Impact of a social prescribing intervention in North East England on adults with type 2 diabetes: the SPRING_NE multimethod study.

Background: Link worker social prescribing enables health-care professionals to address patients' non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking. Objectives: To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement. Data sources: Quality Outcomes Framework and Secondary Services Use data. Design: Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April-July 2020). Study population and setting: Community-dwelling adults aged 40-74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK. Intervention: Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions. Participants: (1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients. Main outcome measures: The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score. Results: Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (-1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to -£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval -0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems. Limitations: The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise. Conclusions: This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances. Future work: To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts. Trial registration: This trial is registered as ISRCTN13880272. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

Social prescribing happens when health-care staff refer patients to a link worker. Link workers support and help patients to access community services to improve their health and well-being. Social prescribing is popular within the NHS, but there is little evidence that it works. We looked at a social prescribing model being delivered in a disadvantaged area in north-east England.

COVID-19 and the role of Voluntary, Community, and Social Enterprises in northern England in responding to the needs of marginalised communities: a qualitative focus group study.

BACKGROUND: The Voluntary Community and Social Enterprise sector has a crucial role in supporting the health and wellbeing of people who are marginalised or who have multiple complex needs. We aimed to understand perceptions of those working in the sector and examine the short-term, medium-term, and long-term effects of COVID-19 on Voluntary Community and Social Enterprise organisations in northern England as they respond to the needs of marginalised communities. This research formed one component of a regional multiagency Health Inequalities Impact Assessment. METHODS: We conducted qualitative focus groups with staff and volunteers from five organisations between March and July, 2021, via a video conferencing platform. Eight of nine focus groups were audio-recorded and transcribed verbatim. One focus group was not recorded due to concerns raised over anonymity and safeguarding, but non-ascribed fieldnotes were taken. Focus group transcripts were analysed using framework analysis. FINDINGS: One organisation supported children and young people; two organisations supported vulnerable women, young people, and families; one organisation supported refugees and asylum seekers, and one organisation supported disadvantaged individuals to improve their mental and physical health and wellbeing. Three central themes were identified: the exacerbation of pre-existing inequalities, adversity, and challenges for vulnerable and marginalised populations; the cost of being flexible, innovative, and agile for Voluntary Community and Social Enterprise staff and volunteers; and the voluntary sector as a lifeline (organisational pride and resilience). INTERPRETATION: The considerable expertise, capacity, and resilience of Voluntary Community and Social Enterprise organisations and the crucial role they have in supporting marginalised communities has been clearly shown in their response to the COVID-19 pandemic. The Voluntary Community and Social Enterprise sector therefore has an essential role in the post-COVID levelling-up agenda. The implications of these findings for service provision are that the Voluntary Community and Social Enterprise sector must be recognised as an integral partner within any effectively functioning local health system and, as such, adequately resourced to safeguard sustainability and to ensure that attempts to involve the sector in addressing the social determinants of health are not jeopardised. FUNDING: National Institute for Health and Care Research (Applied Research Collaboration North East and North Cumbria (grant reference NIHR200173) and Public Health England. SSo is supported by a Health Education England and National Institute for Health and Care Research Integrated Clinical Academic Lecturer award (reference CA-CL-2018-04-ST2-010) and Research Capability Funding, National Health Service North of England Care System Support. VJM is funded by the National Institute for Health and Care Research School for Public Health Research (grant reference PD-SPH-2015).

Managing disruption at a distance: Unequal experiences of people living with long-term conditions during the COVID-19 pandemic.

The COVID-19 pandemic and 'lockdown' restrictions have affected people's health and wellbeing globally. Those who are clinically vulnerable to COVID-19 mortality due to living with long term conditions (LTCs) are at greater risk of negative impacts on their health and wellbeing, and of disruption in management of their LTCs. This study explores how people with LTCs managed their health and wellbeing under social distancing restrictions and self-isolation during the first wave of the COVID-19 pandemic, and examines why some people were more able to manage than others. Interviews were conducted between May and July 2020 with people (n = 44) living in North East England, who had one or more LTCs and were recruited via a social prescribing intervention. Data were analysed using a social constructivist thematic analysis. We present our analysis of the possibilities afforded to people to manage the impacts of lockdown on their health and wellbeing. We find that while some people deployed a range of capitals and/or etched out 'tactics' to make life 'habitable', others experienced 'zones of impossibility' requiring that they rely on contingent events or formal support. Our analysis highlights inequalities amongst people with LTCs, particularly regarding access to and deployment of important resources for health and wellbeing under COVID-19 social distancing restrictions, including outdoor space or greenspace, exercise and social connection. The study is novel in showing the mechanisms for coping with a significant period of disruption in the life-course whilst highlighting that although resilience was common in people with LTCs, this was sometimes at detrimental costs to themselves.

Social prescribing during the COVID-19 pandemic: a qualitative study of service providers' and clients' experiences.

BACKGROUND: COVID-19 public health restrictions, such as social distancing and self-isolation, have been particularly challenging for vulnerable people with health conditions and/or complex social needs. Link worker social prescribing is widespread in the UK and elsewhere and is regarded as having the potential to provide support to vulnerable people during the pandemic. This qualitative study explores accounts of how an existing social prescribing service adapted to meet clients' needs in the first wave of the pandemic, and of how clients experienced these changes. METHODS: Data were collected in a deprived urban area of North East England via remote interviews with clients (n = 44), link workers (n = 5) and service provider managerial staff (n = 8) from May-September 2020. Thematic data analysis was conducted. RESULTS: The research found that service providers quickly adapted to remote intervention delivery aiming to serve existing clients and other vulnerable groups. Service providers experienced improved access to some existing clients via telephone in the first months of remote delivery and in some cases were able to engage clients who had previously not attended appointments at GP surgeries. However, link workers also experienced challenges in building rapport with clients, engaging clients with the aims of the intervention and providing a service to digitally excluded people. Limited link worker capacity meant clients experienced variable contact with link workers with only some experiencing consistent support that was highly valued for helping to manage their conditions and mental wellbeing. Limited access to linked services also adversely affected clients. Clients living in less affluent circumstances and/or with worse health were more likely to experience negative impacts on their long-term condition. Some found their health and progress with social prescribing was 'on hold' or 'going backwards', which sometimes negatively affected their health. CONCLUSIONS: Social prescribing offered valued support to some during the pandemic, but remote support sometimes had limited impact for clients and findings highlight the vulnerability of social prescribing's success when linked services are disrupted. Findings also show the need for more to be done in the upscaling of social prescribing to provide support to digitally excluded populations.

"I wouldn't survive it, as simple as that": Syndemic vulnerability among people living with chronic non-communicable disease during the COVID-19 pandemic.

The co-occurrence of COVID-19, non-communicable diseases and socioeconomic disadvantage has been identified as creating a syndemic: a state of synergistic epidemics, occurring when co-occurring health conditions interact with social conditions to amplify the burden of disease. In this study, we use the concept of illness management work to explore the impact of the COVID-19 pandemic on the lives of people living with, often multiple, chronic health conditions in a range of social circumstances. In-depth interviews were conducted between May and July 2020 with 29 participants living in a city in North East England. Qualitative data provide unique insights for those seeking to better understand the consequences for human life and wellbeing of the interacting social, physical and psychological factors that create syndemic risks in people's lives. Among this group of people at increased vulnerability to harm from COVID-19, we find that the pandemic public health response increased the work required for condition management. Mental distress was amplified by fear of infection and by the requirements of social isolation and distancing that removed participants' usual sources of support. Social conditions, such as poor housing, low incomes and the requirement to earn a living, further amplified the work of managing everyday life and risked worsening existing mental ill health. As evidenced by the experiences reported here, the era of pandemics will require a renewed focus on the connection between health and social justice if stubborn, and worsening health and social inequalities are to be addressed or, at the very least, not increased.

COVID-19 at the deep end: experiences of primary care staff working in the most deprived areas of England during the COVID-19 pandemic

BackgroundCOVID-19 is disproportionately impacting people in low-income communities. Primary care staff in areas of high blanket deprivation (also known as the ‘Deep End’) have unique insights into the challenges posed by the pandemic. We aim to explore the impact of the COVID-19 pandemic from the perspective of Deep End primary care practitioners in North East England, the most deprived region of the country.MethodsSemi-structured interviews followed by thematic analysis. 13 participants were interviewed (11 GPs, 1 nurse practitioner and 1 district nurse) with Deep End careers ranging from 3 months to 31 years. Participants were recruited via purposive and snowball sampling. Semi-structured interviews were conducted using video-conferencing software. Data were analysed using thematic content analysis. Participants were interviewed between September-December 2020, at the start of the UK second wave of the COVID-19 pandemic.ResultsOur results can be categorised into three broad themes: the immediate health risks of COVID-19 on Deep End general practices and patients;factors likely to exacerbate the effects of existing socioeconomic deprivation;and wider implications for remote consulting.DiscussionDeep End practitioners have valuable insights into the impact of social distancing restrictions and remote consulting on patients‘ health and wellbeing and on the delivery of primary care in areas of deep deprivation. Their experiences should guide future pandemic response measures and any move to ‘digital first’ primary care to ensure that existing inequalities are not worsened.

Co-designing a deep end GP network for the North East and North Cumbria (NENC)

BackgroundFrom their Scottish origins in 2009, Deep End GP networks are being established all over the UK and further afield in Ireland and Australia. Formed of primary care practitioners in areas of high blanket socioecocomic deprivation, their common goal it to mitigate health inequalities and champion the cause of primary care. As the North East is the most deprived region in England, it was important to set up a network that was sustainable and reflected the priorities of those who worked in it. The network currently consists of the 34 most deprived practices in the region. Deep End NENC is affiliated with the Newcastle University Applied Research Collaboration’s (ARC) ‘inequalities and marginalised communities’ strand and this work will also be used to direct the ARC research priorities. This project aims to use co-design methodology to gather information from practitioners in the region that could be used to guide the initial steps of the Deep End NENC network. Co-design interviews would also serve to improve engagement and disseminate information about the network.MethodsParticipants were recruited using purposive and snowball sampling, as well as a blanket communication to all Deep End practices. Fifteen semi-structured interviews were carried out with health professionals (11 GPs, 2 social prescribing link workers, 1 nurse practitioner and 1 district nurse) from Deep End practices in the NENC. Due to Covid-19 these were carried out over Zoom before transcription and thematic analysis. Findings from the interviews were communicated to the members of Deep End NENC via webinars and they also formed the part of the Deep End Steering Group spending prioritisation protocol.ResultsA coding framework was used to consider findings at patient level, practice/network level and ‘upstream’ political level. Themes identified were the specific clinical and social challenges in the Deep End;barriers to patient care and access to services;training and recruitment;the need to connect with others who worked in these communities to share best practice;and the need to advocate for the Deep End. The COVID-19 pandemic itself brought challenges that were felt more acutely by Deep End patients and those who cared for them.DiscussionThese interviews were successful at identifying priority areas that will form the basis of the work that Deep End NENC will focus on over the coming years. They also add to the literature around challenges facing staff who work in deprived communities.

COVID-19 at the Deep End: A Qualitative Interview Study of Primary Care Staff Working in the Most Deprived Areas of England during the COVID-19 Pandemic.

COVID-19 is disproportionately impacting people in low-income communities. Primary care staff in deprived areas have unique insights into the challenges posed by the pandemic. This study explores the impact of COVID-19 from the perspective of primary care practitioners in the most deprived region of England. Deep End general practices serve communities in the region's most socioeconomically disadvantaged areas. This study used semi-structured interviews followed by thematic analysis. In total, 15 participants were interviewed (11 General Practitioners (GPs), 2 social prescribing link workers and 2 nurses) with Deep End careers ranging from 3 months to 31 years. Participants were recruited via purposive and snowball sampling. Interviews were conducted using video-conferencing software. Data were analysed using thematic content analysis through a social determinants of health lens. Our results are categorised into four themes: the immediate health risks of COVID-19 on patients and practices; factors likely to exacerbate existing deprivation; the role of social prescribing during COVID-19; wider implications for remote consulting. We add qualitative understanding to existing quantitative data, showing patients from low socioeconomic backgrounds have worse outcomes from COVID-19. Deep End practitioners have valuable insights into the impact of social distancing restrictions and remote consulting on patients' health and wellbeing. Their experiences should guide future pandemic response measures and any move to "digital first" primary care to ensure that existing inequalities are not worsened.