A Learner’s View: Measuring Social Prescribing Outcomes

Conexus Healthcare Social Prescribing

In the first Level 3 Qualification in Social Prescribing course in the UK, Rebecca Dunford, a link worker from the Live Well Wakefield social prescribing service in Wakefield, submitted an assignment during the measuring outcomes unit in the form of a blog.

Ahead of the recruitment of new link workers by primary care networks, Rebecca looks at the tools used in social prescribing, focusing on what’s happening in her patch of Wakefield.

Working with the Conexus Healthcare team, Rebecca kindly gave us permission to publish her blog and share the learning achieved during her qualification. Thanks Rebecca! Grab a brew and take five to read her findings:

Social prescribing is a hot topic, with policies such as the NHS Five Year Forward View (1) mentioning social prescribing, General Practice Forward View (2) listing it as one of its 10 high-impact actions and its place as one of the evidence based components delivering the NHS Comprehensive model of Personalised Care (3).

No set guidelines on models or standardised tools exist at present. Common Outcomes Framework (4) recognises that existing tools reflect local need but note this could impede on collating a national impact picture. It recommends that any tools used by social prescribing services should consider measuring impact on 3 areas, person, community and system.

Wakefield uses a self-developed, holistic social prescribing assessment tool which is freely available to download, but they haven’t always – previously using the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS). Was deciding not to use a validated tool the right move?

Wakefield’s social prescribing assessment tool developed in partnership between South West Yorkshire Partnership NHS Foundation Trust and Conexus Healthcare UK, consists of 25 questions, endorsed by National Institute of Health and Care Excellence and based on New Economic Foundations 5 ways to wellbeing.

The Wakefield tool addresses a wide range of health determinants and asks clients how they’re managing with 5 key areas that are evidence-based ways to improved mental wellbeing (5). Where a client identifies they are struggling with an area linked to mental wellbeing, 0 points are allocated when managing’ 3 points are allocated, resulting in an overall mental wellbeing score. The Wakefield tool is person centred and together client and link worker formulate an action plan to focus on any areas the client feels they would benefit from support.

In contrast, SWEMWBS is a list of 7 statements; clients must rate themselves on a scale of how often they agree with each statement. Resulting in a score that relates to mental wellbeing, it does not highlight specific areas of which the client requires support; this instead must be gathered separately.

When it comes to outcomes, what is Wakefield Live Well Service measuring? What methods are they using? And where do performance indicators and tools come into it all?
Live Well Wakefield provides 4 reviews per client, over a period of 12 months, with their assessment tool used at each review stage, the resulting mental wellbeing scores allow the service to measure impact on mental wellbeing over specific periods and further analyse their effectiveness down to specific support areas; for example debt management or physical activity.

The checklist style of the Wakefield social prescribing tool supports measuring outcomes, ensuring that each client assessed is asked the same questions and in turn offered the same opportunity to request support, resulting in consistency across assessments, and comparability between clients of specific demographics.

SWEMWBS can also be used to assess clients multiple times, maybe easier than the Wakefield social prescribing tool due to its short length and minimal amount of time needed. SWEMWBS limitations within social prescribing is apparent in its lack of ability to highlight specific determinants of health responsible for the scores and therefore additional information would need to be gathered to collect this information. Therefore Social prescribing services using only SWEMWBS could require an additional tool to operate in conjunction.

The Wakefield social prescribing tool, without validation is hard to rival SWEMWBS if we are thinking in terms of evaluations, and evidence base in randomised control trials for example, but in the method used in Wakefield (a heavy focus on a large amount of data collection) it certainly rivals SWEMWBS when it comes to the array of information it can gather.

Wakefield Live Well Service, commissioned by Public Health is required to submit reports relating to key performance indicators (KPI’s). Using data obtained from the Wakefield social prescribing tool is a customised way to allow the Live Well Service to produce reports. KPI’s have been agreed around the Wakefield social prescribing tools data capturing capabilities. Commissioners are informed of referrals in, review figures, face to face/telephone assessment figures, referrals out and to which services. Micro-commissioning is a small grants programme designed to increase capacity in the VCSE, in support of social prescribing interventions. The Wakefield social prescribing tool can be used to provide data on recurrent themes in client need. Most importantly changes in wellbeing scores are recorded from the Wakefield social prescribing tool, allowing commissioners to consider its impact on reducing inequalities and calculate return on investment.

Social Prescribing is about the individual, right? Social prescribing aims to be person centred. Is Wakefield using their clients as a resource to help monitor and evaluate their offer? Is the Wakefield social prescribing tool allowing for this or would SWEMWBS have been a better option to capture this?
Whilst the Wakefield tool does collects baseline scores it is certainly person centred, use of the tool occurs in conjuction with the client, and relies solely on the individual to inform the link worker of their issues by answering the questions. The tool helps clients to prioritise issues and supports in the formulation of action plans. In terms of Arnstein’s Ladder of Citizen Participation (6), the tool places clients at the top, in the ‘Citizens Power’ Area, at the centre of decision making. Due to the lack of details into the cause of selected answers on a SWEMWBS assessment, without further discussion led by a link worker the SWEMWBS assessment doesn’t find priorities or formulate action plans. Tools should be designed to ask clients what they would like to change, otherwise tools fail to be person centred and instead become a baseline and discharge data gathering tool only.

Whilst both the Wakefield Tool and SWEMWBS are filled in with clients present, they differ in that the link worker completes the Wakefield Tool whilst the client completes SWEMWBS. Both approaches allow for client involvement but we have to consider if a client is completing a tool with Likert scales, like SWEMWBS, how ambiguous is the tool? Does one client’s interpretation of the word ‘Rarely’ differ from another’s, and if so, can scores be compared across clients of specific demographics for example? The Wakefield social prescribing tool remains none ambiguous; a person either feels they need support or that they do not.

For interventions to be successful, the client has to be engaged, this is encouraged by making them the decision makers but also equally the skills and knowledge of link workers are key to co-develop the clients action plan.
Outcomes of interventions could therefore rely on the Link Worker themselves.

What skills and knowledge are needed to be able to offer effective Social Prescribing, and how can these be attained?
It is important in social prescribing for link workers to build rapport with their clients, to establish trust; this is achievable through great communication and motivational interviewing skills. Link workers also need to be conscious of their language and consider health literacy at all times to ensure their information is understood.

Link workers should partake in continued professional development, focusing on behaviour change, wider determinants of health and understanding health inequalities, employers should be keen to invest in their workforce to ensure link workers can deal with the multiple complex needs of some clients. Managers should organise appraisals and provide opportunities for link workers skills to be evaluated and action plans to maintain/develop these skills should be put in place.

Shadowing opportunities and peer-learning from senior link workers offers opportunities to support link workers in building skills and knowledge. Shadowing could also extend to other health and social care partners, to improve knowledge on services available and referral criteria’s, to ensure an accurate knowledge base to pass on to clients.

In regards to tools, the Wakefield social prescribing tool with its checklist format is a useful resource to link workers new to the role; this tool also provides prompts to consider what onwards referrals may be suitable. This is very different from SWEMWBS, where link workers are not supported with prompts and any action plan established post SWEMWBS assessment will be solely down to the advisors skills and knowledge.

With a tailored tool and skilled staff, there’s still more that social prescribing services need to focus on to deliver effective services. They should make use of feedback to aid in improvements in quality and resources.
Results of monitoring and feedback on a service guides improvements in many ways, such as improvements in quality, helping to monitor contracts, demonstrating offer of choice and improving staff performance. Feedback can come from many sources, including service users, staff, partners and stakeholders.

Clients in the Wakefield Live Well service are asked to complete Friends and Family forms and comments are reviewed to look for ways to improve service quality. In addition, Wakefield Live Well is engaged in a service evaluation being conducted by its commissioners. As part of this, qualitative interviews with past service users were conducted to evaluate lasting impact. A report was produced, giving feedback and areas of development, a valuable resource for a service keen to meet the needs of its population.

Turning feedback into actions is crucial; it requires good coordination from service managers and a motivated, engaged workforce. In Wakefield they speak of several times how they have used feedback and a plan, do, study, act approach to improve their service:
“We found as link workers we were struggling to find support for clients with learning disabilities, despite our tool reporting struggles, we did not have a solution to offer”. The service asked clients what they would want to see in way of support, the service planned how they could make such a resource available, spoke with VCSE sector organisations, studied barriers and how to reduce them and opened their micro-commissioning fund to welcome applications targeted at meeting the needs of clients with learning disabilities. Finding such a solution demonstrates how social prescribing services can use feedback to improve offering and ultimately improve outcomes.

Utilising staff feedback is another example Wakefield mentioned, due to increasing caseloads, link workers strive to find equal time for all clients on their caseloads. Staff fed back and offered ideas on new ways of working. Since the Wakefield social prescribing tool lends itself to being used in any setting, the service trailed a triage system. This resulted in service improvement as link workers were able to spend more time on those with complex needs. Had the triage service been undertaken using SWEMWBS perhaps they would not have been able to triage as effectively,since action plan generation relies more heavily on the conversation with a link worker.

Of course the above needed a flexible tool and proactive staff to be successful. Can others use resources better to make things more effective and efficient?
With limited budgets in most social prescribing services, utilising resources is key to achieving outcomes. With a social prescribing tool being a huge resource to services, they must ensure it is one that they can make work for anyone, anywhere.

Services can also speak with other organisations to learn how their resources can bring shared benefits. Wakefield Live Well liaised with primary care and other organisations using SystmOne, regarding accessing link workers assessment notes. Feedback suggested it would better link services and ultimately reduce the resource needed (time) to gather the same information. Wakefield Live Well worked with their SystmOne team to have a questionnaire that mimicked their tool, designed and added to SystmOne. SNOWMED codes are also used in SystmOne to record data regarding individuals, which could support other services to follow client journeys.

This would be more difficult if Wakefield were still using SWEMWBS, as other organisations would only be provided a score, and would still have to complete their own assessments to gain causative factors information. If organisations had the resource to do this, then it could be argued that SWEMWBS would be a better option, as a widely used, validated tool’ the scores are recognised across differing services, in contrast the Wakefield tool is unique and therefore their wellbeing scores may not be understood by all.

In conclusion, Wakefield has a brilliant resource in its resource tool, which manages to fit the needs of its link workers, service users and commissioners. When we think about the growth of social prescribing and future evaluations into its effectiveness, social prescribing services may need to use a validated tool’ if great services like Wakefield Live Well are to be recognised as ‘gold standard’ within such evaluations. SWEMWBS being used in conjunction with the Wakefield tool sounds like a great option and one that could support social prescribing services to creating an evidence base.

While tools, skills and resources help to achieve outcomes, what support mechanisms are achieved through social prescribing?
A combination of client feedback, link workers skills and the tool lead to gaps in provisions being identified. Micro-commission is then used to address these needs and as a result VSCE sector organisations are able to offer increased provisions to communities, with funding to support increased capacity.

Clients benefit from a tool covering the wider determinants of health and link worker knowledge regarding these. Clients are offered greater choice of support, increasing their knowledge base, leading to feelings of empowerment, improved wellbeing and building support networks within their community.

We should also ask how effective social prescribing can reduce social inequalities. Should resources be used only on those most deprived?
Marmot Review(7) informs us that the lower an individual’s socio-economic status, the poorer their health is likely to be, and that a person’s socio-economic status is what leads to inequalities. He concludes to overcome inequalities all together’ support should be offered to all.

NHS Comprehensive model of Personalised Care(8) discusses a whole population approach, highlighting how it will help to build community resilience, supporting people to better manage their own health, reiterating the need for social prescribing to be community based.

Services need to ensure they are community based, to reduce barriers such as transport and finances. They also need to be flexible to make the most of resources, for example, visiting with other services to ensure joined up care. Services could also aim to employ link workers who speak the languages of the communities they work within or offer a translation service as to further ensure inclusion for all.

I have to agree, since person centred social prescribing accepts that anyone, anywhere, regardless of socio-economic status, can face things in life they may need support with, it only seems right that it’s a universal offer. Effective social prescribing is about inclusion!

With limited funding and resources, services could find a universal offer difficult to manage, to help they could triage referrals and offer different tiers of support. Services could offer additional options such as micro-commissioning, community developments roles, or base link workers in community venues, to support deprived areas.

After all, if we don’t offer SP to everyone, in the long run won’t we just move inequalities to another area?
By Rebecca Dunford.

Learn more about the Level 3 Qualification in Social Prescribing from Conexus and its partners.