Using RE-AIM to investigate the implementation and impacts of social prescribing: An evaluation of Community Connect 2017-22

Background: During the past twenty-five years, social prescribing has prompted significant government support, while its profile has been amplified nationally and internationally. However, the evidence base for social prescribing continues to elicit scrutiny. Existing research provides valuable insights for commissioners, providers, healthcare organisations in guiding the implementation processes of new social prescribing interventions, yet the weak methodological quality of these studies highlights the need for more rigorous investigations and specifically, those exploring the barriers and facilitators to effective service design and delivery. To this end, the present study sought to address some of those criticisms levied at social prescribing research. The PhD was made possible through the Kent Health Vice Chancellor's Research Scholarship 2017, funded by the Centre for Health Services Studies (CHSS) at the University of Kent, in partnership with NHS Bexley CCG.

Aims: Following the positive outcomes of a pilot study (Palmer et al., 2017), NHS Bexley's Clinical Commissioning Group (CCG) and the London Borough of Bexley Council (LBB), initially co-commissioned a three year service (October 2017 to September 2020), to deliver social prescribing through primary care. The present study aimed to capture both patient outcomes and organisational processes, providing robust evidence to inform commissioners, while contributing to wider research in the field. The evaluation had the following overarching aims:

i. To explore the impacts of Community Connect upon the health and wellbeing of individual adults experiencing a range of physical health, mental health and social issues.

ii. To investigate the implementation processes and outcomes of Community Connect upon the full range of stakeholders.

iii. To inform the development of Community Connect and future social prescribing programmes, while contributing to wider research in the field.

Methods: Informed by implementation science theory and guided by the RE-AIM framework (i.e., Reach, Effectiveness, Adoption, Implementation and Maintenance), this longitudinal evaluation study (2017-22), focused upon the processes, service adaptations and impacts of Community Connect, Bexley's social prescribing programme, as co-commissioned by NHS Bexley CCG and London Borough of Bexley. A convergent, parallel, mixed methods design, the investigation comprises two distinct phases/ cohorts (i.e., pre and post COVID-19). The study examines pre and post outcomes for service users (N=223), alongside investigating the implementation processes and outcomes with service providers (N=30), commissioners and wider stakeholders (N=10), including e.g., reach of services; uptake and adherence; maintenance and sustainability.

Results: Community Connect engaged with its target population, however differences were observed in its Reach pre and post pandemic, including a younger and more ethnically diverse demographic. Service users experienced improvements in all seven outcome measures (i.e., DjG; UCLA-3; GAD-7; SWEMWBS; IPAQ; Rotherham Social Prescribing Scale; BLF Social Wellbeing Scale), while statistically significant improvements in levels of loneliness, social isolation, anxiety, mental wellbeing and physical activity were reported. Again, differences were observed in Effectiveness according to cohort, including escalating mental health needs and lack of service provision. Service users, service providers and other stakeholders were negatively impacted by COVID-19, with multiple programme adaptations documented during and post pandemic, affecting all areas of Implementation, Adoption and Maintenance. Community Connect benefited from its collaboration with key stakeholders, including commissioners, primary care and VCFSE organisations. Importantly, the non-hierarchal positioning of an 'embedded researcher' engendered a collaborative learning culture, resulting in an iterative approach to learning, with the co-presentation and dissemination of findings at local and national levels. At the outset, the aims of Community Connect were clearly aligned to the priorities of its commissioners, yet frequent changes in personnel, policy and practice between 2017-22 were evidenced to prevent the service from becoming fully embedded in existing clinical pathways. These issues appeared to be inextricably interlinked with outcomes for service users, service providers and third sector organisations, reflecting the tenuous nature of maintaining 'effective' social prescribing services during a period of continuous flux.

Discussion: This PhD thesis provides important contributions to the field, including empirical, theoretical, methodological and policy related learning. It is the first study to apply the RE-AIM evaluation framework, to underpin an investigation pertaining to social prescribing. In addition, the study has been informed by a comprehensive, integrative literature review, examining the outcomes of 55 comparable social prescribing schemes for patients, health/social care services and third sector organisations published between 2000 and 2022. The study therefore provides a unique perspective of one 'live' social prescribing intervention between 2017 and 2022. Moreover, the presence of an 'embedded researcher' brought an iterative means to learning across the service. The PhD journey began in line with the delivery of Community Connect, enabling for key stakeholders to contribute to the design of research methods and tools. It also allowed for trusting relationships to develop between the researcher and the delivering team(s), ensuring access to specific data collected by BVSC/ MIND in Bexley. Importantly, in being present from the outset, elements of uncertainty and experimentation were present throughout the programme's design and delivery, requiring adaptability throughout the research journey.

The evaluation of Community Connect and its accompanying literature review aspire to build upon the burgeoning - albeit often contradictory and/ or inconclusive - evidence to elucidate the processes and impacts of social prescribing programmes upon individuals and organisations, thereby enabling effective interventions to be designed and later systematically evaluated in future, in-depth studies.