Abstract
Loneliness is considered to be a global public health challenge, impacting a range of physical and mental health conditions. Social prescribing, whereby service users are signposted into community-based activities and social groups by a community link worker, has been suggested as one mechanism to reduce service users’ loneliness and social isolation. This paper reflects on service users’ experiences of accessing a national social prescribing scheme. Drawing on qualitative findings from interviews with service users who were receiving support through a social prescribing programme between October 2017 and December 2018 (n = 26, with n = 12 interviewed a second time), we reflect on their experiences of the programme. We consider some of the complexities of providing short-term support with a focus on signposting people into local activities, when many service users prefer the companionship of their link worker. Furthermore, we highlight some of the difficulties in ending short-term support. Crucially, we highlight the importance of considering the intersection of the social determinants of health. We suggest that social prescribing schemes may exacerbate inequalities if consideration is not given to the ways in which people are (dis)advantaged in accessing the social capital necessary for their initial and continued involvement.
1. Introduction
Social prescribing has gained momentum over the last decade. Taking a community assets-based approach, social prescribing describes the referral of individuals from statutory health services to local, nonmedical, community-based activities in order to promote health and wellbeing [1]. As such, social prescribing aims to address the social determinants of health. An emerging evidence base highlights numerous international examples of social prescribing, for example, in the USA [2], Australia [3, 4], and Europe [5, 6]. However, the evidence on the impact of social prescribing on reducing health inequalities is limited, and a recent Marmot review [7] called for further exploration of this. Despite this, there appears to be a global movement towards embedding social prescribing within healthcare policy and practice [8]. In England, the social prescribing infrastructure is part of the National Health Service (NHS) Long-Term Plan [9], with a commitment to embed social prescribing link workers within primary care networks.
Numerous models of social prescribing have been developed, but one prominent model involves a link worker providing short-term, person-centered support to an individual to link into appropriate community activities and services [10]. Social prescribing interventions have been implemented with adults with long-term physical and mental health conditions, and studies have reported on the considerable potential that these interventions can have in improving service users’ mental health and self-management strategies and in potentially reducing social isolation and loneliness [11, 12].
In the most recent Community Life Survey (The Community Life Survey is a nationally representative survey of behaviours and attitudes within communities in the UK. The most recent survey was undertaken during COVID-19, and as such, the impact of national and regional lockdowns must be considered.) [13], it was reported that 6% of adults in England feel lonely often or always and that younger age groups, those aged 16–24 years, often report higher levels of loneliness than older age groups. The impact of loneliness and social isolation on health and wellbeing is well recognised. Research suggests a correlation between loneliness and increased risk of depression, stroke, and coronary heart disease, amongst other things [14]. The 2018 “Strategy for Tackling Loneliness” [15] was built on the Jo Cox Commission on Loneliness [16]. The strategy set out the government’s plans to embed tackling loneliness into government policy, including a commitment to personalised approaches drawing on local infrastructure. Social prescribing fits within this more personalised approach, with link workers introducing service users to activities and services based on the individual needs of the service user.
Given the need for person-centred approaches to tackling loneliness and the potential impact of social prescribing, the British Red Cross in collaboration with, and funded by, the Co-op designed a national social prescribing scheme called Community Connectors. The scheme is aimed at individuals across the life course identified as at greatest risk of loneliness, or trigger groups, including people who have been recently bereaved, people living at home without children and retirees, young new parents (aged 18–24 years), people who are recently divorced or separated, and individuals with mobility and other health issues [17]. Thus, in contrast to some social prescribing schemes, and in recognition of the scope and impact of social isolation and loneliness, the British Red Cross Community Connectors targets people across the life course.
In May 2017, the service was rolled out across 37 different locations in the UK. The service model entails a paid link worker coordinating local volunteers who work with service users over 12 weeks to signpost them into community-based activities and local support. Referral pathways into the scheme include self-referral, the voluntary sector, the statutory sector, the NHS, and local authorities. The comparatively short-term nature of the scheme was planned so that it would be accessed as a transitional service, rather than a permanent solution, and to embed service users into longer term community activities and support.
The British Red Cross commissioned an independent evaluation of their Community Connectors’ scheme between May 2017 and January 2020. Specifically, the evaluation aimed to understand the impact of the scheme on service users’ perceived loneliness and to identify barriers and facilitators to service delivery. Two previous papers from the same study, [18, 19], discussed the challenges that the link workers and volunteers faced in delivering the scheme, highlighting the importance of the link worker in tailoring it to meet local community needs. Foster et al. [18] report on the quantitative data, which included prepost analysis of data utilising the self-reported UCLA (University of California, Los Angeles) Loneliness Scale [20] and matched comparator work to explore changes in loneliness. They report that 72.6% of service users felt less lonely after receiving support from the Community Connectors’ scheme and touch on some of the additional benefits that service users experienced such as increased confidence and improved wellbeing. This paper builds on the two previous papers from the same project [18, 19] by focusing on the experiences of service-users themselves, highlighting both the outcomes which matter to service users but also issues they felt were detrimental to service delivery. Reporting on these experiences will help stakeholders interested in developing similar initiatives.
2. Methods
2.1. Sample
Twenty-six service users were interviewed between October 2017 and December 2018. Potential participants were identified from anonymised operational data which showed scheme location, trigger group, and initial and end UCLA loneliness scores. The research team developed a sampling frame encompassing these key categories and worked with the Community Connector link workers to recruit a diverse and broadly representative sample. In addition, 12 of the 26 participants agreed to take part in a follow-up interview three months after their initial interview so that researchers could explore issues such as sustainability, longer-term impacts of the scheme, and how service users’ reflections on their participation in the scheme may have changed over time. Table 1 provides participant demographic details.
2.2. Recruitment and Consent
Once the sampling frame was developed, potential participants were contacted by their relevant Community Connector link worker to ascertain if they were willing to take part. Contact details of those service users who agreed to take part were then given to the research team. Interested participants were contacted by the research team over the telephone to arrange a suitable time and date to undertake the interview, and a participant information sheet and consent form were posted to the service users’ home addresses. Consent was taken prior to commencing the interviews. For the two face-to-face interviews, written consent was taken. For the remaining telephone interviews, the consent form was read out to the participant and verbal consent was recorded; this was approved as part of the ethics process.
2.3. Data Collection and Analysis
Data were collected using semistructured interviews undertaken by three experienced qualitative researchers (JT, EH, and AH). Of the initial 26 interviews undertaken, 24 of these were telephone interviews and two were face-to-face. The 12 follow-up interviews were all telephone interviews. The choice of telephone or face-to-face interview was determined not only by the participant’s preference but also by time constraints or geographical distance. Interviews lasted between 20 and 90 minutes with an average of 30 minutes.
Topic guides were developed in collaboration with the research advisory panel. The topic guides for the initial interviews covered service users’ decision to use the Community Connectors’ scheme, their expectations of the scheme and what they wanted it to address, and their experiences of the scheme and reflections on what worked well and what could be improved. The topic guides for the follow-up interviews focused on the extent to which any “prescribed” activities had been maintained or not, facilitators and barriers to this, reflections on service users’ sense of wellbeing, and consideration of what worked well with the scheme and what might be improved. Topic guides were piloted with the first two service user interviews, following which they were discussed and reflected on by JT & EH. All interviews were digitally recorded and transcribed verbatim for analysis, with participants’ consent. Data were stored and managed in NVIVO 11 and analysed using an interpretive thematic approach, based on open coding followed by more detailed coding [21]. JT & EH read early transcripts and developed an initial coding framework. JT & EH continued to code the remaining transcripts, frequently refining and developing the coding framework. The research team met on a regular basis to discuss the coding framework, compare coding across and within the transcripts, and develop a more detailed analytical picture of the data. The coding framework broadly covered themes pertaining to service users’ social relationships and sense of wellbeing expectations of the scheme, the volunteer/community connector and service user relationship, the impact and sustainability of socially prescribed activities, and barriers and facilitators to activities.
Ethical approval for the project was granted by The School of Health and Related Research ethics committee (015364) at The University of Sheffield.
Pseudonyms have been given to participants throughout this paper.
3. Findings
Within this paper, we report on three primary areas: (1) developing confidence and self-esteem to undertake day-to-day tasks; (2) a cup of tea and company; and (3) sustainability of the programme: ending support and the importance of infrastructure.
3.1. Developing Confidence and Self-Esteem to Undertake Day-to-Day Tasks
Despite the aim of social prescribing being the referral of service users to onward provision, many of the service users in this study required support from their Community Connector link worker or volunteer to help develop their confidence to undertake day-to-day tasks before any consideration could be given to referral into external activities. In this way, the programme could be viewed as a step-change model of care. With step one being the need to develop service users’ confidence, for example, May talked about how a fall had impacted her mentally and physically and reduced her ability to leave her home. She hoped that the Community Connectors’ scheme would help to improve her confidence.
“…I had an accident. I had a fall in [name removed]. I think it was December the eleventh or twelfth. I was taken to hospital, and they interviewed me there and they said they would refer me to the Red Cross because I live alone, and I don’t see anyone … It was just to get my confidence back because after my fall I just had no confidence. I didn’t want to go out. I didn’t want to do anything” (May).
Similarly, Brian set an initial goal of taking a bus into town. The identification of this relatively straightforward task highlights the impact of loneliness on Brian’s life and the need for a stepped approach to change.
“He came for me, he walked me. He already had the bus times and … he walked me to the bus stop, okay? We get on the bus and go down to town, any shops that I wanted to go to, or just to the part of whatever. Goes into town and the main thing was that he was there to support me, you know?”
Meanwhile, David spoke of how his Community Connector link worker had helped him to develop confidence in undertaking daily administrative tasks.
“Well, he’s given me a bit more confidence in how to handle my bills and to make phone calls and write letters if need be” (David)
For Ella (new young parent), working with her Community Connector link worker helped her to develop the confidence to get back into education. She spoke of the importance of the personalised service that she had received through the Community Connectors’ scheme and how the process of identifying her goals had helped her to gain confidence before she had even started to work towards addressing the goals.
“Well, it’s one of those things where you turn into a new mum and everyone says ‘well go out to groups, get involved. And there’s never really that sort of person to signpost you to all these groups that you can do. They don’t sit down individually with you and do it…So having [community connector/come around was a lot, I could actually, she actually listened to what I wanted personally And then she came back with loads of stuff… I’m a lot more confident, before I’ve even done any courses, I am a lot more confident” (Ella).
3.2. A Cup of Tea and Company
In addition to developing confidence and self-esteem, it was clear that service users really valued the company of their Community Connector or volunteer and for many service users, this was their favourite aspect of the scheme. For example, when asked what he wanted to get out of the Community Connectors’ scheme, Edward said the following.
“Just a bit of company, that’s all I wanted because I don’t get any company whatsoever…Well someone who could come in, sit down. I could go and make a cup of tea and a biscuit, and we have a chat and put the telly…watch a film, a DVD or something like that or just sit and chat or whatever. Just a bit of company basically.”
When asked what activities they undertook with their Community Connector or volunteer, Sue said the following.
“… only a cup of tea and a coffee, but it was nice, you know just for that hour when she had free time just to have a laugh really. That’s all I needed.” (Sue).
Similarly, Elizabeth said the following.
“We went to the garden centre, and we’d go out for a cup of tea. And it wasn’t a lot of outings, but she would sit with me, and I would make her a cup of tea and we would talk…” (Elizabeth).
From the interviews, it was clear that the simple act of tea and conversation was what many service users were missing. The companionship that they received through the scheme brought them, in Sue’s words, “a bit of human normality.” This perhaps reflects the scheme’s focus on addressing loneliness. However, there appeared to be a dearth of befriending schemes that Community Connector link workers could refer service users into. Even if befriending schemes were available, relationships had already been formed between link workers/volunteers and service users, and it was these relationships that the service users valued. Despite this, providing companionship or befriending through the Community Connector link workers or volunteers was not part of the programme specification. This raises clear questions concerning the sustainability of support and the impact of withdrawing support if service users rely so heavily on the one-to-one relationship that they develop with their Community Connector or volunteer, which will now be considered.
3.3. Sustainability of the Scheme: Ending Support
Given the emphasis on company and the clear friendships that appear to have developed between some service users and their Community Connector and/or volunteer, it is unsurprising that ending the support provided through the scheme was very difficult for some. During the three month follow-up interviews, many of the service users reflected fondly on the time that they had spent with their Community Connector link work and/or volunteer and that the support finishing had left a void. For example, Laura said the following.
“…I miss her. I wish she could keep doing it…the best part of the programme was being with her because she’s lovely and it was nice to go for a coffee with her” (Laura, follow-up interview)
Meanwhile, May said the following.
“I certainly looked forward to the meetings when she came, you know? It helped me over that period of time. And, of course once she’s gone it’s like losing a friend” (May, follow-up interview)
Likening the ending of the scheme to “losing a friend” does raise questions about the potential detrimental impact of providing friendship and support to service users who have been identified as lonely for a relatively short period of time, especially when service users come to rely on that friendship. Indeed, Fiona suggested that whilst her confidence had improved during her time with the Community Connectors’ scheme, after this had ended, she felt that her mental health had deteriorated.
“When I was seeing the Community Connector, I felt more confident and like reassured in a way. I’m not sure what the right word is…sort of motivated to do things. Afterwards, I felt like less sure of myself…I noticed my mood, what’s the word? Deteriorating” (Fiona follow-up interview)
These experiences highlight the need for Community Connectors to have sufficient training and support to ensure that they are able to sensitively and skillfully manage the ending of support given to service users. In addition, these service user experiences also indicate possible ethical issues associated with short-term social prescribing to address loneliness and the potential that, in some cases, they may do harm.
3.4. Sustainability of the Scheme: The Importance of Infrastructure
Whilst the wider evaluation of the Community Connectors’ scheme revealed that many service users were successfully signposted into local activities (see names removed for peer review), community infrastructure was key to enabling people to be signposted to activities. Where local activities were not available for service users, Community Connector link workers or volunteers often “filled the gaps,” taking their service users on outings or providing company for them to undertake routine daily activities and chores. This increased people’s reliance on the Community Connector programme, which then created challenges when the Community Connector link workers had to withdraw support (as discussed above).
Furthermore, a key issue in relation to sustainability of the scheme was the accessibility of local activities and community transport networks. Given the nature of the target group, many service users had mobility problems and often, this had major impacts on their ability to get involved in local community activities:
“…Sometimes I feel like I want to go out but because of my mobility I can’t, you know, my mobility issues, I can’t go out. I can’t just get up and say I’m going down the road or, you know, just going for a walk or whatever. It’s very painful. The fact that I don’t live on the ground floor, I live on the second floor and there’s no lift, So, if I go downstairs, you know coming back up, going up and down the stairs is, you know, hard for me. I use a walking stick but, you know, going down is not too bad because I take one step at a time. When I’m coming up as well, I do take one step at a time, but it takes longer coming up because I’ve got to manoeuvre myself in a way that, you know, I can take a step up one at a time with my walking stick in position. It’s horrible, you know. But that’s the only reason why I feel lonely because I can’t get out and about and meet people” (Paula, follow-up interview).
In Paula’s case, she relied on her Community Connector link worker to assist her moving up and down the stairs. Without this personal assistance, she was unable to undertake daily tasks, let alone attend community-based activities.
In some cases, service users relied on their Community Connector link worker to provide them with transportation to activities as there were limited public transport systems in place in their local area. This was particularly the case in more rural areas. For some service users, having a Community Connector provide transport had opened up the activities that were available to them during their time with the scheme. However, clear questions were then raised about continuity of attendance at these activities once the official support was removed and service users were then reliant on, what were often, patchy public transport systems. For other service users, Community Connector link workers were mindful to link them to activities that they might be able to access via public transport once the scheme’s support had officially ended.
“…living in [a rural location] there isn’t [good public transport] and you see, I don’t drive, so I makes it so much harder. I mean she [the Community Connector] was limited to where she could take me, because if she wasn’t with me, I’d have to walk or get the bus or something…” (Laura).
Sometimes, where public transport links were inadequate, some service users had paid for private taxis to get them to activities, but again, the sustainability of this method of transport was questioned. For example, Claire talked about the difficulties of relying on taxis.
“So I went, I had to pay for a cab. I had to pay for a cab there and back. But I won’t be able to do that, you know. I won’t be able to afford to keep paying for cabs, you know.”
We now reflect on these findings in the light of the wider literature.
4. Discussion
The findings reiterate the importance of personalising the Community Connectors scheme to individual needs [11, 22]. Often, over, and above signposting into local community activities, many service users in this study wanted to develop or rebuild their confidence or self-esteem. Service users valued the “small things,” such as having company to take a bus ride, sitting with someone to discuss future education opportunities, or working through daily administration tasks, such as paying bills. Perhaps, given the focus of the scheme on service users who are suffering from, or at risk of, loneliness, it is unsurprising that developing confidence and friendship appears to have been prioritised by service users, or was something that needed addressing before consideration could be given to joining local activities. In this way, the “success” of the scheme may lie in a stepped approach to change: firstly addressing immediate issues related to service users’ confidence as a result of their loneliness and then, once this is achieved, moving them on to possible community activities, with a view that they are able to continue with these once their “prescribed time” with a Community Connector ends.
Our study suggests that one of the most important aspects of the Community Connectors’ scheme for the majority of service users was the relationship that they developed with their Community Connector link worker and/or volunteer. A successful relationship ensured that Community Connector link workers and volunteers understood service users’ individual needs, but more than this, it was about the companionship that they provided. These findings echo those from other studies, such as Wildman et al. [23], who highlight the service user/link worker relationship as the most important element in helping service users to access and navigate community resources. However, our study revealed that for many service users, their priorities/needs were simply human company. They wanted someone who would come into their home and watch television with them, have a cup of tea, and talk about everyday things. As such, it would seem that their needs were more befitting a befriending scheme. Furthermore, mobility issues often prevented, or made it difficult, for service users to leave their homes and so signposting service users out into the community was not always their preference. In these circumstances, signposting services into service users’ homes may be a better solution.
In our previous paper reporting on the quantitative evaluation data from the same study, [18] we found that reductions in loneliness achieved during a service users’ time within the programme were not always maintained once the intervention had been completed. Foster et al. [18] suggested that this may be due, in part, to insufficient time to address the underlying psychosocial issues experienced by some service users. The qualitative findings reported in this paper would support this, but our findings also point to the importance of the companionship element of the programme and how, once this is removed, service users are often left with little support in place. Indeed, as our findings suggest, in some cases, service users can be left feeling worse than before, having had a taste of the benefits of a companion to sit and talk with or someone who shows an interest in helping them to achieve their goals. Thus, the ethical implications of potentially enhancing someone’s sense of loneliness after they have had a short-term experience of weekly companionship through programmes such as these need to be considered.
The COVID-19 pandemic has highlighted the acute impacts of loneliness and social isolation on individuals’ health and wellbeing, as billions of people across the globe have endured national lockdowns and social distancing measures [24]. During the pandemic, social prescribing schemes have had to explore new modes of delivery, which maintain elements of person-centredness but without the face-to-face contact [25, 26]. For example, Morris et al. [26] explore how an existing social prescribing scheme was adapted during the onset of the pandemic and highlight the mixed response from service users, from those who were easier to reach over the telephone as opposed to previous face-to-face attempts to those who felt that their progress had regressed due to an inability to physically access services. It is likely that there will be high demand on social prescribing schemes to address some of the social fallout of the COVID-19 pandemic, such as the impacts of social isolation and loneliness. However, without adequate consideration of the complex needs of those who are referred into social prescribing schemes to address loneliness, we are at risk of potentially exacerbating service users’ sense of social isolation.
Social prescribing schemes have arisen, in part, due to a recognition of the centrality of nonmedical factors affecting people’s health [27]. Loneliness is a social determinant of health, with social prescribing considered a mechanism to develop social capital and a sense of community belonging for service users by drawing on local community assets. Yet, it could be argued that the impact of other social determinants of health seems to have been neglected in the development and rollout of social prescribing schemes. In particular, our findings highlight the importance of local transport networks and personal support for those who have physical mobility issues. Tierney et al. [28] drawing on Carpiano [28] label these the structural antecedents of social prescribing and remind us of the necessity that social prescribing fit into existing structures. Without these basic structures in place and despite the best intentions, many service users are simply unable to access any community activities and provision that may be available. Therefore, in some cases, social prescribing may actually serve to widen the inequality gap between those who can and those who cannot access community assets. Beyond the structural antecedents, one might also consider the extent to which socioeconomic conditions impact social capital and can (dis)advantage some individuals. Our findings support the assertion by Gibson et al. [29] that assuming everyone has the same access to the necessary capital for health investment risks exacerbating inequalities. This might go some way to explaining why some of our participants preferred the one-to-one company that volunteers/Community Connector link workers provided, as, in some cases, they needed far longer to develop trust and (as mentioned above), this form of support, provided in their own home, negated some of the structural barriers. As the policy push for social prescribing as a panacea to reduce social ills continues, we would urge that consideration is given to the wider determinants of health and how these intersect to enable or prevent individuals from engaging. This is particularly pertinent for people who are suffering, or at risk of, loneliness and the potential that longer term befriending provision needs to be in place for those who require it.
5. Implications for Policy and Practice
Given the increased policy attention and investment given to social prescribing, our findings shed important light on the potential challenges of delivering support with vulnerable service users experiencing isolation and loneliness. Social prescribing models in the UK involve the referral of service users to community activities. However, the primary goal for service users in our study was the need for companionship and some discussed a deterioration in their condition when the relationship with their Community Connector ended. Such findings may suggest that the traditional social prescribing model may not be beneficial for service users experiencing social isolation and loneliness who need further support to attend activities. If traditional social prescribing models are to be utilised with participants experiencing social isolation and loneliness, we suggest that Community Connector link workers need to be clear on the remit of their job role from the outset, so they are able to manage expectations carefully and carefully consider which referrals to accept. Further still, our study reiterates previous findings of the importance of investing in community infrastructure (such as transport) to ensure the successful delivery of social prescribing programmes [19] and to reduce inequalities in the distribution of services. In particular, as suggested by Holding et al. [19], our findings demonstrate the need for increased investment in befriending schemes. By providing regular social support in the home, befriending may be a more appropriate support model for those experiencing loneliness.
6. Strengths and Limitations
The study adds to a small but growing body of evidence based on service users’ own perspectives of taking part in a social prescribing scheme. A key strength of this study is that follow-up interviews were conducted with 12 of the 26 service users, which enabled us to explore how things had changed over a three-month period. The paper is also strengthened in that it forms part of a wider large-scale mixed methods study, of which other findings have already been reported [18, 19]. Whilst the number of service users interviewed for the study is relatively small, they do reflect the broader characteristics of those involved in the scheme. The study has the following limitations: We did not interview people who withdrew from the scheme; this could be important for exploring issues related to how the social determinants of health may impact people’s participation in the scheme and would be a useful aspect to continue for future research. We relied on the Community Connector link workers to undertake the initial recruitment of service users for interview, which may impact the study sample and findings.
Data Availability
The anonymised qualitative data used to support the findings of this study are available from the corresponding author upon request.
Additional Points
What Is Known about This Topic? (i) Loneliness presents a global public health challenge. (ii) Social prescribing has been shown to have beneficial outcomes for specific individuals with a range of health and wellbeing concerns. What This Paper Adds? (i) Short-term social prescribing for individuals identified as being lonely may exacerbate their sense of loneliness. (ii) Our study highlights the importance of the 1 : 1 relationship and the value of befriending schemes for those with complex issues.
Disclosure
For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any author-accepted manuscript version arising.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Acknowledgments
Funding for the study was received from the British Red Cross and the Co-op. The University of Sheffield Institutional Open Access Fund paid for open access publication.