Promotion of a social prescribing pathway to general practitioners in a rural area (a feasibility study protocol)

Abstract

Purpose

Psychosocial problems, including social isolation and loneliness, are prevalent in rural communities and can impact the use of health services and health outcomes. Current approaches to managing patients with predominantly psychosocial issues may not be the most appropriate. Social prescribing (SP) is a relatively new way of linking patients with sources of non-medical support within the community. Emerging literature suggests that community-based, non-medical activities are an effective and preferred approach to managing psychosocial problems. However, there is little evidence describing the attitudes of general practitioners (GPs) towards formal SP pathways.

Design/methodology/approach

This research will occur in a general practice in a rural area of Tasmania, Australia. The project will deliver an education module to rural GPs to highlight the benefits of SP and provide a streamlined pathway for referring patients to community support hubs. Existing community organisations will act as “link workers” to connect patients with suitable community activities. GPs will complete a baseline and follow-up survey to measure their perception of SP and the acceptability, feasibility and appropriateness of such an intervention.

Findings

The acceptability, feasibility and appropriateness of the pathway will be assessed using published measures. Free-text responses to open-ended questions will be used to complement the quantitative data. A hybrid effectiveness-implementation method will be used to gather information about the rate of uptake and quality of the SP referral process and identify barriers and facilitators of the process in a real-world setting.

Research limitations/implications

While qualitative data for SP programmes is predominantly positive, quantitative data is lacking. Although the planned project is relatively short, it will provide a basis for future SP programme implementation and guide the approach to data collection and implementation assessment.

Social implications

The barriers to and facilitators of introducing a SP programme in a rural general practice setting may be used to guide the development and implementation of future large-scale SP interventions. This research is both timely and relevant as the problem of social isolation and loneliness, especially in rural areas of Australia, is becoming more well-recognised as a driver of poor health and unnecessary health service usage.

Originality/value

Using SP to address psychosocial risks may reduce healthcare burden and costs. Few SP programmes have been delivered and formally assessed in Australia, and the best way to implement SP locally remains unclear. By delivering a SP intervention in a rural setting and assessing GPs’ responses, future SP projects will be better able to design and integrate social and medical care services.

Citation

Ridge, A., Peterson, G., Seidel, B. and Nash, R. (2024), "Promotion of a social prescribing pathway to general practitioners in a rural area (a feasibility study protocol)", Journal of Integrated Care, Vol. 32 No. 3, pp. 270-284. https://doi.org/10.1108/JICA-01-2024-0005

Introduction

Admissions to hospitals caused by the absence, underutilisation or inadequacy of primary care services are often classified as potentially preventable hospitalisations (PPHs) (AIHW, 2018). Almost 750,000 of all Australian hospital admissions (6.6% of total admissions) during 2016–17 were thought to be PPHs (AIHW, 2019). Hospitals and their emergency departments are not appropriate places for primary healthcare as they seldom allow for continuity of care, are relatively more expensive, and there is a risk of exposure to unnecessary testing and hospital-acquired harms (Kraaijvanger et al., 2016).

The rate of PPHs is higher in rural than in urban Australian communities, suggesting a geographical gradient in occurrence (AIHW, 2019). A systematic review (Ridge et al., 2022a) and other work in rural Tasmania (Ridge et al., 2021a, b, 2022b) have identified social isolation and loneliness as being strongly associated with PPHs. Socioeconomic markers and psychosocial determinants, such as health literacy problems, poor social support structures and reduced accessibility of primary healthcare services in rural areas, are often overshadowed by biomedical factors as nominated drivers of inappropriate health service use. The impact that social determinants have on health status has been documented, but the focus typically remains on biomedical causes, such as multimorbidity (Marmot et al., 2011).

The contribution of social factors to hospitalisation risk, specifically in the rural Australian setting, has been understudied (Longman et al., 2013). Evidence is emerging that low social support, social isolation and loneliness are associated with several adverse health outcomes, including increased mortality (Klinenberg, 2016), mental health problems, extended and avoidable hospitalisations (Longman et al., 2013; Ridge et al., 2022a; Mu and Hall, 2023), dementia (Freak-Poli et al., 2022), cardiovascular disease (Teshale et al., 2023) and poor self-rated health among older people (Morgan et al., 2021). Loneliness also carries a considerable risk of harm, comparable to that of obesity, smoking and other chronic disease risk factors (Foster et al., 2020; Longman et al., 2013).

Patients may not differentiate between a “social problem” and a biomedical “health problem” when they visit their general practitioner (GP) (Golubinski et al., 2020) and present seeking treatment for issues that have complex underlying causes. An anticipatory care (AC) approach to healthcare aims to reduce the amount of acute care provided by improving interventions designed to prevent or mitigate future poor health (Watt et al., 2011). The provision of “high-quality, proactive care that identifies individuals at risk of future deterioration with the aim of preventing or slowing that deterioration” is the aim of anticipatory care (Watt et al., 2011, p. 3). Thinking broadly, AC can be viewed as a means of increasing “the capacity of the individual to adapt successfully and to maintain function despite whatever stressors he or she may encounter” (Pridham et al., 1977, p. 1077). Problems that may arise due to social isolation and loneliness should be anticipated and may be mitigated by improving patients’ social connectedness.

Social prescribing (SP) is a relatively new way of linking patients in primary care with sources of support within the community (Zurynski et al., 2020; Pescheny et al., 2018; Kimberlee, 2013). It may be particularly appropriate where there is no “medical” treatment or cure for underlying problems such as loneliness, homelessness, poor financial and health literacy and social disruption. Chatterjee et al. (2017) found that patients’ social inclusiveness, self-rated well-being, depression and anxiety scores all improved after engaging with a prescribed social activity. Simply leaving the house, interacting with others and developing a positive self-identity are important aspects of maintaining social connectedness into older age (Morgan et al., 2021).

Ideally, SP allows a healthcare professional to “refer patients to a link worker, to co-design a non-clinical social prescription to improve their health and wellbeing” (Bickerdike et al., 2017, p. 1). Internationally, the concepts of SP are gaining traction and have seen it become an increasingly recognised component of the primary healthcare system (Morse et al., 2022). In SP programmes in the UK, primary care doctors, administration staff, dedicated external personnel and upskilled community volunteers have contributed to the provision of a social prescription and the co-design of an appropriate social intervention with the patient (Tierney et al., 2019).

The implementation approach and structure of integrated SP models vary greatly in Australia, as they do in other countries (Morse et al., 2022; Tierney et al., 2020). In Australia, dedicated link workers are uncommon, have variable backgrounds/qualifications and are subject to different funding models and degrees of integration within the primary health system (Zurynski et al., 2020). High preexisting levels of social capital (Boyd et al., 2008) may favour the use of SP and other social interventions in rural Australian communities where “buy-in” may be easier to establish (Tierney et al., 2020). Furthermore, link workers may bolster social capital by establishing and maintaining community connections and promoting integration of community and health assets (Tierney et al., 2020).

The most appropriate model for link workers to connect patients with existing community assets is still being informed by emerging research (Zurynski et al., 2020), but an asset-based community development framework would likely help develop a SP intervention that provides an appropriate approach and strategies to fully utilise the community’s existing resources and inherent strengths (Boyd et al., 2008).

Scepticism, limited time and training and a lack of understanding of the service have been identified as barriers for GPs accepting new services, such as SP (Zurynski et al., 2020). These factors and beliefs may perpetuate a siloed approach to delivering health and ultimately be a barrier to connecting patients with community services. Conversely, the acceptance of a link worker’s role and skillset, a simple referral process and positive feedback from success stories are likely to facilitate the uptake of integrative models of care by GPs (Doolan-Noble et al., 2013; Zurynski et al., 2020; Rothe and Heiss, 2022). Understanding local rural GPs’ attitudes towards SP will help direct future interventions.

Rationale/justification

A review from the UK found that SP, on average, reduced demand for GP services by 28% and emergency department attendances by 24%, while return on investment and social return on investment measures were also favourable (Polley and Pilkington, 2017). Up to 20% of GP consultations concern “social problems” faced by their patients (Torjesen, 2016). Primary healthcare workers may feel overwhelmed when asked to provide solutions to complex psychosocial problems (Pescheny et al., 2018). It is clear that psychosocial issues place an “avoidable” burden on the health system, especially the primary healthcare sector.

Qualitative data from patients suggests physical strength, self-confidence, self-reliance and the number of social contacts all improved with social activities and they believed this led to them experiencing better health (Heijnders and Meijs, 2018). Patients’ needs are often unmet by current approaches to managing social issues (Cruwys et al., 2018). Australian studies (Aggar et al., 2021; Sharman et al., 2023; Halcomb et al., 2022) and growing international research (Khan et al., 2023; Morse et al., 2022) report that SP has a favourable effect on psychosocial, biomedical and economic outcomes and therefore, should be further explored in the primary care setting.

Social care includes all activities in society that promote social connectedness, inclusion in the community and assist with social problems (Cheers, 2019). Improving social connections and patient health literacy could potentially help reduce unnecessary use of healthcare resources (Ridge et al., 2021b, 2022b). Initiatives to improve integration between health and social care have been used outside Australia; a frequent feature of these is personalised tailoring of initiatives to improve social well-being among patients in the community (Uribe et al., 2023). Initiatives to identify and support individuals at risk of social isolation, build individuals’ capacity, promote participation in social activities and improve chronic disease management are common approaches to improved social care (Uribe et al., 2023).

Activities that improve social connectedness exist in regional areas of Tasmania, Australia, but GPs are often not aware of them or how to access them. Word-of-mouth has been cited as the primary method that GPs use to become aware of community-based activities and groups. Similarly, patients are often unaware of what activities are available in their area and are uncertain how to access them. Improving awareness of affordable, local services and providing a simplified means of referral to them could help remove access barriers for GPs and patients alike (Longman et al., 2011; Aughterson et al., 2020). Connecting and aligning existing providers, especially volunteer-based general practice services, may be a means to improve social connectivity among target groups (Aggar et al., 2021; Rothe and Heiss, 2022). This integration of the health and social sectors could be achieved through the use of a collaborative, asset-based approach to the design of interventions (Lester et al., 2023; Morse et al., 2022). A needs-based community development approach is in contrast to a needs-based paradigm, with the latter giving preeminence to the problems and deficiencies of a community rather than harnessing inherent strengths and utilising existing resources (Boyd et al., 2008).

In light of the significant role social factors have in causing ill health (Marmot et al., 2011), we suggest that the social care provided to the individual is possibly just as important as addressing their biomedical issues. A person-centred approach to delivering non-medical, community-based care may also be cheaper, safer and more accessible than traditional biomedical interventions (Marshall et al., 2018). Community-based activities that reduce isolation and promote good health have been suggested as appropriate ways to improve health (Roland et al., 2020; RACGP and Consumers Health Forum of Australia, 2020; Thomas et al., 2020; Tierney et al., 2020).

Integrated care addresses patients’ health needs by providing health promotion, disease prevention and management and rehabilitation (WHO, 2016, p. 2). Models that “enhance quality of care and quality of life, consumer satisfaction and system efficiency” for patients may require collaboration between siloed service providers (Goodwin, 2016, p. 1). Despite this understanding, using community and volunteer services to improve health is often neglected when planning care integration (Uribe et al., 2023). Improving population “social health” by addressing social needs can improve both personal health outcomes and accessibility to primary and tertiary healthcare services; this represents better integration of primary and tertiary healthcare providers and the services and activities of the less-recognised community sector.

In the context of this SP research, we seek to integrate the social care provided by community organisations with the clinical care of GPs. A significant barrier to the success of SP (and other) interventions is understanding, acceptance and participation by all players (RACGP and Consumers Health Forum of Australia, 2020; Zurynski et al., 2021). Providing person-centred solutions to health problems via improved collaboration between existing healthcare providers promises better patient health outcomes, more efficient use of existing health resources and end-user satisfaction (Van Kemenade and van der Vlegel-Brouwer, 2019). This project introduces a SP pathway to improve horizontal, sectorial and person-centred integration of existing primary healthcare and community-based services (Goodwin, 2016). The proposed model aligns with the World Health Organisation’s toolkit for SP implementation (WHO, 2022).

Aim

This project has two aims: to deliver a model of SP suitable for a rural primary healthcare environment in Tasmania, Australia, and to measure GPs’ views regarding the acceptability, appropriateness and feasibility of the SP model.

Research questions

RQ1.

Will a SP intervention be considered acceptable, feasible and appropriate by GPs?

RQ2.

According to GPs, what are the barriers and facilitators of this model of social prescribing?

Study design

A hybrid effectiveness-implementation method will be used to gather information about the rate of uptake and quality of the SP referral process and identify barriers and facilitators of a SP referral process in a real-world setting (Johnston et al., 2019; Curran et al., 2012). Using a realist approach in assessing this project will help determine how and why this SP model may be effective (or not) and in what circumstances it is most suitable (Pawson et al., 2005; Rycroft-Malone et al., 2012).

Using principles of implementation science, we hope to identify gaps at the individual, clinic and health system level that are generalisable beyond the immediate SP model (Bauer et al., 2015). We hypothesise that GPs will become more motivated and have greater opportunity and capability to provide SP referrals as a result of this intervention (Michie et al., 2011).

Participants

The Ochre Health practices in the Huon Valley municipal area employ almost 20 GPs of differing experience levels across two locations (the towns of Huonville and Cygnet). All GPs employed at Ochre Health in the Huon Valley will be encouraged to engage with the practice improvement concepts in the education module. The cohort of GPs generally has longstanding engagements with Ochre Health, although, as with most participatory research in general practice, some attrition is expected throughout the study. All qualification levels will be permitted (i.e. GP registrars and Fellows of the Royal Australian College of General Practitioners).

Setting

The project will be conducted in the primary healthcare setting of rural southern Tasmania, Australia. The Ochre Health network of general practices will facilitate the research. Existing community-based organisations (“community hubs”) have been approached and indicated their willingness to collaborate in this project. The community hubs were selected for their geographical location (and therefore accessibility) and ability to cater to a broad cross-section of their local communities.

Data collection

Participating GPs will be invited to participate in a baseline survey to assess their awareness of existing local services, their attitude towards SP and knowledge of SP and existing referral mechanisms. The acceptability, feasibility and appropriateness of the SP model promoted during this study will be assessed. Follow-up at six months will include a repeat of the acceptability, feasibility and appropriateness measures and the opportunity to provide feedback regarding the perceived benefits and challenges of the model.

Acceptability, feasibility and appropriateness will be measured using the Acceptability of Intervention Measure (AIM), Feasibility of Intervention Measure (FIM) and Intervention Appropriateness Measure (IAM), respectively (Weiner et al., 2017). These tools consist of four questions each and have previously been shown to be valid and reliable measures (Weiner et al., 2017) (See Supplementary Material). Cut-off scores for interpretation of this tool have not been specified; however, higher scores indicate greater appropriateness or feasibility (Weiner et al., 2017).

To complement the quantitative tools, the surveys will also allow for free-text responses, enabling the GPs to expand on their perceptions of SP. Both baseline and follow-up surveys of GPs will collect free-text responses using a paper-based tool. The follow-up survey will re-measure the GP-rated acceptability, feasibility and appropriateness of the SP pathway. The questions of the follow-up survey may differ slightly from the baseline questionnaire (see Supplementary Material).

Data analysis and plan

This protocol describes a feasibility study, not a pilot study. Generalisable conclusions based on exhaustive qualitative statistical analysis are not expected from the expected sample size. The analysis will be both quantitative (for scalar measures) and qualitative (for free-text responses to survey questions) (Johnston et al., 2019).

Previous acceptability, feasibility and appropriateness scores using the AIM, FIM and IAM questions have been reported (Abbott et al., 2021) and indicate that statistically significant changes in the scores are unlikely to be observed with our expected sample size. Basic descriptive data will be used; all numerical data will be analysed using the paired student’s t-test (Beauchamp et al., 2015; Jessup et al., 2018). If the distribution of change in scores appears nonparametric, the Wilcoxon signed rank sum test will be used. Quantitative analysis will be performed with the SPSS statistical package (IBM Corp. IBM SPSS Statistics for Windows, Version 28.0.1.0. Armonk, NY: IBM Corp.).

Data from open-ended questions in the surveys will be analysed using a realist, semantic approach to thematic analysis (Braun and Clarke, 2006). An analysis of each response for themes will help understand the complexity of how individuals experienced the SP project. If themes are repeated among responses, a cross-case analysis may be possible to assist reporting and interpretation (Creswell and Poth, 2018). Analysis of qualitative data will be performed with the NVivo qualitative data analysis programme (QSR International Pty Ltd., Doncaster, Australia).

Ethics and privacy considerations

The project and its amendments have been approved by the University of Tasmania Human Research Ethics Committee (Project ID: 24,892). The project has been successfully registered on the Australian New Zealand Clinical Trials Registry (ANZCTR; ACTRN12622000179730), with this protocol focusing on the GP acceptability aspect.

Information regarding the project will be provided to GPs at the beginning of the voluntary practice improvement presentation, along with consent for baseline measurement and follow-up at the end of the study period.

Data will be collected using hardcopy (paper-based) surveys and returned to the research team via a reply-paid envelope. For pairing with a follow-up survey, each GP survey will be coded so that anonymity can be maintained. Only the lead researcher will be able to decode and pair the surveys. Coding will be kept separate from other data and stored securely on the University of Tasmania’s data storage facility.

GPs not wishing to engage with the practice improvement module will not be penalised. They will be offered access to the module for use at their leisure and will be able to incorporate it into their clinical practice.

Procedure

Model delivery

The project is a feasibility study to evaluate the acceptability, appropriateness and feasibility of a GP-led holistic SP referral model (Husk et al., 2020). The project will consist of the following stages:

Practice improvement education module

A Practice Improvement Education Module (the “education module”) will provide GPs with information about SP, the patient-type being targeted, intended benefits of the SP model and the procedure for enrolling patients. The education module will be presented at the GPs’ usual clinical meeting via a once-only, face-to-face or live-streamed presentation. GPs will be encouraged to refer patients at risk of, or experiencing, socio-medical problems (including isolation, low health literacy and recent hospitalisation) for community-based activities via the SP pathway. The referral destination is one of the community hubs recruited for the project.

Patient referral

During routine activities, GPs, practice nurses, social workers or other practice staff will identify patients who may benefit from SP (i.e. be suitable for referral to a non-medical, community-based social activity). The decision to recommend and agree upon use of the SP pathway will remain within the GP-patient framework. Patients willing to participate in the SP pathway will receive a referral to a community hub. The community hub staff will act as a link worker to co-design a social prescription with the patient using their existing methods of meeting with individuals and connecting them with community activities. There will be no alterations to their usual practice model as part of this project.

After the initial referral is made, a patient may decide not to participate in the SP pathway, decline to engage with the community hub or decline to undertake any social activities without penalty.

Deviation from standard care

GPs currently provide ad hoc suggestions or guidance to their patients as to what social activities may be suitable for them. Referral to specific activities depends on the individual GP’s knowledge of what services and groups are available locally. Therefore, there is variability in the referral process between GPs, and it is dependent on GP awareness of local community activities.

This project will suggest a more integrated means of connecting patients with community activities. Existing community hubs are embedded in and accepted by their local communities, so a “formal” referral from the GP may be seen as a more “valid” part of their care.

The concepts presented in the education module will likely reinforce existing attitudes, beliefs and practices of GPs, so only procedural changes to normal practice are anticipated. The education module simply aims to formalise a current practice and make it more visible, available and efficient.

Discussion

This project intends to deliver and assess a SP pathway from within a general practice setting. In doing so, we will provide further evidence surrounding SP in Australia and clarify key aspects of referral pathways that influence GP acceptance and utilisation. Including community-based services in discussions of integrated care will ensure psychosocial drivers of health are not overshadowed by biomedical models of care (Uribe et al., 2023).

Setting the project in a rural area of Australia is a particular strength, as communities in such areas have limited access to health resources (Mullan et al., 2023) and worse health outcomes (AIHW, 2022) compared to urban populations. A salutogenic, asset-based community development approach to health improvement in rural areas is in line with clinical and policy priorities throughout Australia (Active Ageing Plan Community Advisory Group, 2017; Redman et al., 2020; TASCOSS, 2020; Lester et al., 2021; Department of Health, 2022).

Interest in SP interventions in Australia (Dingle et al., 2022; Sharman et al., 2022; Fitzmaurice, 2022) and overseas has been steadily increasing over recent decades (Ebrahimoghli et al., 2023; Khan et al., 2023). While an asset-based community development framework is useful in identifying and harnessing community strengths during the design phase of social interventions (Tierney et al., 2020), evidence guiding implementation remains sparse. Medical and consumer bodies express support for SP (RACGP and Consumers Health Forum of Australia, 2020), but it remains unclear how well GPs accept and integrate SP into their clinical practice (Moore et al., 2022). This protocol describes an intervention designed to help develop an understanding of the most appropriate model of SP for the rural Australian context. Without supportive qualitative and quantitative data, SP interventions are unlikely to be accepted as either effective or economical.

The implementation and maintenance of SP pathways in primary healthcare environments vary in effectiveness, and literature suggests there is more work to be done before firm recommendations for incorporating SP in rural Australia can be made (Pescheny et al., 2018; Bloch and Rozmovits, 2021; Calderon-Larranaga et al., 2021). This research hopes to add to the data supporting SP and offer one referral model that may be useful for resource-poor rural communities. We envisage that future programmes administered by local governments – with state or federal support – would be an ideal means of expanding the role of SP in Australia (Morgan et al., 2023). Needs assessment, programme design and implementation of a SP programme from the “ground up” using an asset-based approach are more likely to produce an effective SP intervention (Tierney et al., 2020).

While the small number of participants likely to be involved and the limited geographical coverage of this project may preclude generalisable recommendations, it may provide a starting point for similar rural communities wishing to pursue SP initiatives based on the priorities, strengths and assets of their particular communities. This protocol offers a blueprint for other GP practices with limited resources seeking to implement SP into their patient services.

This project does not address or solve the perpetual barrier of insecure, time-limited funding for SP interventions (Zurynski et al., 2020). However, through understanding the barriers and enablers that GPs experience, it may be possible to design efficient and cost-effective SP pathways that are both impactful and sustainable.

Supplementary materials Survey forms