care, the IPAC stuff, there is people who do look at that, but again the tension is do you have a group looking at employment, a group looking at poverty, a group looking at social prescribing, and actually what’s different and what’s the same about all of them? I think we’ve got to be careful not to assume that it’ll just happen but not to create structures that just stick things in boxes as well” (Interviewee 2)

Creating a new relationship between health professionals and service users has been

identified as an area for development, to make sure the ‘first point of contact’ has the right

conversations and connects people to the most appropriate source of support, which is

essential for social prescribing to work.

“One of the things we’re talking about now is that if somebody comes into contact with a member of our team is first point of contact, what is our response; our staff keep saying we do it but we have so many cases where people are saying I didn’t get the right response, help, I needed, so we need to create a different culture and if we use the principles of the 3 conversations, if we all adopt that approach hopefully [that will bring about] culture change; if I

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pick up that call it’s up to me not other people, that’s what we now need to look at, us being in a Health and Social Care Partnership, lets really look at what’s within our gift to do, that is within our gift to do.” (Interviewee 4)

Having the new GP Link Workers in post will be an important enabler for social prescribing in the primary care setting.

“I do think that through the Primary Care Improvement Plan our development of the link worker model will be a helpful thing in increasing the visibility and the access to social prescribing across primary care, so that’s one thing we can absolutely do” (Interviewee 3)

There is also potential to harness the influencing power of professional leadership and

opinion leaders to change perceptions and encourage involvement of a broader range of

practitioners in social prescribing.

“I think what’s missing is…these conversations I’ve had with pharmacists, I think the local pharmacists are able to hook into this but that’s not part of their… trying to get that slightly broader perspective; to get that lever there probably requires getting the buy-in from the chief pharmacists and that type of person…if it’s the pharmacist who’s asking these questions it would be a good thing—doing it from the inside” (Interviewee 1)

Not knowing what supports are available is a commonly cited barrier to social prescribing

and making it easy to find out is a commonly cited enabler. North Lanarkshire is ahead of

many areas in having developed several useful resources but there is a need to consider

how to optimise their utility.

“Well Connected, that idea of bringing things [together] is a good idea, and whether some of the stuff we can do about improving Locator, or getting more stuff onto MLE, these different tools we have; somehow we need to make it easy for people to do what we think is the right thing, at the moment I’m not sure it’s as easy as it could be…I’m not sure that we have good ways of making sure that we are always aware of all the things that are available” (Interviewee 1)

“One of the problems from a SP point of view, one of the frustrations, is you’ll go out and speak to people who’ll say ‘nothing happens in Cumbernauld’. Nothing at all…are you sure? Then people have a debate about this happens, this happens, there’s this group and this group… richness of things out there and folk will say ‘I didn’t know about that’, so how do we equip people with that information…how do we start to get much more personalised responses in terms of how we quickly understand what the issue is for you or what your position is and join you to the right bits of information; so that’s a really exciting opportunity for us in terms of technology [that] changes it as much for practitioners and staff as it does for the public.” (Interviewee 2)

“I’m not sure that we have created the environment that encourages people with ideas to be able to put those into practice so, if I had the idea it would be good to do a park run or a walking group in my local park where do I go to get support to make that happen and get it onto the list of things that would be available for my GP to say to other people in the locality ‘here’s a good idea why don’t you do this’; so I think there’s a gap there” (Interviewee 1)

Feedback to referrers on the progress and outcome of the referrals they make is an

important gap in the capability of current tracking mechanisms.

“…I think having the feedback loop is important because that fosters trust over time; part of the problem might be say if someone refers a patient to a voluntary organisation or a community group, if the patient doesn’t come back and tell them that was great they’re not really sure so they’re not sure when the next patient comes in ‘should I do that again or should I not?’ ” (Interviewee 6)

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And currently, North Lanarkshire does not have IT systems that would enable social prescribing activity and tracking to be managed across statutory services and community-based providers.

“We’re way, way off that; I couldn’t even put a timeline on that, when that would happen” (Interviewee 5)

Final words

“…and there’s the whole issue about Scotland’s health, we haven’t touched on what priorities should be like smoking, breast feeding which is a high priority, and there’s also diabetes…social prescribing…it just takes you into a different world” (Interviewee 1)

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4.4.2 Community and Voluntary Sector providers


Focus group participants agreed that ‘social prescribing’ is an unfamiliar term in the

community and voluntary sector. They were also agreed on it being ‘health service’ language

with advantages for the statutory sector including buy-in from health professionals but find it

is not always familiar to health care professionals they work with either.

“I asked two of my staff today if they knew what social prescribing is and they didn’t, ‘Is that a new terminology?’…it’s one of those things where there’s this assumption that everybody knows what it means but I had to kind of look it up myself not that long ago to see what it meant…so [I] would say knowledge is fairly low”

“It’s coming from the medical side, they’re trying to get the GPs to buy into it to make sure that they are not overwhelmed, so if they put ‘social prescribing’ on it doctors will probably buy-in to it more”

“You think when you talk about a prescription, something the doctor prescribes for you, they give you something…we advise something for you to help you feel better, so whether that’s a medicine or an activity…they’re still putting you on that path to make you feel better”

“I think it’s important it does have a name for more clinical sides to say that healthcare is changing, it’s getting more holistic, but I was speaking to a nurse today and they didn’t know what it was, when I explained they said that sounds really good…they followed it”

It is clear however that the concept of social prescribing is nothing new to the community

and voluntary sector: they recognise it as describing the principles that underpin the sector’s

everyday way of working although they don’t call it social prescribing, and that terminology is

not necessarily well-liked.

“It doesn’t mean that it’s not happening, it’s just we don’t use that terminology; I think it’s a horrible term…”

“I think for the majority of us we’re already doing it… we’re just not putting that tag to it.”

“I think we have been doing this for a long, long time but now the GPs are seeing that it’s a really good way of working”

‘We’re already doing it’

Further discussion elucidated what community and voluntary sector organisations mean

when they say they are already doing social prescribing. Although the word ‘signposting’ was

often used as a ‘catch-all’ term it does not adequately describe the spectrum of activity that it

is being used to describe and could, therefore, be easily misunderstood to mean much less

than what is actually happening in the sector.

“…and you’ve just said the word again there, ‘signpost’, I’m sure everybody in this room’s the same, it’s not just going ‘there’s a group you want to go to’…”

“Much more than that…”

As well as signposting in the sense of giving information or directing people to relevant

resources where appropriate, and delivering the community-based services and activities

commonly associated with social prescribing, many voluntary sector providers inherently

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perform a ‘link worker’ function in the way they work with people, taking a holistic approach,

having “the conversation”, identifying wider needs, directly connecting people with other

services and activities, and supporting those who need it to access and engage with those

services and activities. Many organisations offer support at more than one level depending

on the needs of the people they serve.

“…we find that all the time, we get people phoning us up, ‘I’m a carer’, wanting information and you listen to them and you go ‘I think there’s something more here’ and you say ‘why don’t you come and meet with us’ and they’ll come in…basically they’re looking for a solution to something then they start to open up and there’s all these other things…layers and layers”

“…not just the person the whole home environment you’ll take into consideration, if there’s other siblings in the house, if there’s addictions, then there’s that bit about ‘what else can I link people in to?’”

“It’s potentially physically taking them there, arranging transport, checking in with them ‘how did it go; are you going to go next week?’ It’s not just saying there’s a group you can go to…if somebody’s really quite isolated of suffering from anxiety or poor mental health issues to actually ask them to walk into a new group – it’ a big task…even getting on a bus…”

Community and voluntary sector organisations generally do not see this holistic approach

happening in statutory services.

“[with GPs] there’s prescription or referral to mental health services…there’s not that kind of bigger picture of thinking: we’re getting the full picture, how are you meeting the needs of your kids, how are you managing with the house, food, budget and things and then from that you’re [connecting them] to CAB and HOPE [for Autism] and everywhere…”

“On an initial visit the other day just to gather information from a mum, I know straight away that she’d got no food, I’m contacting the welfare fund, waiting half an hour on the phone, and had to go back and get social work on the phone who weren’t interested because we’d provided that service but didn’t see the bigger picture…of mum’s anxiety and depression…’youse have provided food for her so that’s fine’ ”

What is more, community and voluntary sector organisations are often doing this while ‘filling

the gap’ as people wait for access to statutory services.

“I think even looking at time for appointments because one of our families, suicidal and things, [waiting for] a GP appointment weeks down the line, so you’re in action – who can I refer you to, Cruse Bereavement Care…what can I get you?”

“Your biggest problem is now social work picking up, I’ve been waiting since October for a family I referred in with massive issues and they’ve still not allocated a worker and from there I’ve referred mum to x, y and z just to fill in the gaps because social work just aren’t picking up…”

“We’re doing all the social prescribing whilst you’re waiting for that”

It is not having more time available or spare capacity that explains this way of working it’s a

mindset, and many community and voluntary sector providers add more intensive support

provision to their role informally.

“…and it’s not because we’re not rushed off our arses…it’s because we see the need and we see the desperation and we’re prepared to speak to people quickly”

“You’re going above and beyond what you’re commissioned to do because you will not see that person [left] high and dry”

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“…and it’s not my remit to do this, but I went because I knew it was important to go to a walking group with her, I went twice, got her to meet and chatting to people and, it’s two years now, she’s still going to that walking group; so, see, it’s just a small investment for people, if they just have that confidence to attend, or phoning up to make sure…because it is a big step if you’re not used to it”

“We’d be in a sorry state if we stuck to what our remit was”

Being well-placed to do it

Community-based organisations feel well-placed to do social prescribing, and that they are

seen as being more accessible to local people, more likely to be responsive, and less likely

to be judgemental; and to reach people who won’t necessarily seek help from statutory

services, even their GP.

“Social Prescribing is happening at the moment, we’re doing it and we’re really well placed to do it and it shouldn’t be less valued because we’re doing it as opposed to clinical services doing it because we’ve got a better understanding, better relationships with people that need these interventions.”

“…and the thing is the third sector is much more accessible to them so if you try to get hold of a doctor or someone in the third sector you’re more likely to get hold of us and we’re more likely to step up to the plate quickly when you need it…”

“But then people also…they still tell us that in terms of statutory services they can find that really off putting too so what you tend to find is somebody could sit with us for an hour, two hours, and really open up; they’ve phoned you for one thing and before you know it you are looking at everything holistically and you’ve maybe got a dozen different referrals and all of a sudden that person’s on your radar where they wouldn’t necessarily go to the GP, especially carers don’t, they’ve no got time for that so they probably won’t end up at the GP in the first instance, there’s more chance of them falling into one of the third sector organisations and carers have said to us ‘I feel that there’s no judgment’ because there’s that perception with social work still, you know, ‘I’m no going to tell you I’m struggling, you might take my kids away’ or ‘you might put my mother in home’ ”

“You tend to find with the social prescribing that it comes naturally to us because conversation flows naturally when they engage with you…”

Partnership working and feeling valued

HSCNL is viewed as being ‘ahead of the game’ when it comes to working in partnership with

the community and voluntary sector as exemplified by Community Solutions; but a persistent

disconnectedness is experienced in practice that may be understood in terms of having

unequal status in the partnership.

“What has to be said is that in North Lanarkshire there is really good partnership working within health and social care and the third sector, that goes without saying in terms of all the Community Solutions work that’s going on”

“I think health and social care see the value of the third sector but there’s still some of the dots still not joining up: it’s bizarre how it doesn’t work when you think about the number of events you go to, the strategic planning groups where you’re sitting with health and social care and you talk about the job that you do and how, for us, it’s about reaching out to the families, providing information, you know, we provide case studies about what that’s done for that family and they look at you as if to say ‘that’s amazing, where have youse been?’ but then you hear nothing. So you get the vibe that certain people really understand it and want to buy-in to it but I don’t know if there’s just that hierarchy…”

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There is also a sense that statutory healthcare providers ascribe lesser value to what the

community and voluntary sector do compared with clinical services; and can fail to recognise

that this is often a strength.

“There are a lot of places that do value the voluntary sector and Lanarkshire as a whole is much better that other Local Authority areas but there is still a divide between clinical and non-clinical”

“I work quite closely with the NHS Health Promotion Team, who are great, but I’ve had to do quite a bit of work with clinical staff from the Sexual Health Team and there’s very much of a difference there, it’s taken me a long time for them to value what we do, what we bring in, and these are people I have worked with for over 15 years and I’m still sometimes blown away by their flippant remarks about our service”

“That was…we weren’t really valued…because we weren’t clinical”

“But it’s the fact that you weren’t clinical that made that [project] work.”

There is clearly a willingness to work in partnership but as equal partners within HSCNL,

with appreciation of what each partner organisation has to offer the others in order to

maximise the contribution that each can make to achieving shared goals.

“In the voluntary sector we see networking as a big part of our job, we don’t work in isolation we work together and that’s how we can make the strides that we make, is by tapping into other people’s expertise…but the statutory services work very differently, it’s very much like ‘we don’t need you’ although in North Lanarkshire it’s much, much better than it is in other places in Glasgow, here you’ve got a good chance of getting somebody from health round the table to sit and speak to you or join in a conversation…so there is a willingness to work [together] and I really feel like the voluntary sector is valued in North Lanarkshire by NHS Lanarkshire especially different departments but whether that feeds down to GP services I’m unsure”

“To be fair GP practices are changing, they are piloting a lot of different posts, so the referral to CAMHS, referral to mental health services, they know that it’s really long, it’s terrible how long it is, but they’re having now a psychiatric nurse in the practice so they will assess the situation so the family or the person can get support sooner, or if they think it’s appropriate they’ll refer on or refer onto community services; we need to acknowledge that there is a lot of good work being done and I think it’s just trying to collaborate and trying to work together as equal partners”

“Because when it does work, you’ve got examples coming out your ears, when it works it’s amazing…and it is all about these preventative measures and getting people out the house and reducing isolation…we’ve all got the same goals but we just need to get better at statutory talking to us”

Supporting more social prescribing

Expanding social prescribing activity in the statutory sector can reasonably be expected to

result in more referrals to community and voluntary sector service providers. Some increase

in referrals already being experienced in North Lanarkshire is attributed to increasing

dependence on the sector given financial constraints in statutory sector budgets. This

exposes potential negative implications for community-based providers, and the service as a

whole, if more referrals are generated by expanding social prescribing activity in the

statutory sector unless steps are taken to prevent them from happening.

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“…and what we’re noticing as well is not even just the amount of referrals that has really ramped up but [they are] often inappropriate, so it’s almost as if ‘well it’ll get it off my desk so I’ll fire it over to you’: there runs the danger, and I suppose that’s where I would be wary if we go down this, social prescribing, is that it’s just a case of ‘well, we need to get it off our desk so who could we punt in onto?’

“Then you’re messing that person about by saying this isn’t the service for you…”

The importance of embedding ‘first point of contact’ practice principles in social prescribing

initiatives is plain to community and voluntary sector providers and, from their own

experience of statutory provider attitudes, they appreciate how challenging that can be.

“…and as you say, that’s then bringing in other organisations that are unnecessary; certainly everybody around the table are working with vulnerable families and so it’s about regardless of where these families present themselves, it’s about the individuals making a bit of judgement…it’s looking at everything more holistic and not just looking at the wee bit of work that you do, where you expertise is, it’s about looking at everything so that regardless of where that person fits in they’re still getting the social prescribing”

“A while back…when there was a big push on GIRFEC I did quite a lot of training for GPs and pharmacies, because the idea was that it wasn’t just your teachers, janitors, lollipop men it was everybody’s issue…the people who were there didn’t really want to be there…I did feel there was this clear barrier of ‘that’s not our job’; but when I walked into that room I had the assumption that they’d all be on board and it wasn’t like that, it was very much ‘this is something else I have to do’ ”

Grave concerns were expressed about lack of investment to build and sustain the

community provider capacity required for staff and volunteers to feel able to support social

prescribing; even within Community Solutions where financial insecurity threatens capacity-

building provided through Locality Consortia as well as provision of community-based

services and activities.

“I know through a number of groups that we fund [through the Locality Activity Fund], they’re saying ‘we’ve had the referral in from the Community Mental Health Team, we’ve had the referral in from the GP’, we’ve had an example where they’re saying ‘we’ve had 12 referrals from the GP in the past two months’; you’re saying that’s great but then you’re struggling for finance so where are you going to get the finance?”

“They can’t just refer on people to the voluntary sector because the money’s not there: [Community Solutions] for example, we don’t know what’s going to happen after June, we’ve got the first quarter [funding] for the next year to fund groups but I’m thinking if I give out funding to that group they still rely on [the Locality Consortium] to give a bit of support but what’s going to happen if we’re not there to support those groups who depend on that input, what’s going to happen when that money’s gone?”

“…we’re already struggling, not even just the organisations that are paid to deliver a service, even the groups that Community Solutions fund, you’re relying a lot of the time on the good will of volunteers”

“…an example, Elim Church in Motherwell, fantastic group, we’ve funded them a few times [through the Locality Activity Fund]…the Community Mental Health Team are referring people in there, the volunteers are getting free training through VANL or other organisations like Equals Advocacy but it’s going to get to a point where it’ll still be the same number of volunteers there but more people will be coming through the door and more complex people [so] there’ll be more training needed. It’s that thing about ‘we’ll just refer onto them’ and not looking at the impact that that’s going to have…Elim…volunteers are doing fulltime hours”

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Models and menus for social prescribing

As with the term ‘social prescribing’, community and voluntary sector providers see the idea

of developing a model for social prescribing as coming from and having advantages for the

statutory sector such as securing buy-in, facilitating implementation and it “being

measurable”.

“I feel that this model’s more for the clinical side, I really do”

“…and really, should we have a model or should we be thinking about [the person]…we need this/that model, no, somebody needs help, what can you do there and then on the spot with what you’ve got, and if I’ve not got the answer who do I contact?”

“…and I know exactly what you were saying there about the model thing, and mostly agree with that, but I think sometimes if there’s a model it might be easier to get more statutory services to buy into it; as the voluntary sector we’re all quite used to working like this, we don’t need to have a prescriptive model but when you go to different disciplines like doctors, GPs, it might be easier to implement…”

The importance of funding for sustainability was underlined:

“…and, equally, funding, if they’re wanting to put models in, I know from running different projects, if I’ve only got a year’s funding a lot of people don’t refer in because they just think it’s going to go; so we need to be working much more longer term to set these services up…funding is important if they’re creating these models”

The concept of offering a menu or list of options for people through social prescribing does

not fit with community and voluntary sector providers’ understanding of social prescribing as

a person-centred, assets-based approach that gives people choice to decide which services

or activities can improve their personal situation and enable them to take control over their

own health and lives; or their experiential knowledge of the range and complexity of needs

they see within their local communities and the individuals and families they support, and the

wide range of supports they know are locally available. Over reliance on a menu that is not

comprehensive, therefore, risks undermining inclusivity as well as underutilisation of local

assets.

“Should there be a menu…how’s the menu going to look…it’s going to be huge”

“…it’s no different from having a bunch of leaflets out”

“…and also excludes so many amazing organisations”

Concern was also raised that some statutory providers, lacking the depth of local knowledge

that community-based providers have about what local services offer, might simply use a

given menu prescriptively.

“If they’ve got a menu in front of them are they going to say ‘Oh, there’s physical exercise, ok [this organisation] is one that gets used all the time’ because they don’t know what’s involved at each service, so that’s not going to work as there’s no in-depth knowledge of…no linking up the activity and the person, there would need to be more…it’s not just ‘Physical exercise, there you go, it’s the first one there [on the menu]’ ”

The desire to designate approved providers is understood but a downside of a menu for

social prescribing is if some community-based organisations are seen to be approved

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providers and others, possibly leading to less investment in organisations not on the menu;

and raises the notion of mistrust in the sector as reliable delivery partner.

“…the liability thing is quite important, that’s perhaps an element of distrust between the clinical side and the third sector”

Focus group participants sounded a note of caution regarding reliance on North Lanarkshire’s Locality Profiles as the indicator of local need to inform local provision of social prescribing, because that could “promote your postcode lottery” with the risk of increasing inequalities, fail to address the range of problems that people seek help for, and put some providers of valued local services at a funding disadvantage.

“I know they’re there and they’re probably useful for something but whoever presents in front of me you deal with what’s happening with them…”

“Often they can be a precursor for funding, it shouldn’t be like that”

GP Link Workers Programme

Drawing on the richness of experience within the community and voluntary sector in

Lanarkshire, views shared on the introduction of GP link workers stressed the importance of

people skills and local knowledge for successful social prescribing link working.

“…in order for the GP, for social prescribing to start there and for it to work well, they need to have an understanding of absolutely everything that’s going on out there…I don’t think that the knowledge is there so I think in order for social prescribing to work these new link workers that are coming into post that’s the trick”

“…if we don’t know what’s out there we can’t do our job and that’s going to be the absolute key bit for these link workers, not just to know there’s an organisation called [name]… they need to know who we are and what we do”

“…if these GP link workers are going to work they need to have the knowledge and the understanding of who does what out in the community so that they can confidently have that conversation with the person”

“…see if you’re a people person, chatty, make somebody feel at ease, you’ve more chance of somebody opening up and working with you to find alternative things that they can do whereas if you’ve got somebody who’s quite clinical you can see people being like ‘I’m just no gonnae tell them my problem’ ”

“I know some nurses that are classed as clinical and they’re amazing…it’s not so much pigeon holing people as clinical or not it’s having the right skills and background to liaise…”

And emphasised link worker capability to tackle barriers related to the attitudes of practice

staff to the value of social prescribing.

“They’re going to have to influence quite a bit of change; they have to buy-in to it, know what they’re supposed to be doing but also have that willingness to push change not just to sit back and say ‘OK, I know it’s not your job but I’ll no say anything’ ”

Questions arose about integrating the new GP link worker role with existing link worker

initiatives; and attention was drawn again to the risks of not adequately funding all parts of

the system, including the risk of undermining the principle of strengthening community

capacity.

“There’s these link workers coming through the NHS Health and Social Care Partnership but we already have link workers through SAMH who’ve been up and running 3 or 4 years,

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they’re still going to be there but they’re under the third sector and you’ve got these guys coming in from the health, how’s that going to work?”

“…the health link workers are going to have better pay and conditions and holidays, sick pay and all the rest of it. How are they going to balance that out…or is it that people from the third sector are going to go over to health?”

“Look at the amount of money that the GP link workers is going to cost…you can’t just stop there, what investment’s going to be put in place so that we are able to keep delivering these services?”

Community and voluntary sector organisations express a strong willingness to share their

local knowledge and experience with GP link workers newly in post, work together towards

shared goals and share learning.

“We all share…in Lanarkshire everybody wants to share, it’s quite good that way”

“…it would be good to find out how they’re getting on and what barriers have they come across”

Social prescribing for children, young people and families

As noted in sections 3.1.2, most of the attention on social prescribing to date has

concentrated on adults. An informal discussion with members of North Lanarkshire’s

community and voluntary sector thematic network for children, young people and families

revealed a wealth of local expertise so focus group participants were asked specifically

about their views on approaches to social prescribing for this population.

Referral routes into social prescribing for children, young people and families should

encompass health and care services and other organisations they are most likely to come

into contact with including primary as well as high schools, which were seen as especially

important particularly in relation to early intervention. Health visitors, family planning clinics,

sexual health clinics and social work were among the health and care services mentioned,

and many community and voluntary sector organisations are proactive in building

connections with local statutory services to create local referral pathways.

“For young people I’d be looking a family nurses and high schools and things, to link them in so they’re aware of services because young people don’t tend to go to their GP on their own, it’s usually dragged along by their mum, but if we actually look at [linking] to nurses that are in high schools that would be really good”

“We’ve great links with the health visiting team because [we work with parents of] under 5’s, so we have that link direct and that’s where the majority of our referrals come in from; [we] went out and spoke to health visitors so we took responsibility for raising awareness”

Mechanisms for community and voluntary services to refer people back to statutory services are generally inadequate.

“It’s [relying on] faith in the services picking that up, to get an appointment…”

Discussion touched on particular social difficulties affecting children, young people and families in North Lanarkshire and where gaps in support services are most evident, and foremost among these was mental health.

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“Financial’s always a biggie, housing, for me; and [for] young people ours is resilience…being able get back up again when you’ve been knocked down…I work with very vulnerable young people and some of them have to have resilience to be standing in front of me but how many knocks can you take; or you’ll see others with less resilience they’re self-harming, they’re maybe substance misusing, self-medicating with other things…resilience for me’s a biggie”

“Lack of provision for children with ASNs [additional support needs]…our phone calls always ramp up just before school holidays…there’s a huge lack of provision; even befriending… befriending is massive”

“Youth work resources have just been cut and cut and cut, you speak to any youth worker in North Lanarkshire, it’s desperate, and ASN provision among youth workers is even worse, there’s nowhere for kids to go; social isolation and mental health are huge issues”

“I think sometimes [social prescribing] models need to be relooked at… there’s so much physical activity services, a huge amount, but there is a gap or it’s not balanced with nutrition and food, we need to make the ‘food and mood’ link to mental health”

For many, being unable to afford childcare is an important barrier to participation in community-based activities and could, therefore, be a barrier to benefiting from social prescribing. It was thought that more families would benefit if social prescribing could offer free or low-cost opportunities for families to participate in activities together.

Final words“Social prescribing, sometimes it would be nice if it was something to break the monotony, a wee bit of fun, something to lift somebody’s spirits…especially if you can do it as a family”

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4.4.3 Public and service user perspectives

Direct engagement with service user representatives and members of the public in North

Lanarkshire was limited to one session during the Partnership for Change Quarterly

Assimilation Meeting in January 2020. The session entailed a brief presentation introducing

the concept of social prescribing followed by a short interactive exercise in which attendees

engaged in small group discussions of two scenarios describing local people experiencing

social, emotional or practical difficulties affecting their health and wellbeing. Participants

easily recognised the potential for non-medical interventions to help improve health and

wellbeing for people and readily identified a range of relevant community-based supports as

well as potential barriers that could prevent individuals from accessing services and activities

in their local community, frequently citing as barriers lack of awareness of what is available

locally, affordability, lack of transport or money for bus fares, lack of confidence, and mobility

problems.

The statutory stakeholders interviewed in this study expressed optimistic views about public

understanding of the value of social interventions in North Lanarkshire, and the likelihood of

this being an enabler for wider acceptance of social prescribing; and public engagement

should not simply be thought about in terms of public education.

“I think the general public are open to [alternatives to medicine and medical prescribing] more than they were before” (Interviewee 5)

“I’ve got quite a strong belief that it’s a societal issue…so we need to move away from trying to fix people who are ill towards trying to help everybody understand more and do more to help their own mental health and physical health as well; physical health is more embedded already, people understand that you need to keep your weight down and keep fit and do these sorts of things but they don’t think actually you need to do things that support your mental health” (Interviewee 3)

“It’s a difficult one isn’t it because ‘how do we educate the public?’ frequently comes up in debate – do we need to educate the public? I think if we’re doing what we should be doing well then it doesn’t need education it just needs us to behave in a way that is helpful to people and change mindsets through building different confidence” (Interviewee 2)

The Partnership for Change Development Lead emphasised the importance of meaningful

public engagement and the necessity to involve people in any service-level change agenda

from the outset, reflecting on the lack of public engagement in the development of the

Primary Care Improvement Plan and subsequent effort involved in changing negative public

perspectives retrospectively.

The Partnership for Change Development Lead also stressed the need for clarity of

language around social prescribing and a common understanding of the terms being used.

“…all these words mean different things and we need to be clear what we’re talking about” (Partnership for Change Development Lead)

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SECTION 5. Challenges and Opportunities

5.1 Strategic fit

From the overview of strategic plans described in section 2.2, strategic intentions in North

Lanarkshire appear to be united in the direction of early intervention, prevention and a more

assets-based, holistic approach to addressing health and care support needs that puts

people and communities at the centre of how services are organised and delivered; with the

recognition that addressing the social determinants of health is critical to improving health

and wellbeing and tackling health inequalities. All of these things resonate strongly with the

core principles of social prescribing. There is also a shared commitment expressed to

collaborative, cross-sectoral partnership working.

The Community Solutions Programme strategy and commissioning plan has a different

timeframe to HSCNL’s current commissioning plan, which makes maintaining strategic

alignment more challenging. The probable need to take time to ensure this strategic

alignment is maintained was noted in the elucidation of statutory stakeholder perspectives

on social prescribing in section 4.4.1. One of the accepted effective principles for social

prescribing is that partners should cooperate at strategic as well as operational levels so

ensuring strategic cross-sectoral alignment ought to be a collective responsibility.

Development of a framework for social prescribing for North Lanarkshire presents an

opportunity to review how each partner can best contribute to achieving shared strategic

goals.

5.2 Creating a coordinated and strategic approachSeveral social prescribing initiatives are already operating in North Lanarkshire including

various link worker roles that are seemingly not aligned or co-ordinated. An opportunity for

development may be to consider how to increase alignment and co-ordination in how social

prescribing is currently organised and delivered in North Lanarkshire. A more aligned and

strategic approach would potentially help to avoid duplication, reduce inefficiencies, mitigate

against thinking about services in silos and ensure that social prescribing initiatives do not

develop in a fragmented way.

5.3 Funding sustainability

The Community Solutions Programme has been established through sustained partnership

working, its governance arrangements are highly regarded, and it is undoubtedly a robust

model to support the delivery of social prescribing across North Lanarkshire. This study

highlights that current funding insecurity threatens to weaken the programme’s ability to build

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and sustain the community provider capacity required for staff and volunteers to feel able to

support social prescribing and securing longer term investment remains a challenge.

A range of high-quality community-based services has to be available locally for social

prescribing initiatives to be sustainable whatever the delivery model and many community-

based organisations cannot be assumed to have the existing capacity and resources to

support more people referred through social prescribing.

Balancing funding for link workers and community-based activities, for example, requires

planning by commissioners, service designers, and the voluntary and community sectors.

Funding models in which funding follows the patient when referrals are made from primary

care may be worth exploring. As might opportunities to diversify funding streams for social

prescribing beyond the health and social care system.

5.4 What social prescribing means

Social prescribing means different things to different people in North Lanarkshire and the

term itself is not familiar to many. Experiential learning from others indicates that social

prescribing works best where all those involved have a common understanding of what it is,

what it can offer and who it can benefit. However social prescribing is to be framed in North

Lanarkshire, the concept and the terminology need to be clear and easily understood by all

stakeholders. Likely stakeholders include commissioners, referrers, delivery partners and

communities.

Health Improvement teams whose expertise is highly regarded by healthcare colleagues in

North Lanarkshire could play an important role as formal and informal educators. The

informal knowledge transfer that is already happening in the course of everyday

collaborative working should be actively encouraged.

Ways might also be found to enable transfer of the wealth of practice-based knowledge of

the concept and practice of social prescribing that exists within the community and voluntary

sector in North Lanarkshire; possibly joint initiatives with Health Improvement teams who are

also well-connected with local communities.

5.5 Raising awareness

Raising awareness of social prescribing may be required and how social prescribing is to be

framed locally will determine who that would be useful for.

There is a recognised need to raise awareness of social prescribing in the statutory sector in

North Lanarkshire. One of the considerations that informants in this study and other

commentators point out is that promoting the concept and benefits of social prescribing to

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health and care professionals only makes sense if the community-based supports are there

to refer to; and to be assured of that requires sustainable funding arrangements to already

be in place.

Lack of knowledge about what community-based supports are available is commonly

identified as a barrier to social prescribing. Raising awareness of what is available may not

however be sufficient in itself for some healthcare practitioners to respond to problems

caused by social difficulties. Active facilitation may be required to help them see the

connection to the social problems they identify and recognise the potential benefits of social

prescribing for themselves and service users. In order encourage the practice of social

prescribing awareness raising for health and other professionals should encompass the

connection to the social model of health, not just what options are available, emphasing how

the medical and social models together furnish holistic care.

5.6 Skills and competencies

There may be a need to educate some healthcare professionals and other referrers on the

different aspects of social prescribing and challenge negative attitudes to the social model of

health and individual responsibility. The planned piloting of the 3-conversations approach to

improve ‘first point of contact’ practice among health professionals could help greatly in

changing these attitudes. A similar approach could be used to equip other referrers with the

skills, behaviours and attitudes to identify people who could benefit from social prescribing.

Embedding the ‘no wrong door’ principle more widely throughout North Lanarkshire

approach to social prescribing is another possible opportunity for development.

Not having the confidence and skills to engage service users in conversations about social

prescribing can be a challenge for staff. It has been said that social prescribing initiatives can

provide a platform through which practitioners can confidently ask people ‘how can I help

you’ and ‘what matters to you’, knowing they have a process in place to help them guide

people towards a range of suitable local supports. Efforts to raise awareness of social

prescribing and give practitioners the confidence to do it are likely to be complementary.

There is plethora of advice on core competencies for link workers based in primary care

settings including ScotPHN’s guidance for HSCPs on induction and core training for the GP

Community Link Workers being engaged under the new GMS contract. As described in

section 4.3.4 there are several other link worker roles operating in North Lanarkshire

managed largely within the community and voluntary sector and variously situated in

healthcare and community and voluntary sector organisations. Developing a framework for

social prescribing for North Lanarkshire may be an opportunity to consider how to facilitate

shared learning among link workers performing similar roles and whether training and

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development opportunities for link workers and the wider provider base could be more

inclusive.

In regard to developing social prescribing for children, young people and families, but with

wider relevance to social prescribing overall in the context of communities being important

delivery partners, it has been suggested that training in social prescribing skills would be

useful for a number of people including health visitors, school nurses, teachers and

education staff, family support workers, local club leaders, faith leaders and any voluntary

sector or statutory agency working with people at risk.86

5.7 Target groups

While social prescribing has the potential to benefit a whole range of people most initiatives

tend to target specific groups such as groups experiencing particular disadvantage or health

conditions, and some proactively seek-out prospective service users such as ‘hard to reach’

groups or ‘high resource use’ individuals. Some sources caution that aiming to

accommodate the general population can be more challenging and could cause confusion

about who is eligible to be referred and discourage buy-in from healthcare professionals.

In deciding how social prescribing is to be framed in North Lanarkshire it may be worthwhile

revisiting the conceptual stepped model previously envisaged for the delivery of social

prescribing in Lanarkshire (section 3.1.4 Figure 3) that incorporated different levels of

support for different groups dependent on need.

As highlighted in this report, social prescribing for children and young people and explicitly

encompassing families has been largely neglected in the design and implementation of

social prescribing initiatives. Given the social, emotional and practical challenges facing

many young people and families in North Lanarkshire who could benefit from social

prescribing, and the range of expertise within the community and voluntary sector,

development of a social prescribing framework for North Lanarkshire offers an ideal

opportunity to ensure they are included. It is not enough to group this population with adults

and the elderly.

Here also is an opportunity to consider equality proofing North Lanarkshire’s approach to

social prescribing to ensure it does not risk widening health inequalities. Local areas can use

existing knowledge to identify target groups, which in North Lanarkshire might include the

locality profiles, existing needs assessments or information gathered through planning

processes. Community and voluntary sector providers have expressed some misgivings

86 Social prescribing. Healthy London Partnership 2017 https://www.healthylondon.org/wp-content/uploads/2017/10/Social-prescribing-Steps-towards-implementing-self-care-January-2017.pdf

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about placing too much reliance on the locality profiles as indicators of local needs and the

risk of thereby promoting a ‘postcode lottery’ for social prescribing and creating a barrier to

inclusion for some community-based organisations. There may, therefore, be value in

exploring ways of incorporating the experiential knowledge of local needs within the

community and voluntary sector in the interpretation of locality data; and in the context of

prevention and early intervention gaining their insight on how some of these problems arise.

5.8 Enabling referral

Referral pathways for social prescribing should be designed to fit the target population. This

includes consideration of referral routes into the service, who can refer and receive referrals,

who is eligible for referral, and referral criteria that should be co-produced with all partners to

ensure clarity and transparency. Referral guidelines may need to be developed.

Developing a framework for social prescribing may be an opportune time to consider

embedding the approach within existing referral pathways.

Incorporating referral from a wide range of local agencies is recommended as being

conducive to coordinating support around the person and encouraging partnership working.

There are potential sources of referral for children and young people especially that might

need to be considered such as school nurses, education staff and family support workers.

Expanding initial access points for social prescribing could also be a way to reach people

who have little or no engagement with statutory services.

Whatever the approach, to encourage uptake the processes for referral to social prescribing

have to be clear and easy to use for all those involved.

Lack of knowledge about what community-based supports are available is a commonly cited

barrier to referral for social prescribing. Implementing the new GP Link Worker role is a clear

opportunity to enhance referral practice in the primary care setting. Knowledge of the

opportunities that are available locally is however vital to successful link working and every

opportunity should be taken to learn from the extensive local knowledge that community and

voluntary sector providers already have.

Electronic directories of local groups and services available to help people with social

problems can help improve referral pathways if they are user-friendly and kept up to date.

North Lanarkshire has Locator, which is maintained by VANL and like similar resources

elsewhere in Scotland (including the national information system ALISS) keeping it up to

date and optimising its utility in relation to content and accessibility is not without its

challenges. As one statutory sector interviewee suggested, developing a framework for

social prescribing presents an opportunity to consider how the utility of Locator and other

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tools including MLE and Well Connected could be optimised collectively to better support

social prescribing in North Lanarkshire. Since the Locality Consortium has the mapping of

local service provision that is to be made available through Locator within its Terms of

Reference the Consortium may be best placed to consider how that particular process might

be improved.

Navigating the boundary between the levels of need that social prescribing can support and

needs that require clinical or other professional intervention can be a challenge and

community-based organisations often encounter barriers to making referrals in to statutory

services. Mechanisms may need to be put in place to enable this to happen.

5.9 Workforce

Staff training, support and engagement can all help to make social prescribing feel part of

everyday health and social care services and not an additional area of work. It can also

ensure that staff have a sense of ownership and a clear understanding of how they can

contribute to social prescribing.87

Specific resources may need to be developed and as already noted should be set in the

context of inequalities and the social model of health. Opportunities for cross-sectoral

workforce development should be considered, taking account of the whole system including

the statutory and community and voluntary sector paid and volunteer workforce.

HSCNL’s Strategic Plan recognises that the health and social care workforce within public,

third sector and independent organisations and those who volunteer in communities are

central to the delivery of better outcomes for people; and as new services are developed

staff will require different skills and will need to work in different ways, in particular the skills

and capacity for early intervention and preventative approaches. An integrated workforce

strategy is being developed to cover NHS and Local Authority staff who work in integrated

service provision. The high proportion of the workforce for social prescribing will be in the

community and voluntary sector, so in considering a framework for social prescribing there is

an important opportunity for HSCNL and VANL as the Third Sector Interface to work

together to agree a joined-up approach to workforce development for all their delivery

partners.

5.10 Public engagementAs already noted, the Partnership for Change Development Lead has emphasised the

importance of meaningful public engagement to involve people in any service-level change

87 Dumfries & Galloway Social Prescribing Regional Framework https://www.parliament.scot/S5_HealthandSportCommittee/General%20Documents/20191111_Claire_Thirwall_-_Dumfries_and_Galloway.pdf

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agenda from the outset, and that this requires forward planning. In developing a framework

for social prescribing, North Lanarkshire has the opportunity to work with Partnership for

Change to consider any requirements around public engagement and how it should be done

in line with the principles set out in HSCNL’s Participation and Engagement Strategy.

It may also be an opportunity to have conversations to learn from what others have found to

work well. Learning from Dumfries and Galloway, for example, an area which has had

particular success around public engagement in developing its framework for a social

prescribing (which like Community Solutions has its origins in the Change Fund era) points

to the value of working through existing locality structures to involve communities in

developing the local ‘brand’, giving communities a sense of ownership and building the

communication strategy around that (Claire Thirwall, Health and Wellbeing Specialist,

Dumfries and Galloway Council, Personal Communication, 20 Feb 2020)88. Further

engagement brought community groups together to help develop referral pathways; and

higher-level engagement work with local area committees and councillors to ensure they

were always included and aware of what was happening in their local communities. The

importance of giving feedback to the community was considered really important, not just

taking people’s information but telling them how it has been used. This kind of considered

approach takes time.

“As a process it was really useful for us as well; again it was about that engagement and embedding, we were continuously drip-feeding the concept of social prescribing into the community” (Claire Thirwall, Health and Wellbeing Specialist, Dumfries and Galloway Council)

5.11 Outcomes, monitoring and evaluation

NHS North Lanarkshire is fortunate in having an Evaluation Manager as a source of

expertise to support monitoring and evaluation for social prescribing, which can be

challenging.

Commissioners need to be clear about the intended outcomes for any service they

commission, and local stakeholders will have different views on the outcomes they expect

social prescribing to deliver locally. So early discussion with all stakeholder groups and

outcomes prioritisation should be the starting point for planning how progress will be

monitored and what outcomes information will be captured. The existing evidence base

should inform decisions about which outcomes expectations are realistic and likely to be

measurable. This approach provides an opportunity to focus monitoring and evaluation

efforts on intended by the primary intended users to ensure that the information collected will

88 Unfortunately this work has not been written-up

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be useful and used. It can also clarify where monitoring will suffice and evaluation is

necessary.

Attention should be paid to the process of implementing social prescribing as well as

outcomes; and to balancing measures to ensure that improvements in one part of the

system are not causing problems in other parts of the system, which is especially relevant to

cross-sectoral initiatives like social prescribing (for example improving referral rates from

primary care overwhelming the capacity of community-based organisations to provide

support).

5.12 Digital connectivity

Linking statutory service user records to information on services people have accessed in

the community in order to track referrals and enable feedback to the referrer is a major

challenge for social prescribing initiatives. Several companies have developed software for

this purpose, which could be explored, and others can develop a bespoke system89, but cost

could be a barrier especially for implementation on a scale larger that an individual project.

Examples include the Elemental Core digital platform being used in the SPRING Social

Prescribing Project in North Lanarkshire (section 4.3.3) to enable the flow of information

between GP practices and link workers situated in a community and voluntary sector

organisation and the collection of information for monitoring and evaluation. This system

being in use locally is an opportunity to glean any transferrable learning that could help

inform how existing local IT systems might at least be improved. Statutory sector

interviewees in this study confirm that getting feedback on the progress of referrals was a

significant motivational factor for staff buy-in to social prescribing so how feedback loops can

otherwise be established between different sectors will need to be discussed.

5.13 Work best undertaken on a pan-Lanarkshire level

Recent work undertaken in South Lanarkshire to develop a framework for social prescribing

offers a timely opportunity to consider any areas of similarity that could be developed jointly,

such as developing and delivering training around social prescribing skills and

competencies, or investment in improving IT systems. And to ensure that the separate area

frameworks will not create barriers or inequalities of access for people living in either area to

community and voluntary sector services that operate across North and South Lanarkshire

(or operational difficulties for those organisations).

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Section 6. Recommendations The greatest concern identified by the scoping study is funding insecurity within the

community and voluntary sector. Community and voluntary sector organisations have a

vital role to play in any social prescribing initiative as the main providers of community-

based services and supports and sustainable funding models have to be in place for

social prescribing to work effectively.

The Community Solutions programme model and governance structures embody core

attributes for an effective delivery model for social prescribing across North Lanarkshire

that is co-produced, locally owned and highly regarded. Maximising its potential should

be a priority.

Consider what social prescribing means for North Lanarkshire and how it will be defined

in order that all those involved have a good understanding of what it is, what it can offer

and who it can benefit.

Learning from the various social prescribing initiatives already operating in North

Lanarkshire about what works, barriers and enablers, should inform future service

provision; and consideration given to increasing alignment and co-ordination in how

social prescribing is currently organised and delivered, which would help to position new

initiatives to best advantage.

Consider how the utility of Locator and other tools including MLE and Well Connected

could be optimised collectively to better support social prescribing in North Lanarkshire.

The planning and delivery of any social prescribing service should take account of the

support needs of the population served. Available data on deprivation and health

inequalities may help to identify target groups particularly in relation to vulnerable

groups, if that approach is being considered, and the range of local supports that would

need to be available; but it is recommended that these data are considered alongside the

practice-based knowledge of community-based organisations in order to gain a fuller

understanding of local needs and gaps in provision.

Consideration should be given to how social prescribing can best be delivered to be

accessible to and serve the needs of children young people and families; and where

awareness raising and training in social prescribing skills may be useful for additional

delivery partners.

Restricting social prescribing to a limited range of support options is not recommend if it

is to be wholly person-centred and give people choice to decide which services or

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activities can improve their personal situation; and risks undermining inclusivity as well

as underutilisation of local assets.

Work with Partnership for Change to consider requirements and planning around

service-user and public engagement; and make use of existing structures to engage with

different groups.

A need exists to raise awareness of the concept of social prescribing more widely within

the statutory sector as does an element of need to change attitudes to its value as well

as whose responsibility it is to take account of the wider determinants of health in the

care they provide: successfully embedding a ‘3 conversations’ approach is likely to be an

important enabler of effective social prescribing practice.

Opportunities for cross-sectoral workforce development should be considered, taking

account of the whole system including the statutory and community and voluntary sector

paid and volunteer workforce. HSCNL and VANL should work together to agree a joined-

up approach to workforce development for all their delivery partners.

Evidencing the benefits of social prescribing is challenging: social prescribing is not a

discrete intervention so it is important to be clear from the outset about what it is that is

being evaluated; outcomes expectations have to be realistic and measurable, and

agreement reached on the level of evidence that is going to be acceptable in relation to

what the information is to be used for.

The perspectives of other key stakeholders not represented in this scoping study may

need to be ascertained.

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Appendices

Appendix A. Informants and Acknowledgements

Statutory sector

Interviewees

Alastair Cook, Medical Director, HSCNL

Morag Dendy, Head of Planning, Performance and Quality Assurance, HSCNL

Philip McMenemy, Associate Medical Director, NHS Lanarkshire

Robert Peat, Head of Profession – Podiatry, HSCNL

Sharon Simpson, Organisational Development Lead, NHS Lanarkshire

Raymond Taylor, Health & Social Work Manager, HSCNL

Other informants

Susan McMorrin, Senior Health Promotion Officer (South Lanarkshire), NHS Lanarkshire

Helen Alexander, Evaluation Manager, NHS Lanarkshire

Community and Voluntary Sector

Focus group participants

Carolanne Christie, Information and Engagement Worker, North Lanarkshire Cares Together

Jacqui Flanagan, Project Manager, LANDED Peer Education Service

Frances McKay, Information and Engagement Worker, North Lanarkshire Cares Together

Claire Mooney, Nutritionist, Lanarkshire Community Food & health Partnership

Lynne Morris, Family Support Coordinator, Home Start

Mark Soanes, Operations and Development Manager, Hope for Autism

Other informants

Sarah Burgess, Development Officer (Green Health Volunteering), Voluntary Action South

Lanarkshire

Ayeshah Khan, Director, The Health and Wellness Hub, Motherwell

Fiona McCabe, Project Co-ordinator, Community Action Newarthill

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Thomas Moan, Development Worker, Partnership for Change

Anne Marie Toner, Specialist Case Worker, Routes to Work

David Tough, Community Link Worker, SAMH

Ann-Marie Treacy and team, Bellshill & Mossend YMCA

June Vallance, Executive Manager; Katherine and Becky, Social Prescribers, SPRING

Social Prescribing Project, Getting Better Together Ltd

Lorraine Van Beuge, Project Manager; Bryony and Laura, Community Connectors, North

Lanarkshire Disability Forum

Brenda Vincent, Equals Advocacy

Attendees who shared their views at the following events:

Locality Area Events: Airdrie; Cumbernauld and North; Bellshill; Motherwell; Wishaw and

Shotts; Coatbridge, October-December 2019

North Lanarkshire’s Community and Voluntary Sector Children, Young People and Families

Network meeting November 2019

Partnership for Change Quarterly Assimilation Meeting January 2020

External informants

John Cassidy, Chair, Scottish Communities for Health and Wellbeing

Jane Ford and Ruth Dryden, Public Health Intelligence Advisers (Evaluation), NHS Health

Scotland

Claire Thirwall, Health and Wellbeing Specialist, Dumfries and Galloway Council

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Appendix B. Interview and Focus Group guides

Interview Guide – Social Prescribing – Statutory SectorTo what extent do you think the concept of social prescribing is well understood by statutory sector health and care providers in North Lanarkshire?

- Are people talking about the same thing when they talk about social prescribing- What should we be talking about- Is there more that could be done to raise awareness of what it is, what it can offer and

who it can benefit

Alignment with strategic priorities

- Does consideration of social prescribing approaches come up in strategic or planning level discussions around service delivery; in what context

- Attitudes towards social prescribing approaches in helping to deliver on strategic priorities; views on supporting evidence

- Expectations of what it can achieve

In relation to where we are now and where we’d like to be in North Lanarkshire in terms of embedding the practice of social prescribing in how services are delivered, what’s already being done well and what more needs to be done?

- What should we keep doing and build on- To what extent can this be done within existing structures and resources- Governance to ensure coherence and efficiency- What would success look like - what kind of evidence would be sufficient- What is needed to ensure sustainability

In terms of taking the SP agenda forward, is there one major thing we need to do that would make the biggest difference at this time?

Is there anything else you would like to add?

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Community and voluntary sector focus group guide

Explore the meaning of social prescribing

- Opportunities and barriers

Working in partnership with statutory health and social care services

- Relationships between statutory and community services; organisation and individual level

What needs to be considered in order for social prescribing to work for children and young people

- Community resources available for young people- Partnership working with education and other services- barriers

Understanding local needs and gaps in services

- Social prescribing as a means of addressing health inequalities: usefulness of locality profiles; perception of areas of greatest need/disadvantage; demand and gaps in services

- CVS perception of areas of unmet need in the provision of local services If there was a menu of community-based supports what should be on it?

Capacity and ability to deliver social prescribing/respond to increased demand

- How organisations currently respond to increases in demand; accommodating more people referred through social prescribing

- Could increases referrals through social prescribing compromise delivery for other service users, people accessing your service through other routes, direct

- Appropriateness of referrals; people with complex support needs; mechanisms to refer to statutory services

What is already being done well and what more needs to be done

- What should we keep doing and build on- To what extent can this be done within existing structures and resources- Governance to ensure coherence and efficiency- What is needed to ensure sustainability

Additional support requirements

- Capacity building to deliver social prescribing; skills/training needs- Volunteers

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