facilitators and barriers of implementing and delivering
TRANSCRIPT
RESEARCH ARTICLE Open Access
Facilitators and barriers of implementingand delivering social prescribing services: asystematic reviewJulia Vera Pescheny*, Yannis Pappas and Gurch Randhawa
Abstract
Background: Social Prescribing is a service in primary care that involves the referral of patients with non-clinicalneeds to local services and activities provided by the third sector (community, voluntary, and social enterprisesector). Social Prescribing aims to promote partnership working between the health and the social sector toaddress the wider determinants of health. To date, there is a weak evidence base for Social Prescribing services.The objective of the review was to identify factors that facilitate and hinder the implementation and delivery ofSP services based in general practice involving a navigator.
Methods: We searched eleven databases, the grey literature, and the reference lists of relevant studies to identifythe barriers and facilitators to the implementation and delivery of Social Prescribing services in June and July 2016.Searches were limited to literature written in English. No date restrictions were applied. Findings were synthesisednarratively, employing thematic analysis. The Mixed Methods Appraisal Tool Version 2011 was used to evaluate themethodological quality of included studies.
Results: Eight studies were included in the review. The synthesis identified a range of factors that facilitate and hinderthe implementation and delivery of SP services. Facilitators and barriers were related to: the implementation approach,legal agreements, leadership, management and organisation, staff turnover, staff engagement, relationships andcommunication between partners and stakeholders, characteristics of general practices, and the local infrastructure. Thequality of most included studies was poor and the review identified a lack of published literature on factors that facilitateand hinder the implementation and delivery of Social Prescribing services.
Conclusion: The review identified a range of factors that facilitate and hinder the implementation and delivery of SocialPrescribing services. Findings of this review provide an insight for commissioners, managers, and providers to guide theimplementation and delivery of future Social Prescribing services. More high quality research and transparent reportingof findings is needed in this field.
Keywords: Social prescription, Implementation, Delivery, Community care, Community referrals
BackgroundPsychosocial problems impact on the health and wellbeingof people [1]. Primary care staff may feel overwhelmed andnot equipped to handle the psychosocial problems that pri-mary care patients present with [2, 3]. The commonlyavailable options for patients presenting psychosocial prob-lems are medication, psychotherapy (cognitive behaviouraltherapy), and counselling [4]. Despite the potential benefitsand policy attention, third sector (community, voluntary,
and social enterprise sector) support to address the widerdeterminants of health in primary care often remains un-derused due to weak or non-existent links between the twosectors [5].Social Prescribing (SP) is a relatively new approach
in primary care that promotes partnership workingbetween the health and the third sector [5]. Further-more, SP expands the range of options available toGeneral Practitioners (GPs), as it creates a formal meansof enabling GPs to link patients with non-medical sourcesof support within the third sector [2, 6]. There is no* Correspondence: [email protected]
Institute for Health Research, University of Bedfordshire, Luton, UK
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Pescheny et al. BMC Health Services Research (2018) 18:86 DOI 10.1186/s12913-018-2893-4
definition of what sources of support constitute SP,examples of services and activities include art therapy,walking and reading groups, exercise classes, nature-based activities, and volunteering, as well as supportwith employment, debt, housing, and legal advice [3,7]. The current health policy and guidelines, such asthe English NHS’s 5 Year Forward View [8], theSocial Value Act [9], and the National Institute forHealth and Care Excellence (NICE) guidelines [10],are supportive of elements and approaches inherentto SP models.SP models with different referral routes exist, for
example, primary and social care patients may self-refer or be referred by a healthcare or other profes-sional. Models may include a navigator (also termed afacilitator, referral agent/worker, coordinator, and so-cial prescriber). The navigator’s role is to identify thenon-medical needs of patients referred to a SP serviceand to refer, or signpost, them to sources of supportwithin the third sector. Workshops hosted by Brom-ley Primary Care Trust (PCT) established the follow-ing six SP models [6]:
Model 1: Information serviceThis service is an information only service, withadvertising and directory access to SP in a primary carepractice.Model 2: Information service and telephone lineThis service advertises SP on leaflets and notice boardsin a primary care practice. Based on this information,patients can self-initiate a telephone discussion with aworker.Model 3: Primary care referralPrimary health care professionals assess patients duringconsultation and refer them to SP services ifappropriate, for example if patient have non-clinical is-sues and require psychosocial support. Referrals to SPservices are opportunistic.Model 4: Practice based generic referral worker:Primary care patients can be referred by healthworkers, or self-refer to a SP link worker. Clinics areheld in the GP surgery, so that it can act as a “one stopshop”.Model 5: Practice based specialist referral worker:A specialist worker works from primary care practiceand patients can be referred through primary carereferral or self-referral. Direct advice and specific ser-vices, such as Citizens Advice, may be offered, as wellas referral or signposting onwards.Model 6: Non-primary care based referral worker:Patients are referred to an external referral centre byprimary care practice staff, offering one-to-one facilita-tion, for example an outreach service or set in thecommunity.
In addition to these six models, Kimberlee et al. (2014)delineates SP interventions into the following four types:signposting, light, medium, and holistic. More informa-tion on these four types can be found somewhere else[11]. It is clear from the literature, that as of yet, there isno agreed definition of SP and different models exist. Itis likely, that different models face different challengesduring the implementation process and delivery of theservice, due to the involvement of different pathways,organisations, and stakeholders. For instance, referredpatients may be more likely to take up an activity whena supportive structure, i.e. a navigator, exists [2, 3].Previous reviews have assessed the effectiveness of
SP [7, 12, 13]. These reviews consistently found littlegood quality evidence [7, 12–14]. Randomised con-trolled trials are considered as the most reliablemethod, the ‘gold standard’, of determining effective-ness of interventions [15]. Although high quality re-search on the effectiveness of non-pharmacologicaland complex interventions, such as SP, is essential toinform policy and practice, outcome evaluations inisolation leave many important questions unanswered[16]. Effect sizes do not provide policy-makers withinformation on factors predicting or hindering imple-mentation success, the processes of implementation,and how contextual factors influence the delivery andoutcomes of interventions [16]. The value of processevaluations of complex interventions, as a comple-ment not substitute to outcome evaluations, has beenrecognised and process evaluation has been added tothe updated guidance of the Medical Research Coun-cil (MRC) in 2008 [17]. The MRC defines processevaluation as a study that examines the implementa-tion, mechanisms of impact, and contextual factors tounderstand the functioning of an intervention [16].Implementation research can consider any aspect ofimplementation, including factors that hinder andfacilitate the implementation and delivery of an inter-vention [18]. Previous research found that a numberof common facilitators and barriers emerged acrossintegrated care pilots in the UK [19, 20]. Factors thatappeared to be particularly relevant for integratedcare include existence of training for new staff, staffstability, physician involvement, and information tech-nology systems [19]. In addition, many of the barriersand facilitators to the implementation of integratedcare pilots were found to be those of any large-scaleorganisational change [19, 20]. Examples of such fac-tors include quality of leadership at the top andwithin groups, flexibility of organisational culture, andthe availability of resources.The identification of barriers and facilitators to SP
programmes in the UK can inform policy and practice,and potentially improve future implementation of such
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 2 of 14
programmes [19, 21]. A well-led implementation processis important as it influences the delivery and outcomesof a programme [16]. If a health intervention is not im-plemented sufficiently due to encountered barriers, thedelivery process can be disrupted and negative outcomescan occur [16, 21]. To the best of the authors’ know-ledge, there is no systematic review on factors that hin-der and facilitate the implementation and delivery of SPprogrammes. It is imperative for service commissionersand providers to understand the operational facilitatorsand barriers in relation to specific SP models to informfuture service provision. Furthermore, the synthesis ofthe available evidence on factors that hinder and facili-tate the implementation of specific SP models, promotesan understanding of how the findings can be comparedto those of other integrated care pilots and large-scaleorganisational change.The current review focused on facilitators and barriers
to the implementation of SP models based in generalpractice involving a navigator. In this model, generalpractice staff refers patients to a navigator, who assessthe non-medical needs of patients and refer, or signpost,them to sources of support within the third sector.
Study objectiveThe objective of this review was to identify factors thathinder and facilitate the implementation and delivery ofSP services based in general practice and including anavigator in the UK.
MethodsProtocolMethods of the analysis and inclusion criteria were spe-cified in advance and documented in a protocol. Theprotocol is part of a PhD study and will be made avail-able once the thesis is made publicly accessible.
Study designWe conducted a systematic literature review of studiesassessing SP services based in general practice andinvolving a navigator. Data synthesis built on a narrativesynthesis, using thematic analysis for categorising data.Narrative synthesis is a commonly used method to syn-thesise data in the context of a systematic review [22,23]. As thematic analysis provides the means of identify-ing relevant themes (based on the review question)across large and diverse bodies of research [24], thisapproach was employed to synthesise the findings. Asthis research did not involve human subjects or animals,we did not seek an ethics opinion.
Inclusion and exclusion criteriaSP is an emerging field of research and there is limitedevidence on SP interventions in the UK to date. To
maximise the inclusion of the available evidence on fac-tors that hinder and facilitate the implementation anddelivery of SP interventions, this review was not limitedto a specific study design. Hence, all types of studydesigns, qualitative, quantitative, and mixed-methods,were included in the review. As the review focused onSP services that are based in general practice and involvea navigator (see description in introduction), studies thatdid not meet both criteria were excluded from thereview. Studies involving SP services had to be imple-mented in the United Kingdom (UK), and so all SP ser-vices outside of the UK were excluded. Any studies thatmet the inclusion criteria and referenced any factor thathindered or facilitated the implementation or delivery ofSP services were included in the review.
Search methodsSeveral articles and evaluation reports of SP serviceswere identified through an initial exploratory onlinesearch using the search engine ‘Google’ and the elec-tronic database ‘Web of Science’. To get familiar withrelevant terms, the authors attended steering groupmeetings supporting the implementation of a SP servicein England, attended workshops on SP, and reviewed thesearch strategies of previous literature reviews related toSP. This, together with the objective of the review,informed the terms of the search strategy and supportedthe development of an inclusive and rigorous searchstrategy. Searches were conducted in June and July 2016.Detail of the search strategy is provided inAdditional file 1.Eleven databases were searched from their start dates to
July 2016: CINAHL (The Cumulative Index to Nursingand Allied Health Literature), ASSIA (Applied SocialSciences Index& Abstracts), British Nursing Index, Webof Science, Cochrane library, Medline, PsychInfo, SportDiscuss, HMIC (Health Management Information Con-sortium), and University of York Centre for Reviews andDissemination (DARE, NHS EED, HTA). The searcheswere limited to literature written in English. No date re-strictions were applied.To identify relevant evaluations in UK settings, the
websites of the following organisations were searched:
� The Kings Fund� The Health foundation� NESTA� NICE� Nuffield Trust� Department of Health
Additionally, grey literature was searched in Open-Grey, Google, and Google Scholar. The search terms“social prescribing” and “social prescription” were used
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 3 of 14
to identify the grey literature. The grey literature searchwas conducted in June and July 2016. In addition, thereference lists of all relevant studies, reviews, and re-ports were searched.
Selection of studiesAfter eliminating the duplicates (studies that were iden-tified more than once by the search engines), an initialscreening of titles, abstracts, and summaries (if applic-able) was undertaken by one reviewer with a random25% of the sample checked by a second reviewer. Thefull text was obtained for all the records potentiallymeeting the inclusion criteria (based on the title andabstract/summary only). In a second step, one reviewerscreened the full papers against the inclusion criteria,with a random 25% of sample checked by a second re-viewer. Any discrepancies were resolved through discus-sion between the first and second reviewers and, ifconsensus was not reached, with a third reviewer.
Data extractionData extraction of the included studies was conductedby one reviewer and checked by a second reviewer, usingdata extraction forms tailored to the requirements of thereview. The extraction form was tested on threeincluded papers and, where necessary, it was revised toensure it can be reliably interpreted and can capture allrelevant data from different study designs. Extracteddata included authors, year of study/report, type ofpaper (e.g. journal article, annual evaluation report),study design, description of the SP service (model de-scriptions, referrers, target group), study sample, andfactors that facilitate and hinder the implementation anddelivery of SP services. Any discrepancies were resolvedthrough discussion between the first and second re-viewers and, if consensus was not reached, with a thirdreviewer.
Methodological quality assessmentFrom the literature review it is clear that the evidencebase of SP services in the UK is weak. Therefore, tocapture the available evidence on the implementationand delivery of SP services, for which more rigorousstudies are lacking, no exclusion on the basis ofmethodological quality was made. The authors recog-nised that some studies may have poorly documentedmethodological quality but may have contextually richdetail that contributes to the overall narrative synthe-sis. Assessment was undertaken to ensure transpar-ency in the process and to make the limitations ofpoor quality studies explicit to improve futureresearch.The methodological quality of included studies was
appraised independently by two reviewers using the
Mixed Methods Appraisal Tool Version 2011 (MMAT-V2011) [25]. The conference paper by Polley et al., [28]was not quality appraised, as the MMAT-V 2011 wasnot designed for conference papers.
Data synthesisFindings from included studies were synthesised narra-tively. The ‘Guidance on the Conduct of Narrative Syn-thesis in Systematic Reviews’ was used to advise thenarrative synthesis in this study [24]. First, a preliminarysynthesis was conducted to develop an initial descriptionof the findings of included records and to organise themso that patterns across records could be identified. Thisfollowed the iterative approach of a thematic analysis,where multiple ideas and conclusions across a body ofliterature were categorised into themes [26]. The createdthemes were reviewed and refined throughout theprocess.
ResultsIn total, the titles and abstracts/summaries of 6558 re-cords were screened. Of these, 213 records were consid-ered potentially eligible and were assessed in full text.Eight records met the inclusion criteria of the review.An adapted PRISMA (Preferred Reporting Items for Sys-tematic Reviews and Meta-analyses) flow-chart of studyselection is presented in Fig. 1 [27].In total, the included studies comprised of one confer-
ence report [28] and seven evaluation reports [29–35].The publishing date of the Age UK report is unknown[34]. All other included records were published in thelast 5 years [28–33, 35], highlighting that SP is a rela-tively new phenomenon in the UK. None of the includedrecords were journal articles and factors that hinder andfacilitate the implementation and delivery of Social Pre-scribing services were not the main focus of any in-cluded record. This supports previous claims that thereis a dearth of research adequately exploring facilitatorsand barriers to the implementation and delivery of SPservices in the UK. Summary details of the reviewed lit-erature are available in Table 1.
OutcomesFindings from included records were classified in twomajor groups for this review: (i) facilitators, and (ii) bar-riers to the implementation and delivery of SP.The qualitative research findings of seven mixed
methods studies and one conference paper have beenused for the thematic synthesis. The following sectionwill present the facilitators and barrier by the identifiedthemes.
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 4 of 14
Facilitating factorsImplementation approachApplying a phased roll out approach to implement SPinterventions, i.e. changes are made over a period oftime with a scheduled plan of steps, was identified as afacilitator to the implementation and delivery of SP [31].It has the potential to support the development of newand effective partnerships between GP surgeries, naviga-tors, and the third sector and allows time to develop ashared understanding about the programme and expec-tations between involved partners [29, 31]. It is import-ant to plan a realistic ‘lead in’ time for setting up SPservices, considering that it can take several weeks to setup initial meetings with GP practices [34].
Organisation and managementOrganising a series of workshops to design and dis-cuss a SP service prior to its implementation andstandardised training for involved partners, briefings,and networking events to share best practice wereidentified as facilitators to implementation and deliv-ery of SP services [30, 33]. Training for referrers onhow to explain SP to patients, i.e. words and exam-ples they can use, is likely to encourage referrals toSP services [32]. Regular steering group meetings, todiscuss processes, arrange operational procedures, and
react to challenges, facilitate the implementation anddelivery of SP programmes [31].In addition, flexibility, i.e. hearing what stakeholders
need from the service and altering systems, processes,and communications accordingly, during the develop-ment, implementation, and delivery stage was identifiedas a facilitator to implementation and delivery [31, 35].A flexible approach turned out to be effective particu-larly when working in partnership with GP surgeries, aseach surgery is a unique organisation and may have dif-ferent needs to implement and run SP [31]. A referralsystem for SP, for example, that fits with establishedreferral systems and pathways in the general practice fa-cilitates referrals to SP services [29, 34].
Shared understanding and attitudesShared understanding among clinical and non-clinicalstaff of what can be expected by each partner, the scopeof the SP service, which patients to refer, how patientscan be helped, and the capacity and skills offered by anavigator facilitates the implementation and delivery ofSP services [31]. Shared understanding between partnersfrom different sectors, commissioners, service users, andstakeholders, is crucial to manage expectations and toprevent tensions and disappointment during the imple-mentation and delivery of SP services [28, 31]. Sharedperspectives, attitudes, and understanding of the
Records identified through database searches of: CINAHL, Medline, PsychInfo, SocIndex,
SportDiscuss, Web of Science, British Nursing Index, ASSIA, HMIC, University of York for
reviews and dissemination (HTA, DARE, NHS EED), and Cochrane library
(n=6658)
Records after duplicates removed(n=5758)
Records screened(n=6558)
Full-texts assessed for eligibility(n=213)
Records included in narrative synthesis
(n=8)
Records identified through website and OpenGrey
searches (n=600)
First 200 hits in Google were searched because after that
they were irrelevant or repetitions(n=200)
Records excluded based on full texts
(n=205)1) Did not meet inclusion
criteria2) Did not identify factors
affecting implementation or service user outcomes
3) Records referred to included studies
Records excluded based on title and abstract
(n=6355)1) Topic was not relevant 2) Did not meet inclusion
criteriaRecords identified through reference
list follow up (n=10)
Fig. 1 Adapted study selection flow diagram based on PRISMA [27]
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 5 of 14
Table
1Overview
ofstud
iesandrepo
rtsinclud
edin
thereview
Firstauthor
and
year
Type
Stud
yde
sign
Qualitativedata
collectiontools
Objectives
Participantsin
qualitativeresearch
Interven
tionde
scrip
tion
Dayson2013
[26]
Evaluatio
nrepo
rtQualitative
stud
yInterviews
Toiden
tifyem
erging
lesson
sfro
mtheim
plem
entatio
nandop
eration
oftheRo
therham
SPprog
ramme
Serviceusers,pu
blic
sector
stakeh
olde
rs,
projectstaff,voluntary
andcommun
ityorganisatio
ns
Gen
eralPractitione
rsiden
tifyandreferprim
arycare
patientswith
complex
long
-term
cond
ition
sand
carersof
case-m
anaged
patientsto
anavigatorwho
assesses
theno
n-clinicalsupp
ortne
edsof
patients
andcarersbe
fore
referringthem
toapprop
riate
ser
vicesin
thevoluntaryandcommun
itysector
Friedli2012[23]
Evaluatio
nrepo
rtMixed
metho
dsstud
yInterviews
Tobu
ildlocalevide
nceof
the
bene
fitsof
SPforpatientsand
health
profession
alsandto
iden
tify
operationalissuesandsolutio
nsin
runn
ingapracticebasedsche
me
Serviceusers,ge
neral
healthcare
profession
als,
navigators
Gen
eralpracticestaffiden
tifiesandreferssuitable
patientsto
anavigatorwho
assesses
thepsycho
social
need
sof
patientsandreferthem
toapprop
riate
sourcesof
supp
ortin
thethird
sector
TheHealth
Foun
datio
n2015
[24]
Evaluatio
nrepo
rtMixed
metho
dsstud
yInterviews
Tofillthe
gaps
intheexistin
geviden
cebase
Serviceusers,
navigators,G
Ps,
commun
ityorganisatio
ns,stafffro
mCity
andHackney
CCG
Gen
eralpracticestaffiden
tifiesandreferpatientsto
anavigatorem
ployed
byFamily
Action(FA).The
navigatorassesses
theindividu
als’ne
edsto
refer
them
toapprop
riate
non-clinicalcommun
ityservices
delivered
by85
statutoryandvoluntarygrou
ps
Age
UKnd
[25]
Evaluatio
nrepo
rtNot
specified
Not
specified
Not
specified
Not
specified
Gen
eralPractitione
rsreferpatientsto
localA
geUK
team
swho
assess
thepsycho
socialne
edsof
service
usersandreferthem
toapprop
riate
services
provided
byAge
UK
ERSResearch
and
Con
sultancy2013
[21]
Evaluatio
nrepo
rtMixed
metho
dsstud
yInterviews
Toassess
theim
pact
and
achievem
entsof
theSocial
Prescriptio
nprog
rammein
New
castleandto
documen
tlesson
slearne
dto
inform
furthe
rpractice
Serviceusers,he
althcare
practitione
rs,m
embe
rsof
thesteerin
ggrou
p
Health
care
profession
alsreferpatientswith
psycho
socialne
edsto
oneof
thefivecollabo
ratin
gLinkworkOrganisations
(Age
UK,Health
Works,
New
castleCarers,Search,and
WestEndBefrien
ders).
Link
workerfro
mtheLinkworkorganisatio
nassess
theno
n-clinicalne
edsof
referred
patientsandeither
referthem
toactivities
provided
bythem
orrefer
them
toothe
ractivities
inthethird
sector
tomeet
theirno
n-clinicalne
eds.
Farend
en2015
[22]
Evaluatio
nrepo
rtMixed
metho
dsstud
ySemi-structured
teleph
one
interviewsand
in-dep
thteleph
one
interviews
1.Assesstheim
pact
ofthepilot,for
patients,volunteers,and
Gen
eral
Practitione
rs2.Analyse
costs-be
nefitsandsocial
value
3.Outlinekeylesson
s,challeng
es,and
successes
4.Discuss
oppo
rtun
ities
andrisks
5.Presen
tabu
sine
sscase
with
optio
nsforafuture
mod
el
Serviceuser,G
eneral
Practitione
rs,p
ractice
manager
Gen
eralPractitione
rsiden
tifyandreferpatientswith
psycho
socialne
edsto
anavigatorwho
assesses
the
psycho
socialne
edsof
patientsandrefersthem
toactivities
andservices
inthethird
sector.Six
appo
intm
entsof
45min
areofferedto
areferred
patient.O
nceapatient
isreferred
toan
activity,the
navigatorfollows-up
theprocess,andifne
eded
,of
fersfurthe
rsupp
ort.Navigatorsarevolunteerswith
abackgrou
ndin
helpingpe
opleto
meettheirsocial
orsupp
ortne
eds.
Brandling2011
[20]
Evaluatio
nrepo
rtMixed
metho
dsstud
ySemi-structured
interviews,no
tes
ofnavigators’
reflectivediaries
1.To
measure
theim
pact
onindividu
als’
men
talw
ellbeing
andspecificissues
iden
tifiedat
assessmen
t2.To
assess
user
satisfactionwith
the
socialprescribingservice
Patients,navigators,G
PsHealth
care
profession
alsreferpatientswith
social
diseng
agem
entor
low
moo
dleadingto
aloss
ofconn
ectio
nto
othe
rpe
opleandthecommun
ity,to
theSocialPrescribingprog
ramme(New
Routes).
Navigatorsassess
patients’no
n-med
icalne
edsin
aon
e-ho
urappo
intm
entandconn
ectthem
with
approp
riate
sourcesof
supp
ortin
thethird
sector.
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 6 of 14
Table
1Overview
ofstud
iesandrepo
rtsinclud
edin
thereview
(Con
tinued)
Firstauthor
and
year
Type
Stud
yde
sign
Qualitativedata
collectiontools
Objectives
Participantsin
qualitativeresearch
Interven
tionde
scrip
tion
3.To
unde
rstand
thenature
ofen
gage
men
twith
a‘New
Routes’service
from
different
stakeh
olde
rpe
rspe
ctives
4.To
providecase
stud
iesof
New
Routes
that
illustratethetype
ofworkbe
ingcond
ucted
5.To
useresearch
finding
sas
they
emerge
toinform
thecond
uctof
theSocialPrescribing
servicedu
ringtheservicede
velopm
entand
research
perio
d6.To
useresearch
finding
sas
they
emerge
toinform
thecond
uctandsustainabilityof
the
New
Routes
service
Polley2016
[19]
Con
ference
pape
rQualitative
survey,
discussion
sin
mixed
stakeh
olde
rgrou
ps
NA
Therepo
rtprovides
asummaryof
the
emerging
them
esof
thepre-conferen
cesurvey
anddiscussion
sfro
mtheday
Relevant
stakeh
olde
rsNA
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 7 of 14
programme and strength of partnership are essentialfor effective partnership working between the health,community, and the third sector, which is a keyprinciple of SP interventions [31]. To increase pri-mary care patients’ understanding of SP interventions,the following approaches were recommended: a publi-city campaign [32], working in collaboration with thepractice manager to promote SP on TV screens ingeneral practices [32, 34] and through the practicenewsletter, the practice website, and information inwaiting rooms [34].
Relationships and communicationCreating new relationships between partners based onreciprocity and trust may facilitate the implementationand delivery of SP services [31]. A good relationship be-tween navigators and other partners (i.e. general practicestaff and service providers), is particularly important, asit promotes effective communication [31, 34]. Feedbackon service users’ journeys and outcomes to GPs andpractice staff, via the navigator e.g. during regular meet-ings or a short periodic report, helps general practicestaff to understand how patients progress after their re-ferral [30, 31, 33, 34]. In addition, structured contactand regular communication between navigators andpractice staff, served as a reminder for SP, encouraged ahigher number of referrals, and ensured a greater appro-priateness of referrals [30, 31].Regular feedback and effective communication be-
tween the navigator and service providers in the thirdsector facilitates the implementation and delivery ofSP services, as it allows to react to emerging chal-lenges and promotes shared delivery and partnershipworking [33, 35].
Organisational readinessLessons learnt form the SP pilot in Brighton and Hoveshow that general practices need to be ‘Navigator ready’before a navigator can start to work in a practice. Thefollowing is recommended by Farenden et al. [31] for aGP surgery to become ‘Navigator ready’:
1. It is important that the SP team meets the wholepractice team (clinical and non-clinical staff ) be-fore SP commences. This could happen during atraining session or practice meeting. The SP teamshould ensure they work flexibly when arranginga visit.
2. A partnership agreement needs to be signed betweenthe SP service and the GP surgery hosting it.
3. GPs agree to make regular referrals to the SPservice. Numbers depend on navigators’ capacity.
4. Navigators should be treated as a member of theprimary care staff team. To ensure this happens,surgery staff need to:
� Understand the scope of the SP programme and thenavigator’s role and skills
� Provide a room for the navigator, which areaccessible for patients and allow meetings withoutinterruptions
� Provide an induction including available stafffacilities, safety procedures, computer login details,and telephone access
� Invite the navigator to relevant meetings� Clarify how and when the navigator can contact the
GP directly� Provide a lead staff member who can answer queries
relation to surgery systems and communications� Provide a secure space for navigators to keep their
files, working material, and confident records in thegeneral practice
‘Navigator ready’ practices are crucial to facilitate theimplementation of SP and to ensure that an effectiveand equitable service is delivered to service users [31].A key lesson learnt from the SP programme in Mary-
field is that GPs are more likely to make regular referralsto SP when the practice culture supports holistic andpsychosocial approaches [32]. Moving away from thebiomedical model of health towards a biopsychosocialmodel of health, considering alternatives to traditionalmedical interventions, and addressing wider determi-nants of health, i.e. considering social, psychological, andenvironmental determinants of health instead of focus-ing solely on medical needs, facilitate the implementa-tion and delivery of SP services [32].
General practice staff engagementHealth professionals and practice staff engagement,involving regular referrals to SP, is a facilitator andcrucial for the implementation and delivery of SP ser-vices [31]. Strategies that may encourage and main-tain engagement of health professionals includefeedback letters from navigators to prescribers, regulareducation events and training sessions, encouragingnavigator attendance at surgery staff meetings, havinginformation stalls within practice reception areas, anda brief and easy to complete referral form to reducethe workload for prescribers [31, 33, 34]. Further-more, having SP champions based in general practiceand Clinical Commissioning Groups (CCGs), fosterssupport, encourages regular referrals to the SP ser-vice, raises the profile, and perceived value of SPamong general practice staff [28, 31, 34].
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Support and supervisionThe support of the practice manager is vital for arran-ging meetings with GPs, to build relationships betweenthe SP team and the general practice, and to increaseawareness about SP during the ‘lead in’ time, implemen-tation, and delivery [34]. A supportive structure for navi-gators can facilitate the implementation and delivery ofSP services, however a diverse nature of the supportstructure may require the adherence to multiple differ-ent interests which may have felt conflicting for naviga-tors at some times [29]. A framework for the supportthat should be provided by navigators, facilitates theconsistent delivery of SP services [30].
InfrastructureA wide range of good quality third sector based servicesand activities, that are easily accessible with pubic trans-port, facilitate the implementation and delivery of SPservices [31, 32].
BarriersLeadership and organisationA collaborative multi-sector approach to project man-agement, i.e. involving a diverse group of stakeholders,contributed towards a delayed implementation and de-livery of SP [30]. The lack of a targeted approach to stra-tegic and robust project management, to undertake allthe coordination required for the programme, may resultin less effective and delayed implementation and deliveryof SP initiatives [30].The absence of a robust risk management system, to
be prepared for scenarios that could disrupt implemen-tation and delivery, was identified as a further barrier tothe implementation and delivery of SP [30].Operating a SP service with volunteers as navigators
may delay the implementation and requires a higherlevel of flexibility than is necessary with paid staff [31].Changes to processes and procedures can take longerand may require more intensive support to be imple-mented than what would be expected of paid staff [31].Another identified issue were inconsistencies in recordkeeping that resulted in extra work an costs for staff[31]. Furthermore, volunteer turnover is generally higherthan paid staff turnover, with an average of one in threevolunteers leaving the role within a year [31]. Fre-quent staff turnover disrupted the continuity of thedelivery process and required resources to train newvolunteers [31].A lack of a partnership agreement between the SP ser-
vice and the GP surgery hosting it, outlining the scopeof the programme, the role, and what can be expectedfrom each partner, was identified as a barrier [31]. Itmay lead to tensions, a mismatch of expectations, anddifferent understandings of the SP programme between
partners, which were identified as barriers to implemen-tation [31]. The absence of a mutually agreed servicelevel agreement, including the scope, model, data re-quirements, arrangements, and details of governancestructure was identified as a further barrier [31]. It maylead to constant changes to the agreed model and datarequirements, resulting in increased staffing costs forservice management, navigator coordination, and datamonitoring [31].
Implementation approachA ‘go live dates’ approach to initiate SP in general prac-tices, i.e. following set dates to initiate SP in surgeries,was identified as a barrier to the implementation and de-livery of SP services [31]. Navigators and practice staffwere rushed into hosting SP without building relation-ships and trust between partners, developing shared un-derstanding of outcomes and expectations, agreeingmutually effective working practices, and ensuring thesurgery is prepared to host a navigator [31]. Limitedavailability or lack of designated rooms for navigators insurgeries was identified as a key barrier to the imple-mentation of SP models in which navigators are based insurgeries [31].
Economic climate and fundingIn markets where there is high employee mobility, staffwho are employed via temporary contracts to supportSP pilots (e.g. navigators or project managers), may seekalternative more stable employment, as the future orprospect of their roles might be unclear [31, 35]. Limitedresources may create a barrier to recruit highly skillednavigators, due to relatively low pay [28], and to engageservice providers in the third sector, due to little avail-able funding to support them [33].
Shared understandingThe lack of shared understanding of a SP service andpathway among stakeholders, including prescribers, nav-igators, service users, and service providers, was identi-fied as a barrier to the implementation and delivery ofSP services [29, 31, 33]. Lack of shared understandingmay result in the lack of mutual trust between partnersand prevent effective partnership working, a key elementof SP [31]. Furthermore, limited understanding of the SPpathway among prescribers may result in uncertainty onhow to explain SP to patients, which in turn may hinderreferrals to SP services [29, 32]. It may also hinder theprovision of consistent and fulsome information topatients, which may lead to wrong expectations towardsSP [29]. Lastly, lack of referrers’ understanding may leadto large numbers of inappropriate referrals which hinderthe delivery of the programme to the target group, and
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requires additional time (staff hours), which result inadditional costs and delays [31].
General practice staff engagementLow or no practice staff engagement is a key barrier tothe implementation and delivery of SP, as the SP path-way starts with a referral from practice staff to the SPservice [31]. Lack of trust in navigators, lack of timewithin busy consultations, lack of confidence to explorethe social determinants of health, forgetting about theavailability of SP, and scepticism about patients effect-ively attending activities in the third sector once re-ferred, were identified as barriers to making referrals toSP programmes [28, 29, 31, 33].
Staff turnoverThe continuity of the SP programme in City and Hack-ney was affected when two of the navigators left the SPproject after the first year [33]. The CCG senior projectlead officer left the SP project in Newcastle, which re-sulted in the loss of links to key personnel within theCCG and GP practices, delaying the delivery of the SPprogramme [30].
Patient engagementNo or low patient engagement is a major barrier to theimplementation and delivery of SP services [29, 30, 32].GPs felt that engaging patients is difficult because SP isa new way of working in general practice, which is diffi-cult to explain, and patients do not understand the ideaof SP when GPs explain it in a consultation [32]. Otherreasons for disengagement in SP are: lack of interest inSP and scepticism around its potential benefit [29], pa-tient entrenchment in medical solutions [29, 32], lowmotivation to move from contemplation to action [29],perceived threats to welfare benefits [32], fear of stigma-tisation because of a link to mental health services anddata collection tools such as the Warwick EdinburghMental Wellbeing Scale (WEMWBS) [29], lack of confi-dence [29], money issues, and transport issues to theprescribed services [29].
InfrastructureThere is a risk that available services and activities in thethird sector may be cut below the level of service users’needs, which could hinder the delivery of SP services.Navigators have reported difficulties to refer serviceusers to appropriate services and activities because of re-ductions in scope and long waiting lists [31, 32].The results of the systematic review are summarised
in Table 2.
Quality appraisalMost of the included records failed to attain higher qual-ity scores as a result of lack of detail on methodology.Most of the included evaluation reports lacked clear andwell-focused objectives and did not provide detailed in-formation on data collection tools, recruitment and sam-pling strategies, and data analysis methods.Methodological information tends to be spread overevaluation reports and can be found, for example, infootnotes in small print or in the Appendix. There is alack of a structured and detailed methodology section inmost evaluation reports of SP in the UK, which creates achallenge to the quality appraisal of available evidence.The quality scores of each study are presented inTable 3.
DiscussionMain findingsTo our knowledge, this is the first systematic reviewidentifying factors that facilitate and hinder the imple-mentation and delivery of SP programmes based in gen-eral practice. The review has identified a range ofbarriers and facilitators, which are summarised in Table2. The following barriers and facilitators were found tobe similar to those of other integrated care programmes:Relationships and communication between individualsand organisations [19], professional engagement [19],shared understanding [20, 36], support and training for
Table 2 Summary of identified facilitators and barriers to theimplementation and delivery of SP services
Facilitators Barriers
• A phased roll outimplementation approach
• Realistic planning of ‘lead in’time to set up a SP service
• Workshops to design anddiscuss SP services prior toimplementation
• Standardised trainings,briefings, and networking eventsfor involved partners
• Flexibility during the development,implementation, and delivery of aSP service
• Shared understanding, attitudes,and perspectives of stakeholders
• Good relationships and effectivecommunication betweenstakeholders within and acrosssectors
• SP champions in CCGs and generalpractices
• Navigator ready general practices• A general practice culture thatsupports the biopsychosocial modelof health
• General practice staff engagement• A wide range of good quality thirdsector based service providers
• A ‘go live dates’ approachto implementation
• Lack of partnership andservice level agreements
• A collaborative approachto project management,which results in the lackof a targeted approachto strategic and robustproject management
• Absence of a robust riskmanagement systems
• Volunteers as navigators• Staff turnover• Limited financial resourcesto fund service providersor secure a high salary foremployed staff
• Lack of sharedunderstanding amongstakeholders and partners
• General practice staffdisengagement
• Patient disengagement• A reduction in availableand suitable serviceproviders in the thirdsector
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staff in new roles [20], leadership [19, 37], staff stability[20], a phased roll out approach to implementation [20],and flexibility and permissiveness of organisational cul-ture [19]. All these factors are similar to those identifiedby the Department of Health’s national evaluation of 16integrated care pilots across England [19]. However, thefollowing two themes were not identified by the Depart-ment of Health’s evaluation: Service level and partner-ship agreements and patient engagement. Previousresearch stresses the importance of patient-level factors(e.g. health-relevant beliefs, personality traits, motiv-ation, and trust) for the implementation of health careinterventions [38]. Patient-level factors impact on theoutcomes of implementation efforts, as patients are ac-tive agents and consumers of healthcare [38]. Patient-level factors were identified as relevant factors for theimplementation of integrated diabetes care in Ireland[39]. As found in this study, service level and partner-ship agreements seem to determine the level of sharedunderstanding of stakeholders’ roles, values, and the in-tervention’s goals, scale, and scope. Hence, partnershipand service level agreements may have a direct influenceon shared understanding, which was identified as a rele-vant factor for implementation of integrated care pilotsin the current and a previous study [19, 36]. In additionto the themes that are relevant to integrated care pilotsin general, this study identified a theme that seems to berelevant to SP interventions explicitly: Local infrastruc-ture. Given that SP interventions usually include serviceproviders in the third sector to deliver care to serviceusers, the local infrastructure was identified as a factorinfluencing the implementation process of SP interven-tions. Finally, two factors that are specific to SP modelsbased in general practice and involving a navigator wereidentified: Navigator ready surgeries and the involve-ment of primary care practice managers in the develop-ment and implementation of the intervention.Findings of this study indicate that many barriers and
facilitators to the implementation of SP programmes aresimilar to those of other integrated care pilots and any
large-scale organisational change [19]. However, someidentified factors are specific to social prescription inter-ventions, and specific to SP models. Hence, lessonslearnt from the implementation process of other inte-grated care pilots can inform the implementation of so-cial prescription interventions, but do not considerintervention specific factors such as the local infrastruc-ture, navigator ready surgeries, and the involvement ofpractice managers. Developing an evidence base on facil-itators and barriers to specific SP models allows policymakers, managers, and practitioners to promote facilita-tors and overcome specific potential barriers, to improvethe implementation and delivery process of SPinterventions.Consistent with the findings of other reviews of SP
services, this review has found that the quality of themajority of included studies was poor [7, 12–14]. Themethodologies were often poorly reported, with sparsedata on numbers of participants, a non-comprehensivesampling strategy, and a lack of information on theprocess of collecting and analysing data. In addition, thereview found that all of the included studies and reportsmade reference to barriers and facilitators to the imple-mentation and delivery of SP services, but none lookedspecifically at these factors. In addition, besides a com-prehensive search strategy including a large number ofdatabases, all included studies were identified throughthe grey literature search or screening of reference listsof relevant literature. Hence, there is a clear need forrigorously designed, analysed, and transparently reportedresearch studies on barriers and facilitators to the imple-mentation and delivery of SP services. Particular consid-eration should be given to the dissemination of researchfindings.The publication date of the included AGE UK report
is unknown [34]. All of the other seven included recordswere published in the last 5 years [28–33, 35], indicatingthat SP is a relatively new phenomenon in the UK.
Relationships between identified facilitators and barriersThrough the thematic analysis, the interrelationship be-tween identified facilitators and barriers was exemplified.For example, a phased implementation approach affectsother factors that were identified as facilitators, namelyshared understanding, relationships, and navigator readysurgeries. Figure 2 shows the identified interrelationshipsbetween facilitating factors and Fig. 3 shows the interre-lationships between barriers. These interrelationshipsshow that the implementation and delivery of SP ser-vices is a complex process. Barriers and facilitators canpromote other barriers and facilitators or their relation-ship can be bidirectional, as for example between thefollowing two facilitators: Relationships and communica-tion (Fig. 2). Good relationships between partners seem
Table 3 Quality scores of included studies calculated using theMMAT-V 2011
First author and date Overall quality score
Brandling 2011 [20] ***
Dayson 2013 Chapter 4 [26] **
Farenden 2015 [22] **
Friedli 2012 [23] *
The Health Foundation 2015 [24] *
ERS Research and Consultancy 2013 [21] *
Age UK n.d [25] –
Scoring metrics: ‘-’ = Further appraisal was not feasible as the answers to thetwo screening questions were ‘no’ or ‘can’t tell ‘*’ = 25%, ‘**’ = 50%, ‘***’ = 75%
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 11 of 14
APhased roll out implementation approach
BFlexibility when developing, implementing, and delivery SP
C Shared understanding
D Relationships
E Communication
F Supportive general practice culture
G General practice manager involvement
H Navigator ready surgery
I Training for stakeholders
J Stakeholder engagement
D J
E K
C
J
D H
D
H J K
D J K
K
H J K
E
K Partnership working
C J
K
Fig. 2 Interrelationship between facilitators to the implementation and delivery of Social Prescribing services
Fig. 3 Interrelationship between barriers to the implementation and delivery of Social Prescribing Services
Pescheny et al. BMC Health Services Research (2018) 18:86 Page 12 of 14
to promote effective communication between them, and,in turn, effective communication between partners fos-ters good relationships.
LimitationsThere are important limitations to this review. A firstlimitation is the potential publication bias. Other studiesmay exist but have not been accepted or submitted forpublication and therefore were not identified throughthe authors’ searches. Second, not all findings can begeneralised to other SP models. Generalisation of find-ings between different SP models has to be made withcaution, as some findings are context and interventionspecific and may not be transferable to other settingsand interventions. Another limitation is that all eligiblerecords were included in the review independently oftheir appraised methodological quality. Poor qualitystudies were retained because more rigorous studies arelacking. Although the quality of included studies and re-ports is considered to be low, they contain relevant in-formation that could contribute to improved futurepractice.
ConclusionThis review identified a range of facilitators and barriersto the implementation and delivery of SP services basedin general practice involving a navigator. Some of theidentified themes are similar to those of other integratedcare interventions, whereas others appear to be specificto SP interventions, and SP models. Findings providevaluable and unique insights that commissioners, man-agers, and providers can use to guide the implementa-tion process and delivery of SP interventions. The lackof published studies in this field and the poor methodo-logical quality of available evidence highlight the needfor rigorous and high quality studies that evaluate factorsthat influence the implementation and delivery of SPservices.
Additional file
Additional file 1: Demonstrating the search strategy for CINAHL(EBSCOhost). The advanced search techniques were adjusted to meet thedifferent requirements of the included electronic databases. (DOCX80 kb)
AbbreviationsASSIA: Applied Social Sciences Index& Abstracts; CCG: Clinical CommissioningGroup; CINAHL: The Cumulative Index to Nursing and Allied Health Literature;GP: General Practitioner; HMIC: Health Management Information Consortium;NICE: National Institute for Health and Care Excellence; PCT: Primary Care Trust;SP: Social Prescribing; UK: United Kingdom; WEMWBS: Warwick EdinburghMental Wellbeing Scale
FundingNo funding was obtained for this study.
Availability of data and materialsNot applicable.
Authors’ contributionsThe study was conceived by JVP, YP, and GR. JVP drafted the initial versionof the paper, and YP and GR drafted revisions of this paper. All authors readand approved the final manuscript.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Competing interestsThe authors declare that they have no competing interests.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Received: 8 December 2016 Accepted: 25 January 2018
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