Title: Understanding the implementation of link workers in primary care: A realist evaluation to inform current and future policy
Funder: Department of Health and Social Care

Abstract: Background_x000D_ Approximately one in five people see their GP with problems that are mainly social (e.g. loneliness), environmental (e.g. housing issues) or economic (e.g. worries about debt) in nature. These ‘non-medical’ difficulties can affect how someone feels physically or psychologically. A GP may not be the best person to help. This is why social prescribing has been introduced into primary care. Social prescribing involves drawing on ‘community assets’ (e.g. local groups, organisations, charities) to assist with ‘non-medical’ difficulties._x000D_ _x000D_ Link workers are now being employed to facilitate the delivery of social prescribing in primary care. GPs can refer a patient they think has ‘non-medical’ difficulties to a link worker (in some locations other health professionals can refer, or patients self-refer). The link worker meets with the patient (often more than once) to find out what is happening in that person’s life and what they want to change/address. They then co-produce an action plan, based on the individual’s health and well-being priorities. The action plan concentrates on linking the patient to relevant ‘community assets’. _x000D_ _x000D_ We have reviewed existing literature on link workers to develop guidance on optimising their implementation in primary care. Our review highlighted gaps in knowledge (e.g. how to sustain patient benefits, how to ensure people ‘buy-in’ to the idea of link workers). We will build on this review by carrying out some primary research to strengthen our initial recommendations. _x000D_ _x000D_ Aims_x000D_ Our research will explore why link workers may produce benefits in some settings for some individuals but not for others. We aim to understand and explain how and why link workers produce specific outcomes in certain contexts. _x000D_ _x000D_ Design/methods_x000D_ We will collect data from 6 primary care sites. We will observe link workers’ interactions with patients and staff; interview link workers, health professionals and patients; examine key documents on the link worker’s role; use data collected routinely by link workers (e.g. on who is referred to their service). We will also follow up a sub-group of patients 9-12 months after they first meet a link worker. This will allow us to examine how they have benefited (or not) from seeing a link worker. We will explore their experiences through a semi-structured interview. Data collection and analysis will provide useful insights into how link workers are implemented in different parts of England. We will use a research approach called realist evaluation to explain what causes different outcomes from link workers seen in different circumstances. Our approach will allow us to compare and contrast what we learn from each site. We will be able to explain why differences may arise across varying contexts._x000D_ _x000D_ Patient/public involvement (PPI)_x000D_ Members of the public (our PPI group) have commented on the need for the proposed research. We will continue meeting with this group for feedback on areas such as materials to be sent to participants and our interpretations of data. One PPI group member agreed to be a co-applicant on this project. He is interested in the optimum use of NHS money to address psychosocial factors affecting health and well-being._x000D_ _x000D_ Dissemination_x000D_ We have support for this research from bodies such as the Royal College of General Practitioners, NHS England and the King’s Fund. We will use these contacts to ensure widespread dissemination and impact of the findings.

Lay abstract: Research question: When implementing link workers in primary care to sustain outcomes – what works, for whom, why and in what circumstances?_x000D_ _x000D_ Background: Social prescribing addresses ‘non-medical’ issues affecting how people feel, by linking them to ‘assets’ in the community (groups, organisations, services) to assist with social, economic or environmental difficulties (e.g. loneliness, unemployment). The NHS made a commitment to social prescribing by funding link workers in Primary Care Networks. Link workers develop an action plan with patients and direct them to relevant local support. It is anticipated that link workers will improve patient well-being and reduce GP workload. However, evidence on optimising their implementation and sustaining outcomes is lacking. _x000D_ _x000D_ Aims/objectives: To produce evidence-based recommendations on how to best execute link workers in primary care. Objectives will include to:_x000D_ _x000D_ • undertake an in-depth examination of the delivery of link workers in a purposive sample of primary care settings;_x000D_ • critically exam the impact of link workers in practice, examining if, what and how link workers deliver sustained, desired outcomes;_x000D_ • compare and explain proximal outcomes (e.g. patients attending community activities or seeking advice from local organisations) and more distal ones (e.g. patients engaging more in self-care or reducing how often they see a GP);_x000D_ • examine how a) models of link worker delivery and b) patient characteristics may influence the production of sustained, positive outcomes; _x000D_ • integrate findings to produce detailed, real-world recommendations for those commissioning, providing or acting as link workers._x000D_ _x000D_ Methods: A realist evaluation, composed of 2 work packages (WPs), will be conducted. WP1 will explore implementation of link workers in primary care. A purposive sample of 6 cases (link workers) within 6 sites (geographical areas) will be selected. A researcher will focus for 3 months on each case. This will include 3 weeks of fieldwork, during which the researcher will observe the link worker’s interactions with patients and staff, have conversations with the link worker about what they have done each day and read through key documents about the link worker role. They will conduct semi-structured interviews with primary care staff, a member of the voluntary-community sector, and the link worker. They will also access routinely gathered data (anonymised and aggregated) from the link worker (e.g. number of patients referred, how they were referred, changes to service usage). In the remaining 9 weeks for each case, the researcher will conduct semi-structured interviews with 10 patients and perform a preliminary analysis to inform data collection in the next site. WP2 will involve semi-structured interviews with patients from WP1 (9-12 months later), to understand how they benefit (or not) from seeing a link worker. A realist logic of analysis will be applied to data, to confirm, refute or refine our programme theory. Analysis will explore connections between contexts, mechanisms and outcomes._x000D_ _x000D_ Timelines for delivery: Months 1-3 – study set up and approvals; Months 4-16 – WP1; Months 17-27 – WP2; Months 28-30 – developing recommendations and dissemination._x000D_ _x000D_ Anticipated impact/dissemination: Recommendations on implementing link workers in primary care will be disseminated using innovative approaches (e.g. RapidMOOC videos) and traditional publications/presentations

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE