This document is a stand-alone discussion paper that forms part of a wider programme of research into understanding the barriers that exist for a Social Prescribing Link Worker to refer into physical activity. The hypothesis is that Open Data will provide a richer, more reliable and broader set of information that will support Social Prescribers to encourage an increased number of patients to take up physical activity.
The document sets out some headline information about
The current and growing scale of Social Prescribing activity across the country
An estimate of the value of SP activity in providing a successful referral into physical exercise
A broader perspective on potential referral activity
An overview of the different measurement tools that are used in association with Social Prescribing
Some conclusions, therefore about how to best position OpenActive within this broader set of considerations.
The information presented is based upon a limited set of data; narrow sample sizes will always provide information that will make any decisions difficult, as it represents limited and unscientific evidence. However, there is some emerging dialogue locally and nationally that there is a need for some evaluation of Social Prescribing. This paper simply plays back findings about what is currently being measured and offers commentary about where and how this research might move forward.
The Scale of Social Prescribing Activity
There are 1250 Primary Care Networks across the country; each has an average of approximately 1.5 Social Prescribing Link workers currently. The ambition is that this may increase to nearer two by the end of the current calendar year. A PCN consists of 4 or 5 GP practices on average and covers a population of approximately 30-50,000 people. Each PCN has autonomy on how their
@SPLW
will work. However, broadly the interviews across all of Pennine Lancashire, Southport, North Lincolnshire and one London Borough indicate the following
On average, each SPLW tends to support a case load of about 40 people at any one time
They tend to “turnover” their case load approximately every two months (meeting people 3-4 times in that time period perhaps)
This therefore equates to an annual case load of about 200-240 people in a year per SPLW (allowing some time-off for leave and training etc).
What seems to be emerging, is some angst that this level of productivity is too low. One of the GPs interviewed commented, when pushed, that there is a notable discrepancy between their own workload in treating 30 people per day, which is 50% more than a SPLW “treats” in a month.
It seems appropriate therefore to predict that caseloads may increase slightly in the coming months. The table below offers a potential range of the total numbers of SPLW cases per annum, therefore. It is believed that these figures may err on the high-side – mainly because Pennine Lancashire, which was the biggest influence into these estimates, has had a number of SPLW trials in place for 5 years and hence have a more established team.
The Structure of SPL Workers
It is important to recognise that each GP practice is a highly autonomous business. The process and approach that each PCN takes to how their SPLW will work differs markedly. On top of that, there have been probably 1,000 SPLW recruited in the last 12 months, who have come from a variety of backgrounds with different experiences. Finally, it is also important to recognise that come April 2022, PCNs will have more freedom about how they invest certain funding; they can choose to invest funds into a range of roles across a PCN, which include physiotherapists, pharmacists, Health and well-being coaches, Occupational therapists and care co-ordinators (which is mostly about palliative care support). The informal indication is that perhaps 30% of PCNs will cease to commission Social Prescribing Link Workers; there is a chance that this flexibility may change.
Social Prescribing is a “busy” market with a lot of initiatives and strategies emerging locally and nationally. Any ambitions to drive change within this sphere needs to recognise these contextual factors.
SPLW process and the ability to make referrals into physical activity
Through the interviews, it was clear that the likelihood that a SPLW would discuss or explore someone’s attitude to or interest in being more active varies enormously. One individual commented that this discussion had happened about 3 times in the last 12 months, where for another SPLW, they commented that in at least 75% of cases, they would encourage someone to consider being more active.
Without fail, every single SPLW interviewed commented that roughly 90% of the people they support are pre-occupied with issues of debt, concerns about housing tenancies, relationship issues, unemployment and underlying anxiety or Mental health issues. All felt that the greatest support they could provide was to help find and then link the patients into an appropriate service or process to help them come to terms with or resolve those issues. Against this backdrop (and with increasing pressure to be more productive perhaps), it is important to recognise that the opportunity and the skillsets required to motivate these individuals into increased levels of activity are under pressure.
The core question is how likely is it that an SPLW process will result ultimately in a prolonged behaviour change in relation to increased exercise. Beyond the individual estimates, there was one GP who kept a more robust set of information; over a two-year period, he tracked how successful he was at encouraging patients to join the Park Run. The result was that he was successful 20% of the time to persuade people to attend at least once; this is someone with great skill and experience, with significant passion for the Park Run and who was targeting the recommendation at people who he was confident would benefit. Over those 2 years, the GP will have delivered over 13,000 appointments that resulted in believing that the Park Run was relevant for 300 people and of those 20% (or 60) ultimately attended. This is in effect is a success rate of 0.5%.
Obviously, a GP has a much broader role, but actually the similarity to the real impact that a SPLW might have could be similar. Most link workers believed that 20% of the time that they recommend anything, then someone would take it up; this is across the board, including getting financial / benefits advice for example as well as referrals to start exercise-related behaviour change.
The range may therefore be that between 0.5% and 2% of all SPLW caseloads may take up exercise once. If the assumption is that 25% of these people take it up sustainably, then the table below offers some indications about the impact that Social Prescribing Link Workers may have on increasing take up of exercise. There are a huge number of factors that will influence these variable outcomes, not least age, underlying conditions or situation, cultural attitudes / beliefs and location; as well as recognising that the starting position of every SPLW will differ in terms of their own beliefs and skills in having these types of conversations.
It is certainly easy to claim that these figures could be higher; the research and the information provided indicate that the current reality is more likely to be significantly less than 1,000 people are persuaded to change their behaviour sustainably through SPLW.
Based upon light-touch research admittedly, what is interesting, is that the scientific evidence is strongest for exercise having a positive impact upon outcomes, for precisely the cohort of people that tend to be supported currently by SPLW. The scientific evidence for the impact of exercise on weight for example is not very good, whereas the scientific evidence for the impact of exercise on Mental Health is fairly good. This certainly, theoretically if not necessarily financially, strengthens the case for the need to invest in the right motivation skills and time to encourage this cohort to consider exercise for their own improved health.
A broader perspective on Social Prescribing
There is a certainly, therefore, a case to be made that there is an opportunity to improve the use of Open Data within GP-referred SPLW cases to deliver an increase in the volume of referrals into exercise. Whether there is a financial return on any investment is less evident, let alone starting to consider who should fund the costs to deliver the changes. There will need to be significant investment into cultural and process change, as well as investment into making Open Data and the supporting technology a reality.
However, similar to the approach adopted by London Sport, any work looking at the use of Open Data within GP-led Social Prescribing, should perhaps consider simultaneously the broad range of other community referral processes, many of which have higher volumes of cases. Perhaps more importantly, some may also target / find people earlier in the development of any underlying health issues. This is important for a number of reasons.
Firstly, arguably, there is better evidence for the positive impact of physical exercise on preventing health conditions, rather than exercise as a “treatment” for existing concerns or issues. In particular, for example, the impact on preventing escalating risks in cardiovascular disease, stroke, diabetes, bone fractures and at a very headline level mortality from all causes. The GP-led referral process targets people who, rightly or wrongly, have decided to seek support from Primary Care and hence their own view is that they need and want treatment – for them the discussion is about treatment rather than prevention
Secondly, people have fewer barriers to overcome where they are found earlier in any health pathway and hence they will be more likely to engage, compared to a stage where they have plucked up courage to seek support from a GP
Driving behaviour change is easiest where there is speedy feedback in terms of evidence of the impact. People may make quicker progress where there are fewer barriers to overcome and hence they may feel encouraged / incentivised to continue.
The following table and diagram, therefore, sets out some other potential referral processes that should also be targeted as opportunities to promote the adoption of Open Data in the same way, alongside SPLW processes. These are estimated volumes, but provides an overview of potential areas to consider.
Many of the recommendations that are being made about changes to the data standard and the tooling, would apply equally to most of these referral pathways. Similarly, it is likely that many of the actual patients being supported by SPLW may well also be receiving support from other community-based professionals and support services; having two professionals advocating similar messages may increase the likelihood of lasting behaviour change.
Looking at this same argument from an alternative perspective, the highly disjointed and variable approach to Social Prescribing indicates that the model remains immature and overly-generic. There may be significant value in re-designing specific SPLW pathways that support specific cohorts, across all of the referral pathways above. Similar to the recommendations in the London Sport research, there may also be some benefit here in creating some specific diagnostic questionnaires that can identify the holistic types of exercise and non-exercise opportunities that may be appropriate for typical client groups such as
· Low level Mental Health
· Those with finance and housing concerns
· People worried about controlling their behaviour
· People with ASD seeking support and access to the right type of reasonably-adjusted pathways and offers.
In summary, any further investment or next steps to drive accelerate the adoption of open data might consider the following:
There may be some changes to the expectations around caseload and productivity for SPLW. It is not guaranteed that increased throughput will drive increased volume of referrals for exercise; the cohort being supported tend to be anxious and moving from say 4 conversations to only 2 with someone may not provide the time to gain their confidence and motivate someone to start to take exercise
The SPLW market is highly fragmented, in terms of the cultural leadership and decision-making. There may be a very high volume of people to influence with each PCN employing 1-2 SPLW on behalf of an average of 3-4 GP practices
There are a high number of other community-based referral processes that might be targeted simultaneously.
The final consideration is that the approach to increasing exercises referral into Social Prescribing should look to position a holistic approach, for the following three reasons
Firstly, the evidence demonstrates that the greatest impact on health outcomes is where exercise is alongside other behavioural change (most notably diet);
Secondly and more importantly, people are within these referral pathways for a reason; what where are seeking is short-term respite from often fairly debilitating concerns; in this context, any push to use social prescribing to increase referral into exercise will need to considered sensitively to ensure it can be positioned as something that people will engage with as an opportunity and discussion
Finally, change being driven within the SP processes is going to create increased pressure on outcomes and productivity and hence it may be better to position OpenActive generically as part of Open Data rather than trying to explain that there are different Open Standards and that not all software products can work with them all. This level of complexity may be a hard set of messages to promote across the very fragmented SP world where there is a lot of competing marketing and transformation pressures.
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