Institute for Community Research and Development
An evaluation of Wolverhampton’s Social Prescribing Service: A New Route to Wellbeing
Dr Rachel Massie and Dr Nahid Ahmad
February 2019
Executive Summary An evaluation of Wolverhampton’s Social Prescribing Service Background Wolverhampton Clinical Commissioning Group (CCG), in collaboration with Wolverhampton Voluntary Sector Council (WVSC), launched a social prescribing pilot service in April 2017, including three link workers located across the City. The social prescribing service provides a link between primary care services and the voluntary and community sector, and aims to help people with non-clinical needs access a wide variety of services and activities in Wolverhampton to support their health and wellbeing. The Institute for Community Research and Development was commissioned to undertake an independent evaluation of the service. The evaluation took a mixedmethods approach to review the current delivery, evidence impact and provide recommendations for future service provision. Quantitative analysis of routine monitoring data, including measures of wellbeing and loneliness, and NHS use data examined the impact of the service. This was complemented by focus groups and interviews conducted with service users, referrers and providers to understand their experiences.
Key findings • • • • • •
•
The service received 676 referrals (64% female; mean age 66.4 years) between May 2017 and December 2018 The most common reasons for referral were loneliness and low-level mental health conditions Link workers made onward referrals to over 150 groups/services There was a statistically significant improvement in service users’ reported wellbeing following contact with the social prescribing service Service users reported a statistically significant decrease in feelings of loneliness following contact with the service A reduction in primary care health use was statistically significant for those service-users who were the highest utilisers of GP/practice nurse appointments (6+ appointments in six months) The estimated Return on Investment means that for every £1 spent on the social prescribing intervention, there will be a saving of £0.15 for primary care services. This is a conservative estimate considering the data limitations described in the report
•
Qualitative findings support the quantitative findings. The service is highly regarded by referrers, providers, and service-users. In addition to improved wellbeing and loneliness, respondents discussed improved mental health, confidence, self-esteem, and in some cases improved physical health.
Recommendations The findings of this evaluation clearly demonstrate that the Wolverhampton social prescribing service has had a positive impact on service users’ wellbeing and loneliness, highlighted potential cost savings for primary care services and received overwhelmingly positive feedback from a range of stakeholders. We recommend that: •
•
• • • •
the findings are shared with both internal and external stakeholders to highlight the evidence of the positive impact of the programme at a time when the policy context is favourable and evidence of effectiveness is of national interest given its success to date, the service is supported to continue* and build upon its strengths (i.e., person-centred approach, empathetic link workers, breadth of local knowledge and clear referral form) a progress summary is provided to referrers once a quarter, highlighting the volume and nature of support provided and any updates to the service awareness of the service is raised across the City to promote wider referrals the gaps in befriending, outlined in this evaluation report, are addressed to free up time for the link workers some elements of data capture are improved (i.e., routine monitoring of wellbeing and loneliness every three months and clearer recording of engagement with and exit from the service).
*Since completion of the evaluation, the service has expanded to include a Project Manager and two further link workers who commenced in post during November 2018, with the aim of increasing awareness of the service across the City and therefore boosting referrals particularly across the deprived areas of Wolverhampton.
Dr Rachel Massie and Dr Nahid Ahmad Institute for Community Research and Development University of Wolverhampton February 2019 ii
Authors Dr Rachel Massie is Research Fellow in the Institute for Community Research and Development (ICRD) at the University of Wolverhampton. She has experience of conducting mixed-methods evaluations of community programmes designed to improve the health and wellbeing of vulnerable groups (including young people, individuals living with long-term conditions, and individuals with multiple and complex needs). Dr Nahid Ahmad is Deputy Director of ICRD, and a Chartered Health Psychologist with substantial expertise in evaluation and research in holistic support for those living with long-term conditions. Nahid’s previous experience includes leading evaluations of the Dudley social prescribing service, and a national signposting service for the British Red Cross.
Acknowledgements The authors would like to thank Wolverhampton Clinical Commissioning Group (CCG) for funding the evaluation. We are extremely grateful to Wolverhampton Voluntary Sector Council and Wolverhampton CCG for collating and sharing service data and arranging the focus groups to support the evaluation. Thank you to all the participants who took part in a focus group/interview. Finally thank you to Andy Jolly (ICRD Research Associate) and Dr Bozena Sojka (ICRD Research Fellow) for supporting qualitative data collection.
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Contents Executive Summary .................................................................................................... i Authors ....................................................................................................................... iii Acknowledgements .................................................................................................... iii 1.
Introduction .......................................................................................................... 1 1.1 Wolverhampton Social Prescribing Service ................................................... 1 1.2 Evaluation Methodology ................................................................................ 2
2.
Context: Policy and Research ............................................................................. 3
3.
Findings ............................................................................................................... 5 3.1 Monitoring Data ............................................................................................. 5 3.2 Impact on Wellbeing and Loneliness ............................................................. 9 3.3 Health Service Use data .............................................................................. 12 3.4 Return on Investment .................................................................................. 14 3.5 Qualitative Data ........................................................................................... 16
4.
Conclusion and Recommendations ................................................................... 22 4.1 Conclusions ................................................................................................. 22 4.2 Recommendations....................................................................................... 23
5.
References ........................................................................................................ 25
iv
1. Introduction 1.1 Wolverhampton Social Prescribing Service The social prescribing service aims to help people with non-clinical needs access a wide variety of services and activities provided by voluntary and statutory organisations and community groups in Wolverhampton. The social prescribing pilot model is based on tried and tested models that have been developed and evaluated across the country. Wolverhampton Clinical Commissioning Group (CCG), in collaboration with Wolverhampton Voluntary Sector Council (WVSC), launched a social prescribing pilot service in April 2017. The service consists of three link workers, one located in each of the three following localities in Wolverhampton - the South East, South West and North East. A 0.5 WTE Project Manager has been appointed to oversee the implementation of the pilot and is supported by a 0.5 WTE Administrator. The Project Manager and link workers work closely with GP practices within their locality to build relationships and promote the service. They also have contact with staff in A&E and at West Midlands Ambulance to raise awareness about the service, referral criteria and pathways. The link workers are employed by the WVSC and continually update and maintain their knowledge of organisations that can offer support to patients. Referrals into the service can be made by GPs, practice nurses, community nursing teams, care navigation staff, social workers, West Midlands Ambulance Service and A&E. Upon receiving a referral, link workers make contact with the patient within three days, to introduce themselves and the service, and arrange a face-to-face meeting within 10 days. From these conversations the link worker will identify the issues and co-design a solution with the service user. This may include the link worker accompanying an individual to the first session of a group activity and follow up phone calls to check on progress. The link worker makes a judgement as to when the service user is ready to exit the social prescribing service – this can vary dependent upon the support required, and in some instances are open for longer due to complex lives and multiple issues. The service provides support to identify issues and develop action plans and solutions, in addition to active signposting to some statutory organisations (independent living service, adult social care, fire service), but mostly voluntary organisations in line with individuals interests, hobbies and support needs. These organisations provide a range of activities to promote social connectivity; physical activity levels; mental health and independent living. Such support includes exercise programmes, social activities, healthy eating, self-management of long-term conditions and support with welfare benefits and financial issues. 1
1.2 Evaluation Methodology The evaluation aimed to review the current social prescribing service model and delivery provision, identify strengths, evidence impact to date, identify gaps and provide evidence for future service development opportunities. Anonymous service monitoring data was received from the WVSC to review delivery provision and impact on wellbeing and loneliness. The research team received anonymised data for 676 referrals. Data from each of the scale measures were scored and entered into an Excel spreadsheet. The data were cleaned and processed ready for analysis using the Statistical Package for the Social Sciences (SPSS). The results for each measure were analysed using a Wilcoxon Signed Ranks Test to identify whether there were any statistically significant differences between service users self-rated scores of wellbeing and loneliness. Participants’ scores for wellbeing were compared to national, regional and local levels of wellbeing measured in the Annual Population Survey (Office for National Statistics (ONS), 2018a). Wolverhampton CCG requested anonymous health service use data from GP practices which was subsequently shared with the evaluation team. The data provided the number of primary care appointments and secondary care admissions for the 6 months pre and 6 months post social prescribing referral. Data were analysed in SPSS using a Wilcoxon Signed Ranks Test. Twenty participants also shared their views and experience of Wolverhampton’s social prescribing service in a focus group (service users and providers) or telephone interview (referrers). Qualitative data was analysed using a process of thematic analysis (Braun & Clarke, 2006; Caulfield & Hill, 2018). A highly trained research team, with considerable experience of conducting research in health and social care and with vulnerable groups, conducted the evaluation. The evaluation was granted ethical approval on 27th November 2018 by the Faculty of Social Sciences Ethics Committee at the University of Wolverhampton. No data was collected or shared prior to participants providing fully informed consent.
2
2. Context: Policy and Research Social prescribing enables primary care professionals to refer patients to a range of local, non-clinical services (The Kings Fund, 2017). It aims to improve patients’ quality of life, health and wellbeing through addressing their needs in a holistic way. Social prescribing is not a new concept, but has gained considerable political interest and support in recent years. In October 2018, through the cross-Government strategy to tackle loneliness, the Prime Minister has pledged to support all local health care services to implement social prescribing schemes by 2023. It received national endorsement, with NHS England appointing a national clinical champion for social prescribing in 2016; the role included advocating for schemes, and sharing lessons from successful social prescribing projects. Social prescribing offers an assets-based approach to meeting the challenges related to increasing pressures on the NHS, an ageing population and the widening gap in health and social inequalities (Brandling and House, 2009). It has been estimated that 20% of patients consult their GP for what could be considered a social problem (Torjesen, 2016). By placing the patient at the centre of their care, the use of social prescribing has the potential to make general practice more sustainable through the reduction of costly – and inappropriate – interventions, and to help patients overcome some of the social and behavioral determinants of poor health through self-management and use of relevant community services. Current health and care policy is supportive of this solution, encouraging preventative, holistic approaches to health and wellbeing, with better integration of services and a greater role for voluntary and community service providers (e.g. the White Paper ‘Our Health, Our Care, Our Say’ (2006), the ‘NHS Five Year Forward View’ (2014) and the ‘General Practice Forward View’ (2016)). Most recently, this support has come in the form of the NHS 10 year plan (2019), which extends the emphasis on more care being delivered in the community with GP practices working together. According to the plan, an additional 2.5 million people are expected to use social prescribing over the next 5 years. There is a clear rationale for social prescribing, and evidencing its impact is crucial for ensuring the most effective and cost-effective models are rolled out across the UK. Previous evaluations investigating the impact of social prescribing are typically small scale pilot studies but report broadly positive outcomes, for example improved quality of life, improvements in feelings of social isolation and loneliness, and a reduction in the usage of health services and resources (Bickerdike et al., 2017). A recent evidence review reported an average of 28% reduction in demand for GP services and a 24% fall in A&E attendances following referral to social prescribing services (Polley et al., 2017a). Qualitative evidence gathered from both patients and GPs is largely supportive of the health and wellbeing benefits of social prescribing (Polley et al., 2017a). 3
Given the wide scale of social prescribing interventions taking place (using different activities and focussed on different populations), it can be difficult to demonstrate the impact and value of social prescribing. Nevertheless, one component believed to be key in delivering successful social prescribing programmes is the link worker. The role of link workers may vary between programmes, but could include giving practical support to help people develop their knowledge, confidence and skills; providing advice on local community services available that may help improve health; and developing personal health plans towards agreed goals. Previous research has suggested that embedding a link worker from a voluntary organisation into general practice can help facilitate and signpost patients to wider services without overburdening GPs (Nesta, 2013). Other essential components include the collaboration between sectors and ensuring the service remains holistic and personcentred (Polley et al., 2017b). Evaluating the Wolverhampton service will contribute to the wider evidence base for social prescribing, and also allow opportunities for comparison to impacts shown in the national evidence. Ultimately, a robust evaluation of the service will inform commissioners’ decision-making on future investment in the service.
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3. Findings 3.1 Monitoring Data Referrals in to and out of the service The Wolverhampton social prescribing service received 676 referrals between 5th May 2017 and 17th December 2018. The mean (SD) number of referrals link workers received per month was 34 (11). The distribution of referrals by quarter and for each area are shown in Figure 1. Figure 1. Number of referrals made to the service each quarter 150
138 123
Number of Referrals
120 98
98 84
90
83 SW
60
52
SE NE
30 0 May - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec 2017 2017 2107 2018 2018 2018 2018 Referral Date
Referrals were received from across the City, with 47% from the South East, 30% from the South West and 23% from the North East. A large proportion of the referrals (79%) were received from GPs, across 38 different practices. The mean number of referrals per practice was 13 patients, but this varied extensively between practices, ranging from 1 to 81. Referrals were also received from Advanced Nurse Practitioners (7%) and Community Nurses (9%), with fewer referrals from the Falls Prevention Service (1%), Connect Health (1%), Care Navigation (0.6%), Occupational Therapists (0.6%), Health Care Assistants (0.4%), District Nurses (0.4%) and Adult Social Care (0.2%). Of the 676 referrals received, 213 have now exited the service. The main reasons for leaving include completed the service (20%); declined the service (27%); unable to contact/did not attend appointment (17%); and onward referral/signposted (12%). The remaining 463 referrals are still actively involved with the service. 5
Eight percent of patients referred declined support from the service. Only 24 participants (4%) received more than one referral to social prescribing. The second referral was received between 2 weeks and 15 months after the first referral. A different referrer made over half of the re-referrals (54%), and 25% were a result of the link worker being unable to make contact with the patient/or the patient declining the support at the time of the first referral. The link workers referred service users into a wide range of (approximately 150) services, groups and activities across the City, supporting individuals to increase their social connectivity; physical activity levels; mental health and independent living. Some examples of services are shown in Figure 2. Figure 2. Examples of groups/services that link workers referred/signposted patients to
Category
Examples of Groups / Services
Accessibility
Ring and Ride Meals on Wheels Home Improvement Service
Church Groups
St Matthews Church Excel Church
Physical Activity
Dance Walking Gardening Leisure Centre
Social Prescribing Activity Groups
Employment and Training
Choirs Computer Hub Film Club Knit and Knatter Bridges Aspiring Futures Talent Match
Health Specific Support
Age UK Falls Prevention Dementia Carers Support group Macmillan Cancer Support
Welfare
Citizens Advice Bureau Wolverhampton City Council
6
Personal characteristics of service users Sixty-four percent of individuals referred to social prescribing were female. The mean age was 66.4 (18.6) years. Further breakdown shows 69% were aged 60 and above, and 30% aged 80 and above (Figure 3). For individuals for whom the employment status was supplied (n = 177), 67% were retired, supporting the age demographic of those referred into social prescribing. Two thirds of the services users were White British (68%), with a further 21% being Asian and 11% being African Caribbean. Forty-three individuals (6%) referred required an interpreter. One of the link workers speaks Punjabi, which was a great advantage to delivering this service in Wolverhampton without the need for the additional costs of an interpreter. Figure 3. Age profile of service users 25 23 20 Percentage
20
19
15 10
11 10
5 5
7
5
0
Age
Support needs/reason for referral There were a variety of reasons for which individuals were referred to the social prescribing service. Multiple reasons (≼ 2 reasons) for referral were identified for 66% of service users. The most common reasons were to address social isolation and loneliness (35%); anxiety and depression (29%); and long-term health conditions (15%). Alternative reasons for referrals, reported less frequently, are presented in Figure 4.
7
Figure 4. Presenting issues / reason for referral Reduction in social isolation and loneliness
35
Symptoms of anxiety and/or depression
29
Support for long-term health conditions
15
Frequent presenter
6
Poor mental wellbeing
5
Finances
3
Medical solution unlikely to be successful
3
Mental health condition
1
Bereavement
1
Household issues
1
Family relationships
1 0
5
10
15
20
25
30
35
40
Percentage
Service Delivery Link workers made contact with service users in a variety of ways, the most frequent being via phone and outreach. The data to date shows the mean number of contacts between the link worker and service user was 5 (range 1 to 32), totalling an average of 4 hours per service user. Figure 5. Number of contacts with link worker
13.4% 1 to 3 11.4%
4 to 6 50.3%
7 to 9 10+
24.9%
8
3.2 Impact on Wellbeing and Loneliness Wellbeing Wellbeing was measured using the ONS Wellbeing Scale. This scale consists of four questions related to life satisfaction, feeling worthwhile, happiness and anxiety, each scored on a Likert scale of 0 to 10. For the first three aforementioned questions, responses between 0 and 4 were considered low, 5 to 6 medium, 7 to 8 high, and 9 to 10 very high scores of wellbeing. Anxiety was reverse scored, with 0 to 1 representing very low levels, 2 to 3 low levels, 4 to 5 medium levels and 6 to 10 high levels of anxiety (ONS, 2018b). Link workers completed the scale with service users upon their referral, at an interim time point and upon completion of the service 1. Of the 676 referrals, baseline data was available for 193 individuals (n = 57 male, n = 136 female). The baseline scores shown in Table 1, were considerably lower than for the general population reported in the Annual Population Survey 2017-18 (ONS, 2018a). Table 1. Mean national, regional and local estimates of wellbeing compared to baseline data for social prescribing service users Data Source
Satisfaction Worthwhile Happiness
Anxiety
Social Prescribing Pre
4.34
4.82
4.28
5.65
England*
7.68
7.88
7.52
2.90
West Midlands*
7.67
7.82
7.52
2.70
Wolverhampton* 7.28 7.56 7.25 2.31 * Estimates of personal well-being from the Annual Population Survey 2017-18
Just over a quarter of service users with baseline data, also completed a follow-up questionnaire (n = 22 male, n = 30 female, mean age 60.2 y). The mean length of time between assessments was 3.3 months, ranging between 1 and 7 months. For these individuals (n = 52), total wellbeing scores significantly improved over time from a mean score of 15.2 at baseline to 25.1 (out of a maximum of 40) at follow up 2 (Z = -6.08, p ≤ 0.005). Each individual subscale (life satisfaction, worthiness, happiness and anxiety) also improved significantly at the time of follow-up (Z ≥ 5.08, p ≤ 0.005, Figure 6). This data supports previous findings of social prescribing evaluations, such as in Rotherham (Dayson and Bashir, 2014) and Bristol (Kimberlee, 2016).
1
Time points for the interim and post measures of wellbeing varied for each service user. Follow-up data includes the most recent score collected (either interim or post) compared with the baseline wellbeing score. Anxiety scores were reversed for the purposes of collating a total wellbeing score.
2
9
Figure 6. Change in wellbeing scores between pre and follow-up (n = 52) 7 6
6.52
6.46
6.19
6.56
Score
5 4 3
3.71
4.10
3.90
3.92
Pre Follow-up
2 1 0 Satisfaction
Worthwhile
Happiness
Anxiety
Wellbeing Question
A within measures one-way ANOVA for the eight individuals for whom data was available at three time points (pre, mid and post), revealed a significant improvement in wellbeing over time (F(1,7) = 14.6, p = 0.005). Post-hoc analyses showed that wellbeing was significantly higher after social prescribing compared to interim and baseline measures, 27.8, 22.3 and 17.9, respectively 3.
Loneliness Loneliness was measured using the validated De Jong Gierveld scale for loneliness and social isolation. The six item questionnaire asks respondents to rate emotional and social isolation on a Likert scale of ‘Yes’, ‘More or less’, ‘No’. Scale scores were based on dichotomous item scores with the answer “more or less” always indicating loneliness. The questionnaire provides an emotional loneliness score, ranging from 0 (not emotionally lonely) to 3 (intensely emotionally lonely) and a social loneliness score ranging from 0 (not socially lonely) to 3 (intensely socially lonely). When the two scales are combined, the result is a score of 0 (least lonely) to 6 (most lonely). Link workers completed the scale with service users upon their referral, at an interim time point and upon completion of the service 4. Baseline data for loneliness was available for 181 individuals (n = 55 male, n = 126 female), with a mean score of 4.2 out of 6.
3
A very small sample size available (n = 8), thus caution must be taken when interpreting this change in wellbeing score. 4 Time points for the interim and post measures of loneliness varied for each service user.
10
Of the service users who completed a measure of loneliness and social isolation at baseline, 51 also completed a follow-up questionnaire (n = 21 male, n = 30 female, mean age 60.0 y). The mean length of time between assessments was 3.6 months, ranging between 1 and 10 months. Analysis showed a significant decrease in overall loneliness score over time from 4.5 to 2.8 (Z = -5.5, p ≤ 0.005) 5. Of these, 39 individuals reported a reduction in loneliness score and 12 reported no change. No individuals reported an increase in loneliness and social isolation between baseline and follow-up. A significant decrease was also found for both subscales of emotional and social loneliness (Z ≼ -4.4, p ≤ 0.005) (Figure 7). Figure 7. Change in loneliness scores between pre and follow-up (n = 51) 3
2.49 2.04
Score
2
1.73 Pre Follow-up
1 0.98
0 Emotional Social Loneliness Subscale
Box 1 highlights some of the limitations of the wellbeing and loneliness data provided for analyses.
5
Follow-up data includes the most recent score collected (either interim or post) compared with the baseline loneliness score.
11
Box 1: Limitations of Monitoring Data •
•
•
•
Baseline data for wellbeing and loneliness were only collected for 29% and 27% of those referred into the service, respectively. Although representative of gender and age, it is possible service users completing follow-up measures are not representative of the sample. Data at three time points were only available for eight individuals for wellbeing, thus it is not appropriate to generalise these findings to all service users. Follow-up measures were not collected at fixed time points (i.e., every 3 months), which would help distinguish if there is a specific time point in which social prescribing has a larger impact. More complete follow-up data would allow further analyses to be completed taking into account participant demographics, such as age and gender to see if certain groups/individuals may benefit from social prescribing more than others.
3.3 Health Service Use data GP practices that actively referred into the Wolverhampton social prescribing service were asked, by Wolverhampton CCG, to supply anonymous data about the use of health services (GP appointments, nurse appointments, A&E attendances, urgent care attendances, emergency admission and hospital bed days) for individuals 6 months pre and 6 months post referral to social prescribing. Data were requested for any individuals referred to social prescribing between May 2017 and July 2018. Five GP practices supplied this data, totalling 97 patients. A Wilcoxon Signed Ranks Test showed no significant differences for any health service usage between the 6 months pre referral and 6 months post referral (Z ≤ 1.38, p ≥ 0.17). However, upon more detailed interrogation of the data large variability between individuals was identified – which could have skewed the findings. For example, for GP appointments, 42% of patients decreased the number of appointments (one individual had 10 fewer appointments in the 6 month period post referral), 50% increased (with one individual increasing by 18 appointments) and 8% had the same number pre and post social prescribing (Table 2).
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Table 2. Changes in mean (SD) health service use (n = 97) Pre
Post
% increase
% decrease
GP Appointment
4.0 (3.8)
4.2 (5.0)
50%
42%
Nurse Appointment
1.4 (2.6)
1.1 (1.9)
22%
25%
Primary Care
5.4 (5.0)
5.3 (5.4)
44%
39%
A&E Attendance
0.3 (0.8)
0.3 (0.7)
15%
14%
Urgent Care Attendance
0.3 (0.8)
0.4 (1.0)
14%
12%
Emergency Admission
0.1 (0.3)
0.1 (0.4)
7%
6%
Hospital Bed Days
0.3 (2.0)
0.6 (2.3)
9%
5%
Secondary Care
1.0 (2.7)
1.4 (3.5)
23%
22%
When analysing the data available for individuals who attended six or more appointments 6 with either their GP or nurse combined in the 6 months pre social prescribing (n = 36), there was a significant decrease in primary care use from 10.6 to 8.0 appointments (Z = -3.26, p = 0.001). The mean number of GP appointments decreased from 7.6 pre referral to 6.1 post referral, and nurse appointments from 3.0 to 1.9 (Z ≼ -1.97 p ≤ 0.05). Box 2 highlights some of the limitations of the health service use data, which may in part explain the lack of overall significant differences in the health service use over time.
6
A minimum of one appointment a month during the recorded period was used.
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Box 2: Limitations of Health Service Use Data •
•
•
•
• •
Many patients had only visited their GP or nurse once or less in the 6 months pre social prescribing (28% and 73% respectively) thus reductions in service use are unlikely for these individuals. Increased appointments post referral may not be a direct result of social prescribing but rather medical requirements, given the long-term health conditions of many service users. Only five practices (from the 38 that had referred patients to the service) returned health service use data, hence it provides only a snapshot of the impact of social prescribing across the City. It is possible some of the patients for which data is available declined the service. If these could be identified it would provide a comparator group beneficial for analyses. Additional demographics (i.e., age and gender) within the health service use data would aid more complete analyses. There was considerable variation in sample size in data provided by GPs compared to data provided by WVSC: referrals from the five practices totalled n = 189 in monitoring data but only n = 97 in health service use data. This would appear to be a recording issue and should be addressed.
3.4 Return on Investment This Return on Investment (ROI) is reliant on health service use data. Given the limitations of this data, presented above in Box 2, these findings should be interpreted with caution. The ROI has been limited to looking at impacts on primary care utilisation. Potential savings from secondary care and mental health services, and wider societal impacts were not within the scope of this evaluation. The full year cost to the CCG for the social prescribing service is £148,000. The baseline scenario was considered to be 443 referrals made over a one-year period in social prescribing 7. Taken from analysis of health service use data (section 3.3 above), it was assumed that 37% of the sample would decrease their primary care use significantly by 25% (reduction of 1.5 GP appointments and 1.1 nurse appointments over a 6-month period).
7
st
th
Calculated from the monitoring data between 1 July 2017 and 30 June 2018
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The estimated cost of primary care utilisation for individuals who are socially isolated and lonely in Wolverhampton (thus referred to social prescribing) is approximately £147,953 in the absence of an intervention. With the social prescribing intervention supporting the reduction of primary care use for 37% of individuals referred, it was estimated that primary care costs would be reduced by £22,000. This was calculated using the following unit costs (Curtis and Burns, 2018): • •
£37.40 per 9.22 min GP consultation per patient £42 per hour / £10.50 per 15 min nurse appointment per patient
An estimated breakdown of the ROI for this intervention is shown in Table 3. This estimated ROI means that for every £1 spent on the intervention, there will be a saving of £0.15. As previously mentioned, this should be interpreted with caution, in light of the data limitations (Box 2). These estimates could be considered conservative as they do not account for outcomes seen over the longer term: self-management of social isolation, loneliness and anxiety could potentially reduce primary care use in future years without the continued support of the link worker. This is of particular relevance for younger age groups referred to the service. Table 3. Annual return on investment for primary healthcare utilisation Patients receiving the intervention
443
Patients with 6+ appointments to primary care pre
155
Annual cost of intervention
£148,000
Cost of primary healthcare use pre intervention
£147,953
Cost of primary healthcare use post intervention
£125,764
Total annual saving
£22,189
Return on Investment
0.15
There are likely to be additional cost savings resulting from the social prescribing service when accounting for the improvements in wellbeing and loneliness. Previous research has highlighted the wider societal impact of improving wellbeing and social isolation. McDaid et al. (2016) conservatively estimated the ten-year cost of loneliness to health and social care to be in excess of £1,700 per person (£6,000 for the most severely lonely). Furthermore, a Return on Investment modelled savings of £2 to £3 for every £1 invested for signposting/navigation services (McDaid et al., 2017), and a Social Return on Investment (SROI) of £2.90 for the Wellbeing Programme at the Wellspring Healthy Living Centre, Bristol (Kimberlee, 2016). This SROI accounts for the wider benefits associated with social prescribing for example, return to employment, an outcome seen for some service users in the social prescribing service in Wolverhampton. 15
With almost a third of referrals based on depression and anxiety, a further example of additional savings not considered in the above ROI are the potential reductions in numbers accessing support from stretched and costly mental health services. For example, the Improving Access to Psychological Therapies Programme (IAPT) costs £95 per care contact and Mental Health Care £410 per bed day (Curtis and Burns, 2018).
3.5 Qualitative Data Qualitative data was generated from three focus groups with link workers, providers, and service users, and three telephone interviews with referrers. We consulted with a total of 20 people, including the three link workers, nine service users, five voluntary sector providers, a GP, a practice manager, and an occupational therapist from the falls prevention team. Amongst the service users there were four Punjabi speaking people for whom an interpreter was provided by the social prescribing service. Knowledge of the social prescribing service There was a good level of understanding of the service amongst all respondents. Referrers had first heard about the service through CCG and WVSC communications, such as meetings and visits. These meetings and conversations with the social prescribing team were of great importance for referrers to understand what social prescribing is and who it is appropriate for them to refer. Link workers and service users supported the view that social prescribing can be “an abstract concept” that requires explanation and examples of how it works. In line with this, there were some respondents however – particularly amongst the referrers and providers – who thought that more awareness of the service was needed across the City. Referrers described the service as appropriate for those with low level mental health issues, for elderly home-bound patients, and for those who are lonely. One referrer thought that young, and/or single parents also benefitted from the service. Key outcomes for these groups were described in terms of improved quality of life, and a reduction in frequent attendance at the GP practices: “Patients who are attending regularly, or presenting at the desk a couple of times a week, not wanting to leave, coming for non-medical issues. Or the GP was identifying patients with no (medical) diagnosis but lots of anxiety around their home situation or finances. They were seeing their GP regularly but had no diagnosis or treatment, just wanted to talk. Before social prescribing the GP would have seen these patients.” [Referrer]
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Perceptions of the social prescribing service Our consultation has shown that respondents were unanimous in welcoming the social prescribing service in Wolverhampton, as one that is reliable and well run, staffed by informed and compassionate link workers, and bringing a positive support and care experience to service users. The social prescribing team was described as “being proactive in finding out what was going on” and having a broad knowledge of local services, which helps to support non-clinical needs: “Such a broad knowledge within the team as to what services are there that they really can support and suit everybody’s needs.” [Provider] Referrers described how their initial expectation of the service was that it would be a signposting service, but that their experience since had shown that it is much more than this, with link workers often accompanying service users to signposted activities. Providers too described how the service is an ‘enhanced’ signposting service with one saying how link workers “have gone the extra mile to signpost to other relevant services”. Providers considered this an important feature to support successful attendance and engagement with onward referrals. Another provider described social prescribing as an “immediate service” by comparison to other services like mental health where there are long waiting lists. For service users, trust in their confidentiality is paramount: “You feel secure your confidentiality is not going to be breached. You form a rapport with your link worker and it does raise confidence to be able to speak confidentially.” [Service user] Key to an enhanced signposting service like this is the ‘personal touch’ that this service gives. Respondents talked about how link workers are approachable, warm and kind. Pacing is also significant, allowing patients space and time when assessing their needs is central to a patient-centred approach which ensures support is led by patient need. The quotes below indicate how the link worker role is crucial in giving a personalised and compassionate service: “Link workers are friendly, down to earth and easy to approach. Makes you feel more confident to talk.” [Service user] “They’re just really calm, you feel like there’s somebody that’s got your back, when you can’t do it for yourself.” [Service user] “It was very slow, it wasn’t harsh, it wasn’t all pushed on me in one go.” [Service user] “It’s important to let people do things at their own speed. We’re conscious of previous unhelpful experiences with services. You need to give them enough encouragement and time to support them. To be patient, some people open
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up to you very slowly, so it can take time to find out something that is very important which we can work on to help improve their lives.” [Provider] “They don’t make assumptions about what people want, they very much want to hear from that person and wait for them to be able to articulate what they want. They may make suggestions but not in a leading way, which is really useful.” [Provider] Service users and providers also reflected on how the support given is empowering, with link workers encouraging independence and managing expectations well. The social prescribing service is almost working to capacity; ensuring that the service scope is clearly defined is therefore important for its continued success. Clear communication of this scope has also had the added benefit of helping service users, and providers, navigate the local system, by understanding where other statutory and voluntary sector services can support them. “Good split, that they can’t do everything for you, you have to do stuff for yourself.” [Service user] “They are really good at managing patient expectations, so patients know you are not going to pop round every week for the rest of their lives. They give them a time frame and ‘wean them off.’” [Provider] “There is clarity, they are very good at building a relationship with the person that is being referred, so very clear about what isn’t part of social prescribing. It’s clear from our conversations when someone needs to be referred back to social services, because those needs couldn’t be met through our service or social prescribing. That is really clear for the service user as well, because of the explanations as to who can do what. So they are not getting confused. They [the link workers] are good at recognising these things, and helping the person know what help and support they can receive from the onward referral.” [Provider] A number of challenges for the service were also described by respondents: •
Link workers were applauded for their extensive local knowledge. They were described as well connected to local services, and therefore able to know when services have been lost or changed – something which is difficult for other services to keep abreast of. This is however, a significant challenge for the service as the impact of the wider context is keenly felt – public sector cuts and short term funding means that the local support service landscape is constantly shifting with link workers describing it as feeling “like quicksand”. Substantial inputs are required by the team to ensure that services they refer into still exist and are of suitable remit.
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•
The absence of certain services has been a challenge in itself. Often service users will “fall between gaps” where they do not quite fit the remit of existing services. A particular gap has been befriending services, which to some extent has been filled by link workers accompanying service users to activities. This is not a sustainable solution however, and requires a more strategic approach across the City.
•
Public transport networks do not always offer the cover required for service users to get from home to activities/services. Ring and Ride transport has been widely used but this too does not offer adequate flexibility for the most vulnerable groups of service users. This has meant that often the only option available is a taxi – which is an expensive resort for people living with financial difficulties.
Impact of the social prescribing service Respondents were unanimous in reporting positive outcomes for service users. These included improvement in wellbeing, mental health, social contact, and in some cases physical health. One referrer also reported seeing a reduction in frequent attendances, although there was no reported impact on attendances for the falls team. In terms of social outcomes, a sense of ‘connectedness’ was described by respondents in all groups, which for some was linked to improved self-esteem and confidence. The development of a trusting relationship with link workers was also described as confidence-building in its own right. For some service users these outcomes had led to a whole new outlook. The quotes below show the range of outcomes discussed by respondents. “Surprisingly good really. One lady, frequent attender, wasn’t really going out. She’s been introduced to low level exercise classes and she absolutely loves it. She’s got fibromyalgia, so if I’d told her she had got to exercise, she said ‘I can’t possibly’. She got taken by this lady [link worker], thoroughly enjoys the social outlet, and the exercise has helped with her muscle aches and pains.” [Referrer] “If you can build trust you can resolve a lot of things as the roots can be uncovered. Allow the time to figure out the problem and not go round in circles in the system.” [Link worker] “When you suffer from anxiety and depression, when you’ve got a named person to go to it fills you with confidence. It’s not a crutch, it’s filling a gap they are really good at bridging the gaps.” [Service user] “I feel more confident. Then she referred me to [name of support service] and they helped me a lot with everything, I’m going back into my job now. From next month I start my new job and I’m feeling very proud of myself. I think this 19
is the right organisation who can support me when I was feeling very lonely and helpless.” [Service user] “You realise there is a place for you to go to, someone to talk to. 45 years I have suffered from depression, and now I am starting to feel better.” [Service user] “It empowers people to empower themselves, enable people to become independent again.” [Service user] “Given me a different outlook on life, first meeting I went to [name of support service]. I said I don’t want to exist, I want to live. Before this I had been existing, eating, sleeping, watching the telly. Now I go out, I meet people, probably talk too much.” [Service user] “It’s changed my direction in life. I felt like there was nothing out there for me, and I didn’t want to get involved in different things. But now I’m open to anything, I’ll do anything just to keep myself occupied, doing things and eventually enable me back into work.” [Service user]
Improvements to the social prescribing service As shown above, respondents were overwhelmingly positive about the need for the social prescribing service, about its implementation, and its impact for service users. Nevertheless, some suggestions for improvement were made: •
Referral routes: The service has expanded its referral routes to care navigation and frontline staff over the past year, which has been viewed favourably by respondents. There was a suggestion that opening up the service to allow for self-referral would potentially benefit a wider cohort of patients, and save time for referrers. However, this view was not uncontested as some also made the argument that accessing the service via ‘prescription’ meant that referrals are more appropriate, and that this helps manage the workload and safeguard the capacity of the service, maintaining the person-centred approach and impact demonstrated earlier from both quantitative and qualitative findings.
•
Starting the conversation: With respondents describing initial confusion with the term ‘social prescribing’ there was a suggestion that, ‘some literature to say these are things to look out for and this is how to strike up a conversation about what social prescribing can do for you’, would be useful for referrers when speaking with patients.
•
Communication: There was a suggestion for better communication of how a referral has progressed – e.g. whether the service user has engaged and what 20
the outcome has been. This seemed to be dependent on type of referrer, with the falls prevention team being better informed than GPs at present. One referrer also suggested that, as the service grows, it would be useful to receive regular updates of the average waiting time to speak to a link worker to ensure smooth transitions for the patient. A further related suggestion was for link workers to work more closely with GPs, for example by being co-located in practices across the City. •
Awareness of service: Many respondents thought that there needs to be greater awareness of the social prescribing service, with one respondent commenting that some GP practices are not engaging with it as well as others. Referrers reflected that case studies are very powerful as they show both potential impact and scope of the service: “case studies about outcomes and that’s just clarified to all of the team who you would refer and for what reasons”.
•
Children eligible for service: A final suggestion was that the social prescribing service is opened up to support children, who would also benefit greatly from support with non-clinical needs.
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4. Conclusion and Recommendations 4.1 Conclusions The evaluation clearly demonstrates that the Wolverhampton social prescribing service has been successful in advocating its presence across the City since its launch to receive a wide range of referrals, and overwhelmingly positive feedback from referrers, providers, and service-users. There is also strong evidence of impact for a range of outcomes, with statistically significant differences showing positive impact on wellbeing and loneliness. More specifically, the main conclusions from this evaluation are: •
The policy context is favourable. Despite social prescribing not being a new concept, political interest in it has recently grown. The cross-Government strategy to tackle loneliness (2018), together with the NHS 10 year plan (2019) sets out commitments to extend these approaches further. Evidence of their effectiveness is therefore of significant national interest.
•
The right people are being supported. Referrals have increased steadily with the last quarter of 2018 seeing nearly double the number of referrals seen in the first quarter the service ran. As is common with this sort of service more women are being seen than men. There is a good mix of ethnic groups representing the make-up of the Wolverhampton population, and most service users are aged 60 years or over. The most common reasons for referral are loneliness and lowlevel mental health conditions.
•
Impact on wellbeing and loneliness is statistically significant. Consistent with previous evaluation findings (for example, Kimberlee et al., 2014; and Woodall et al., 2018), service users made significant improvements in wellbeing following their contact with the service, compared to their baseline measures. This was also the case for each of the wellbeing subscales of life satisfaction, feelings of worthiness, happiness, and anxiety. Levels of loneliness also decreased for service users following their contact with the service. This finding was evidenced separately for both emotional and social loneliness sub-scales.
•
Impacts are potentially cost-saving. Findings of a reduction in primary care health use were also statistically significant for those service-users who were the highest utilisers of GP/practice nurse appointments – those who had attended six or more appointments in the six months preceding contact with the service. This is consistent with the research literature, (e.g. Polley et al., 2017a). Based on the healthcare utilisation data, a conservative Return on Investment was 22
calculated to be £0.15 for every £1 invested. Given data limitations, these findings should be treated with caution however. •
Qualitative findings support quantitative findings. The service is highly regarded by referrers, providers, and service-users. A range of outcomes were reported; in addition to improved wellbeing and loneliness, respondents discussed improved mental health, confidence, self-esteem, and in some cases improved physical health. The service has met with challenges however – a key one being in relation to service gaps; befriending services were highlighted as a particular gap. Suggestions for improvements to the service included further awareness-raising of it, better communication (to service users of nature of the service, and to referrers in relation to progress of those referred), and wider access – e.g. through self-referrals and supporting children.
4.2 Recommendations The conclusions above lead us to make the following recommendations: •
Disseminate findings widely. The favourable policy context should be utilised to maximise visibility of this report and other related outputs. Although data limitations mean that these findings are preliminary, the evaluation has made a valuable contribution to the wider evidence base on social prescribing. The research literature in this area is still scant – these findings should therefore be disseminated in local and national fora to help put Wolverhampton’s social prescribing service ‘on the map’.
•
Continue supporting the service. All evidence reported here points to a continuation of the service, ensuring that its key strengths continue to be reflected at the core of the service offer. These include: o Link workers provide a person-centred approach that ‘listens’, and responds, to the needs and pace of the service user. o The service has recruited well to the link worker positions - empathetic, kind and approachable staff who are suited to the role working with oftenvulnerable individuals. o The link workers have a breadth of knowledge of local services available. o Validated and widely used scales used to monitor the impact of the service on wellbeing and loneliness. ONS Scale is used in the Annual Population Survey and use of the De Jong Gierveld Scale of loneliness has been advocated by the Campaign to End Loneliness (no date). o The referral form is simple and easy to complete for referrers and embedded into the systems in place. 23
In addition to these strengths, the service would benefit from the following improvements: o Routine provision (around once a quarter) of a progress summary document to referrers detailing the number of referrals received from each practice, and the nature of support provided and progress made. This could be used to highlight examples of inappropriate referrals or updates to the service that they may find useful. Given the capacity of link workers at present, the CCG may need to support this additional request of the service. o Raise awareness of the service and its impact to relevant services across the City to promote wider referrals to the link workers. Utilise the evidence in this report and case studies to highlight how the service works, who it is suitable for, and its potential for impact. The CCG would need to closely monitor increased demand of the service and consider whether additional link workers need to be supported to meet this demand. o Create a short crib sheet for referrer use, with a simple explanation of what social prescribing is and how to start up a conversation with patients. o The gaps in befriending be strategically addressed, to free up time for the link workers to be the ‘link’ rather than becoming a befriending service themselves, in the absence of such a service to refer on to. •
Improve data capture. The evaluation has highlighted data limitations which hamper the confidence with which we can report impact. We therefore recommend this is improved to enhance future evaluation of impact and cost effectiveness. In particular we recommend: o Collecting outcomes data for loneliness and wellbeing routinely every 3 months for all service-users. This will strengthen the evidence available to examine the impact of social prescribing. o Improve clarity of records to explain whether individuals accepted the referral and describe duration for which they were actively engaged with the service. Clearer recording of dates exiting the service would also aid data analysis. o Clearer information recorded about the role of the link worker and number of visits for more extensive ROI calculations.
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5. References Bickerdike, L., Booth, A., Wilson, P.M., Farley, K., Wright, K. (2017). Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open. 7, e013384, doi: 10.1136/bmjopen-2016-013384 Brandling, J., and House, W. (2009). Social prescribing in general practice: adding meaning to medicine. British Journal of General Practice, 59 (563), 454-456. Braun, V. and Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2), 77-101. Campaign to End Loneliness (no date). Measuring your impact on loneliness in later life. Campaign to End Loneliness: London. Caulfield, L.S. and Hill, J. (2018). Criminological skills and research for beginners: a student’s guide. London: Routledge. Chatterjee, H.J., Camic, M.M., Lockyer, B., and Thomson, L.J.M. (2018). Non-clinical community interventions: a systematised review of social prescribing schemes. Arts and Health, 10 (2), 97-123. Curtis, L., and Burns, A. (2018). Unit Costs of Health and Social Care. Personal Social Services Research Unit (PSSRU): University of Kent. Dayson, C., and Bashir, N. (2014). The social and economic impact of the Rotherham Social Prescribing Pilot: Main Evaluation Report. Sheffield Hallam University: Centre for Regional, Economic and Social Research. de Jong Gierveld, J., and van Tilburg, T.G. (2006). A 6-item scale for overall, emotional, and social loneliness: Confirmatory tests on survey data. Research on Aging, 28, 582-598. General Practice Forward View (2016). https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf Kimberlee, R. (2016). What is the value of social prescribing? Advances in Social Sciences Research Journal, 3 (3). Kimberlee, R., Ward, R., Jones, M., and Powell, J. (2014). Measuring the economic impact of Wellspring Healthy Living Centre's Social Prescribing Wellbeing Programme for low level mental health issues encountered by GP services. University of the West of England. McDaid , D., Bauer, A., and Park, A-L. (2017). Making the economic case for investing in actions to prevent and/or tackle loneliness: a systematic review: A briefing paper. Personal Social Services Research Unit: London School of Economics and Political Science. 25
McDaid, D., Park, A-L. and Fernandez, J-L. (2016). Reconnections Evaluation Interim Report, London, Social Finance. Nesta (2013). More than medicine: new services for people powered health. London. NHS Five Year Forward View (2014). https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf NHS Long Term Plan (2019). https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-termplan.pdf Office for National Statistics (ONS) (2018a). Personal Wellbeing estimates. https://www.ons.gov.uk/releases/personalwellbeingintheukjuly2017tojune2018 and https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/datasets/headline estimatesofpersonalwellbeing Office for National Statistics (ONS) (2018b). Personal well-being user guidance. https://cy.ons.gov.uk/peoplepopulationandcommunity/wellbeing/methodologies/perso nalwellbeingsurveyuserguide Our health, our care, our say: a new direction for community services (2006). White Paper. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/272238/6737.pdf Polley, M., Bertotti, M., Kimberlee, R., Pilkington, K., Refsum, C. (2017a). A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications. Technical Report. Department of Health, University of Westminster. Available from: http://eprints.uwe.ac.uk/33144 Polley, M.J., Fleming, J., Anfilogoff, T., Carpenter, A. (2017b). Making sense of social prescribing. London University of Westminster. https://westminsterresearch.westminster.ac.uk/download/f3cf4b949511304f762bdec 137844251031072697ae511a462eac9150d6ba8e0/1340196/Making-sense-ofsocial-prescribing%202017.pdf The Kings Fund (2017). https://www.kingsfund.org.uk/publications/social-prescribing Torjesen, I. (2016). Social Prescribing could help alleviate pressure on GPs. BMJ, 352, i1436. Woodall, J., Trigwell, J., Bunyan, A-M., Raine, G., Eaton, V., Davis. J., Hancock, L., Cunningham, M., and Wilkinson, S. (2018). Understanding the effectiveness and mechanisms of a social prescribing service: a mixed method analysis. BMC Health Services Research, 18: 604.
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