The consequences of micro-discretions and boundaries in the social prescribing link worker role in England: a realist evaluation
Authors: Tierney Stephanie , Westlake Debra , Wong Geoffrey , Turk Amadea , Markham Steven , Gorenberg Jordan , Reeve Joanne , Mitchell Caroline , Husk Kerryn , Redwood Sabi , Meacock Anthony , Pope Catherine , Mahtani Kamal R 
Published: October 2024

Background
Social prescribing addresses non-medical factors affecting health and well-being. Link workers are key to its delivery by connecting people to relevant support, often in the voluntary, community and social enterprise sector. Funding from the National Health Service means that link workers are becoming a common part of primary care in England.

Objective
To explore and understand the implementation of link workers in primary care in England.

Design
A realist evaluation addressed the question – When implementing link workers in primary care to sustain outcomes – what works, for whom, why and in what circumstances?

Setting
Link workers and staff associated with seven primary care sites across England.

Methods
Researchers spent 3 weeks with each link worker, going to meetings with them, watching them interact with patients, with healthcare staff and with voluntary, community and social enterprise organisations. In addition, interviews were conducted with 61 patients and 93 professionals (voluntary, community and social enterprise representatives and healthcare staff, including link workers). Follow-up interviews were conducted with 41 patients and with link workers 9–12 months later. Data were coded and developed into statements to identify how context around the link worker triggers mechanisms that lead to intended and unintended outcomes.

Results
We found that link workers exercise micro-discretions in their role – actions and advice-giving based on personal judgement of a situation, which may not always reflect explicit guidance or protocols. Our analysis highlighted that micro-discretions engender positive connections (with patients, healthcare staff, the voluntary, community and social enterprise sector) and promote buy-in to the link worker role in primary care. Micro-discretions supported delivery of person-centred care and enhanced job satisfaction. Data also highlighted that lack of boundaries could place link workers at risk of overstepping their remit.

Limitations
Our research focused on link workers attached to primary care; findings may not be applicable to those working in other settings. Data were collected around seven link worker cases, who were selected purposively for variation in terms of geographical spread and how/by whom link workers were employed. However, these link workers were predominately white females.

Conclusions
Enabling link workers to exercise micro-discretions allows for responsiveness to individual patient needs but can result in uncertainty and to link workers feeling overstretched.

Future work
Poor link worker retention may, in part, be associated with a lack of clarity around their role. Research to explore how this shapes intention to leave their job is being conducted by authors of this paper.

Funding
This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.