Title: Impact of a community social prescribing intervention on people with type 2 diabetes living in an ethnically diverse area of high socio-economic deprivation. Exploiting a natural experiment to evaluate effects on health & health care utilisation with economic assessment and ethnographic observation
Funder: Department of Health and Social Care

Abstract: Since April 2015, a Link Worker social prescribing intervention has been delivered in community venues to people with one or more long term health conditions (LTC), including T2D, aged between 40 and 74 years and living in an ethnically diverse socio-economically deprived urban area. This community based intervention aims to improve health-related measures and behaviours, social involvement and wellbeing, and to narrow health inequalities. Link Workers employed by three not-for-profit community-based organisations deliver the intervention and are tasked to develop sustained, supportive relationships with people referred from primary care. Link Workers support their clients to identify goals and encourage goal achievement by linking them into community, voluntary and NHS sector services. The proposed study will evaluate the impact of the community based intervention on people with T2D, who comprise 41 per cent of the population referred to the intervention. At least 25 percent of the study population have one or more physical co-morbidity, over 50 percent have weight management problems and 25 percent have mental health co-morbidity. We will conduct a mixed methods study with four work packages (WP). WP1 will evaluate the effect of the intervention on measures of health and healthcare utilisation in adults with T2D (N=1600) in relation to comparable non-participants at one, two and three year follow up periods using regression methods. Routinely collected primary care and Secondary Uses Service (SUS) hospital data will be used to explore change in HbA1c (primary outcome), body mass index (BMI), systolic blood pressure (SBP), total cholesterol, smoking status, and health care utilisation (secondary outcome measures). Link Worker collected EQ-5D-5L data will be used to analyse quality of life of those entering the programme between April 2018 and March 2019. We will seek to mitigate bias and ensure robustness of our results through a statistical analysis plan with three scenarios: (i) the dynamic nature of the study whereby individuals receive the intervention across different time periods; (ii) participants and eligible patients who do not receive treatment within the intervention practices; and, (iii) participants and comparable patients from other areas. Study numbers will allow sub-group analyses by age, gender, multi-morbidity and provider organisation to be undertaken. WP2 will assess the cost-effectiveness of the intervention by comparing intervention costs and outcomes (as outlined in WP1) against eligible individuals who do not take part in the intervention. WP3 will use ethnographic (observational) methods and undertake a multi-site ethnography to describe how participants engage, leave and remain with the intervention; whether and how the intervention impacts on health and wellbeing and on family, friendships and community networks. The findings from WP1-3 will be integrated using mixed methods (WP4). This evaluation will provide new knowledge on the effectiveness/cost-effectiveness, acceptability, potential for and barriers to long-term behaviour change of a community-based social prescribing intervention. Through its focus on people living in ethnically diverse areas of very high socio-economic deprivation, it will provide important evidence about the role of community-based interventions in improving public health and reducing health inequalities.

Lay abstract: The number of people in the UK with type 2 diabetes (T2D) is expected to rise to six million by 2035. Poor diabetes control uses a great deal of NHS resources and can have severe impacts. It is important that people with T2D are given proper help. If no changes are made to the way T2D is treated, the costs to the NHS are estimated to be about £17 billion by 2035. It is very difficult for busy health professionals to provide the full range of support that is necessary. Health programmes that involve individuals and communities more directly in the management of their own health conditions and support them to adopt healthier behaviours can improve health and reduce NHS costs. Social prescribing is a form of support for people with long term conditions like T2D. We plan to find out about the effectiveness of a new community based programme that has been developed over eight years by local health and voluntary sector organisations with input from patients and the public. It involves referral to a trained ‘Link Worker’ who supports and empowers people with T2D to make healthier lifestyle choices, to improve their health, self-care and quality of life. People can access the programme through their GP surgery. On referral, the Link Worker discusses healthier lifestyle options with each person individually and helps them to plan positive health behaviour changes. Link Workers also provide information about other community services such as walking groups, welfare rights or employment advice and support people to attend. The programme is open to people aged 40 to 74 years. The aim of this research is to find out the effect of the programme, how much it costs, and how it affects family members and social networks. A team of university researchers will use a number of different research methods, known as ‘mixed methods’. In study one, information on 1,600 people from GP records will be compared in three ways: (i) with people who entered the programme at the beginning with people who entered it later; (ii) with people from the same practice who are eligible but don’t take up the intervention; and (iii) with people in GP practices who don’t have the intervention. In study two, the costs and effectiveness of the programme will be compared to existing treatment to see whether the intervention is value for money compared to other treatments. In study three, observations and interviews with people using the service will be used to find out how they experience it. This will help us find out what does and does not work and why. Study four will bring all of the information together and examine impacts on health inequalities. A group of service users and Link Workers will advise researchers on involving people with the study, participant information, what the findings mean and producing user-friendly information about the study. The results of the research will help decide whether this type of programme should be funded in the future. A study website and social media will be used to publicise the research to the widest possible audience. We will target key influencers and policy makers, with written and oral presentations to a wide range of audiences including not-for-profit sector and health care organisations. Results will be made available to those using the service, Link Workers and community groups. Results will also be published in academic, practitioner and policy journals, and presentations will be given at national and international conferences.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: METABOLIC AND ENDOCRINE