Overall, 33 subthemes across twelve domains of the TDF [31] were identified as factors that were barriers or facilitators to SP for CYP with mental health difficulties. These spanned all three areas related to capability, opportunity and motivation. The results are highlighted in Table 1.
Capability
Knowledge
- An understanding of the CYP
The majority of Link Workers discussed that as part of SP, an understanding of the CYPperson was needed. This included their background and why they wanted to see a Link Worker:
I want to know the demographics of the young person, and things like the age and if they’re in school…and see also what they want from a social prescriber (Link Worker 05)
Such information was also highlighted as important by those involved in the setting up or running of SP, including SP Co-ordinators and Heads of Services:
So knowing a bit of background about the child…why this might be appropriate for them to be referred to (Social Prescribing Co-ordinator 1)
Link Workers highlighted that such information was sometimes difficult to gather, either because the CYP “was reluctant to share information” (Link Worker 5), or because the referring healthcare professionals did not provide it. When this occurred, Link Workers tried to ascertain this information from “speaking to other professionals [or]…maybe looking through [the young person’s] medical record” (Link Worker 7).
- How to work with CYP
Both Link Workers and those involved in the setting up or running of SP for CYP highlighted that knowledge of how to work with CYP was essential to their roles.
You're obviously going to need to know young people. I feel you need to have a good sense of young people (Link Worker 11)
This included how to interact with CYP, a knowledge if the issues they face, and boundary setting:
How to work with young people, how to put in boundaries, safeguarding …the kinds of things that they come up against (Social Prescribing Manager 1)
Importantly, in organisations whose remit was broader than CYP, this knowledge also included an “understanding of development, and developmental stages” (Link Worker 3) and “the differences between adults and children” (Link Worker 7).
- Knowledge of where the local community assets are and what they offer
For successful SP to occur, a knowledge of local community assets was highlighted as important by both Link Workers and those involved in the setting up or running of SP:
So I think one of the key things, the contacts in the community, knowing what's going on in the area so that you can link up with those services and those groups that are available (Link Worker 1)
Link Workers and Co-ordinators often felt that they had a good knowledge of local assets, but acknowledged that the landscape could change quickly sometimes leaving them struggling to find other suitable sources of support.
- Knowledge of policies and procedures specific to CYP
Overall, both Link Workers and those involved in the setting up or running of SP for CYP highlighted that there were a lack of policies, procedures or guidelines relating to SP with CYP.
So a lot of the information out there for social prescribing within the NHS is mainly for adults (Link Worker 2)
What information was available was via a module provided by the SPYN. Consequently, Link Workers and those in management and implementation roles were limited to adapting resources which were already available for adults, as well as following policies and procedures embedded within their local organisation:
Not really, not specific [guidelines] to children and young people. There are some guidelines for social prescribing with adults. For myself my background is paediatrics so I’ve kind of taken a lot of that, other guidance as kind of more generalised things and applied it (Link Worker 4)
- Skills
- Interpersonal skills
All Link Workers and those involved in the setting up or running of SP for CYP highlighted the importance of interpersonal skills when working in a SP context. This included skills such as having “empathy” (Social Prescribing Co-ordinator 3), as well as skills around “listening and encouraging” (Social Prescribing Organisational Head 1). Most individuals felt that they had these skills as a result of previously working with CYP:
the need to enjoy working with people for a start, so they need to be happy to have those regular face-to-face or online conversations. And be interested and be able to listen, have empathy, and be non-judgemental, and to take an open view and be patient (Social Prescribing Organisational Head 1)
- Networking skills
For individuals involved in delivering SP, networking was seen as an important skill. Networking allowed for services to make others aware that SP was a service available within their area and that Link Workers were able to accept referrals:
We need to know who to speak to, to promote our service, and who to connect with and network with, to ensure that we actually receive referrals and they know we’re here (Social Prescribing Co-ordinator 1)
For others, networking also allowed for services to better understand the needs of their communities and what assets were out there:
We network loads. We do know other organisations. We know our communities and their needs (Social Prescribing Co-ordinator 2)
Memory, attention and decision-making
- Deciding on who to involve and level of involvement
Link Workers outlined that one of the early decisions they made was how to involve CYP in SP. Providing that the CYP had capacity, some Link Workers spoke about supporting them to be involved in deciding activities, even if they thought others were a better ‘fit’:
If an individual has capacity to make their own decision it’s important you allow them to make decisions that you wouldn’t necessarily deem as good (Link
Worker 1)
For other Link Workers and those involved in the setting up or running of SP for CYP, the involvement of family was also a consideration. This was particularly relevant when the CYP did not have capacity, or when the family structure was affecting the CYP’s mental health:
As a children’s social prescriber I might be thinking about to what extent do I involve the family? How can we as a system help the family? Because kids are influenced by the context that they’rein. (Social Prescribing Co-ordinator 3)
- Safeguarding
Link Workers and those involved in the setting up or running of SP for CYP stressed the importance of assessing risk and keeping the CYP safe. This pertained to both the mental health and wellbeing of the individual, but also the activities they may be participating in:
The forefront of our work is safeguarding. We need to make sure these children are safe, they're obviously vulnerable and can be living in or involved in activities that perhaps are not the safest. So we do a lot of safeguarding and safety planning and protective behaviour work with our young people (Social Prescribing Organisational Head 3)
Link Workers and those involved in the setting up or running of SP for CYP outlined that they understood how to pay attention to risk and implementing safeguarding protocols as necessary.
- Structuring sessions
Another decision made by Link Workers was the structure of the sessions. Meetings with CYP would often be CYP led and sessions paced according to what they felt comfortable sharing. Whilst on the surface the approach was flexible, Link Workers spoke about gently structuring sessions to facilitate movement towards the CYP’s goals:
I would say that there isn’t really a clear beginning, middle and end in terms of their support. So yeah, there definitely has to be some form of decision making; obviously, they're in the driving seat, but in the background, you are sort of saying there is a structure to this, there is a destination; they can decide how they're going to get there, but you're definitely having in mind some sort of journey (Link Worker 10)
Following on from conversations, Link Workers would then often go away and research available support for the CYP to present at the next session.
Another decision made by Link Workers was when to refer on and stop support.
Also, which is a really big part that is overlooked, I think sometimes, is you need to decide when your support ends …such a hard part of social prescribing is ending it, because people get so attached, and it’s so hard to let people go and it’s so hard for them to let go of you (Link Worker 9)
Given the time limited support around SP, some Link Workers felt ill equipped to manage endings. This was because they often formed close trusting relationships with CYP and did feel equipped with the vocabulary and skills to smooth transitions.
- Whether referral is appropriate
When a referral came through, both Link Workers and SP Co-ordinators outlined that discussions were had around whether the referral was appropriate to take on:
You need to decide whether that person is suitable or not for you. And then …you need to decide what you're going to do… where that person needs to go because you can’t just leave them in limbo (Link Worker 9)
Decisions on what to do with the CYP included not accepting the referral, as well as picking the referral back up at a later point if it was felt more benefit could be added then:
So, like, making sure that the referral is appropriate for me. Making sure that I can see them and add benefit to their situation. Sometimes there are lots of professionals already involved and I have to make an assessment of whether I can actually add something in a beneficial way at the current time. Or if maybe I need to step in later (Link Worker 9)
The appropriateness of referrals was also echoed by SP Co-ordinators and Heads of Service, highlighting that referrals were discussed at team meetings, prior to accepting them onto an SP pathway:
it’s something we have to consider every single time we receive a referral, we do work with children with very complex needs, and sometimes it’s either not safe or not appropriate for them to take part (Social Prescribing Co-ordinator 1)
- Evidencing effectiveness
A couple of individuals involved in middle and senior management roles, outlined that part of their role remit was to think around how to evidence SP activity, which could be linked to funding key performance indicators:
So I make decisions … about how we build the evidence base, so what research might we undertake to strengthen the business case and the evidence base for youth social prescribing (Social Prescribing Organisational Head 1)
Linked with this, decisions about what metrics to use and how to demonstrate service need was discussed:
Stuff around monitoring and evaluations. So how we evaluate the impact on young people. So that sits with me and I would work with the young people connectors to understand that and to make sure it’s being used and capturing what we need (Social Prescribing Manager 1)
Behavioural regulation
- Monitoring service user feedback via questionnaires
All Link Workers and those in management and implementation roles outlined that the impact of SP was monitored via questionnaires. Routinely used metrics included the ONS4 and the Warwick-Edinburgh Mental Wellbeing Scales:
So my service as a whole uses the ONS4 (Link Worker 4)
Despite using these measures, some individuals felt that they were not appropriate to use with CYP as concepts were often not clear:
Yeah. I think with the ONS4, it can be quite difficult because the questions are quite vague, and people generally, tend not to really know how to answer them (Link Worker 6)
Others felt that these questionnaires did not get at the heart of what they were trying to achieve with SP. Therefore, they chose sometimes not to complete them with CYP:
It’s quite difficult to measure. I think I’m meant to be doing like the Warwick-Edinburgh Scale and stuff like that. But I don’t. Terrible. But what I do see instead is those lifestyle changes and changes in attitude and in the things that they [young people] say (Link Worker 7)
As a result, it was suggested by some participants that a more inclusive and user-friendly wellbeing measurement framework was needed, incorporating domains relevant and important to the CYP specifically:
I think just tailoring it to things like a young person specifically would be experiencing, like with their family life or with their friends, or I guess with school as well (Link Worker 5)
Alongside standardised metrics, the use of goal-based outcome measures were often used and preferred, due to their personalised, ideographic nature:
I’ve devised a different outcome measure where we set some wellbeing goals and we score on a scale of 1 to 10 and it’s also got an emoji face underneath each number. So they can grade kind of how important this goal is to them, how kind of close they feel to reaching that goal (Link Worker 4)
Opportunity
Environmental context and resource
- Having appropriate spaces to talk to CYP
For the majority of Link Workers and those involved in the setting up or running of SP for CYP, the need for appropriate spaces to work with CYP was of paramount importance. Participants commented on how some locations may not put an individual at ease and facilitate having open conversations:
I would love for social prescribing to be in a less formal setting. I work for different [GP] surgeries and I’m either on the phone or in the surgery. And that’s really quite formal. I have to wear like business uniform … If I could turn up to a community centre and see them there, and I was wearing something more casual, like jeans and a nice top, there might be less of that power imbalance that I mentioned (Link Worker 7)
Locations where Link Workers could meet CYP varied, but shared the feature of being welcoming and friendly. Schools and leisure centres were popular choices, as well as online.
- Limits to who could be worked with
Some Link Workers and those in management and implementation roles outlined that there were limits, often due to contracts and funding, on the populations they were able to work with:
So a lot of the link workers we work with, they work with parents, they can only work with 18+, so it’s often through the parents that they have that contact with the family, and then the child is referred via the family, as opposed to direct contact with the child (Social Prescribing Co-ordinator 1)
- Supervision
For Link Workers, having appropriate clinical supervision was important. Often, they were working with vulnerable CYP suffering from mental health difficulties. Supervision was therefore a structure to make sure they, as well as the CYP, were being properly supported:
I think absolutely everyone should have supervision in every single role that they have. As someone to complain about the cases that you're seeing, to make sure that you're on the right track, to highlight any new services and resources that you can tap into. Often you need that reassurance that you’re doing everything you can (Link Worker 7)
Despite this, some Link Workers did not receive any supervision, whilst others felt the supervision that they did have was inadequate:
And in terms of supervision from a manager, again, I feel as if they do check-in on what I’m doing, but I’ve never felt as if they were really giving me that feedback…It’s more just kind of, if you’re ticking the box, that you’ve had that conversation, then that’s good (Link Worker 6)
Co-ordinators and those involved in service delivery also agreed that supervision was essential, but often ad hoc and not formalised:
We’re asking them [Link Workers] to do the toughest of jobs, and we’re not giving them any outlet for those emotions that come up, or for the challenges that come up. So absolutely supervision that’s really built in [is essential] (Social Prescribing Co-ordinator 1)
- Money
Money was something that almost all participants suggested as helping to facilitate SP. For Link Workers, money was required to help CYP access activities which were not free in the community. For those that did not have pots of funding for activity spending, this meant CYP often had restricted or time limited options available:
I think for a lot of them, it’s about money. So, a lot of them, they’re living in poverty. Like for people who have a lot of money, and stuff like that, then they… that’s not really a problem, is it? So, if somebody who’s quite a well-off family…they’ll just book them in and they’ll go. I think for kids that are from lower income families, it’s not like that, because you’re then having to choose between food, and that, and gas and electric, and that, and you just can’t afford it (Link Worker 8)
Not knowing where the money was coming from, or who was going to pay for activities often meant Link Workers felt caught in the middle of a broken, bureaucratic system.
- Tools for engagement
Around half of the Link Workers outlined that they used tools to help engage CYP in SP. This included aspects such as cards, board games and sports equipment. Both Link Workers, as well as those involved in the setting up or running of SP for CYP, saw such tools as important in order to make individuals feel comfortable and to facilitate positive relationships:
We have a little kit, so when somebody starts, Jenga is our go-to guy for an activity. So we have a kit of resources that we would take in. We do use a workbook for the resilience programme, and we have workbooks for other programmes. But we tend to have a selection of games, art and craft materials, drawing, colouring in, and the young people, we play to their strengths. So if we've got a young person who actually likes to kick a ball around or is very lively, we'll go outside and we'll run their session whilst we're playing a little game of football or basketball (Social Prescribing Organisational Head 3)
Social and professional influences
- Clinical leadership
Link Workers and those in middle-management roles outlined how clinical leadership influenced how SP was delivered. Clinical leadership included GPs who led primary care networks (PCN)s, as well as commissioners. These individuals often were involved in hiring the Link Workers and setting up the SP pathways. Thus, they determined how referrals could enter the system, and what types of populations Link Workers could engage with:
So the staff at the surgery have a big impact, especially partnered GPs and practice managers…clinical directors of the PCN as well, based on if they’re willing to sign or if they’re not willing to sign [contracts with SP services], and that will affect, obviously, children’s access to our service (Social Prescribing Co-ordinator 1)
- Community assets and third sector organisations
Community assets and third sector organisations also influenced SP. Link Workers and Co-ordinators spoke about needing to form good relationships with these partners, in order to be able to refer CYP into them:
I mean the community organisations we work with, they can influence the process, massively. We need them to be able to accept young people otherwise the system malfunctions (Link Worker 9)
If organisations were unable to accept referrals, Link Workers then had to work with CYP to find another appropriate activity.
- Wider policy and practice groups
Other stakeholders which influenced SP with CYP, revolved around policy and practice organisations, namely NHS England, The National Academy for Social Prescribing, and the SPYN. Such organisations were seen as pushing the agenda forward around SP with CYP, and often a key source of support for those in management positions wanting to set up SP:
NHS England, for example, who’ve put a lot of effort into social prescribing recently, they did describe it as an all-age service from the outset. So their expectation was that it should be available to young people (Social Prescribing Organisational Head 1)
Similarly, the SPYN were discussed as having spearheaded initial guidance on how to work with CYP:
I’ve look at quite a lot of the stuff that they [SPYN] have produced on how to work with young people (Social Prescribing Manager 2)
Motivation
Beliefs about capabilities
- Feeling confident engaging with CYP
The majority of Link Workers discussed feeling confident engaging with CYP, feeling that they had the necessary skills and experience to carry out their role. Central to this were interpersonal skills such as building relationships, empathising, listening, and talking:
I mean I feel like I’m a good listener and I’m good at talking to young people (Link Worker 9)
- Feeling less confident engaging with parents and guardians
However, some Link Workers felt less confident working alongside parents and guardians:
I’m so used to speaking to a service user directly…But I’m not very well versed in how to speak to a parent about their child who I’m supposed to be helping (Link Worker 5)
In particular, managing and navigating situations where families differed in terms of what SP activities the CYP should pursue was outlined as potentially challenging:
I would be less confident in terms of the inter-relationship between the parent and the child. So, for example, I think there would quite often be conflict of interest, where the child would say they wanted one thing, and the parent would say they wanted another thing. And I think negotiating that would be quite difficult (Link Worker 6)
- Feeling less confident that some clinicians saw a role for SP
For some Link workers, particularly those split across multiple sites, engaging with clinical teams felt disjointed. They spoke about how SP sat outside of traditional clinical systems, and as a result, felt less confident that they were seen as a valid and useful part of the healthcare team:
But what tends to happens is that social prescribers sit outside of that, and direct, and it’s not really, I guess, partnership working, it's more that everyone’s aware where everybody is in the system, but they’re not genuinely collaborating to get the best outcomes for people. (Link Worker 3)
This was echoed by other Link Workers who worried about not getting referrals through as they were forgotten about:
… how to maintain that contact with people, how to be present without being present physically. And I've really struggled with that. I don't know if it is, but for me it feels like that's part of the reason why the numbers of referrals and the flow of referrals aren't as high as I'd like them personally (Link Worker 11)
- Feeling confident around implementing and executing SP
For those in management roles, implementing and executing SP pathways, was something that they felt confident doing. This included understanding the detail behind SP and taking it through to execution to benefit service users:
What am I most confident about? I’m quite confident about how we communicate this stuff. I’m quite confident about organising things. I’m fairly confident about detail, and making sure that when we’ve come up with a good idea, or someone’s come up with a good idea, that we actually plan it through in a way that works (Social Prescribing Organisation Head 1)
Beliefs about consequences
- Social prescribing empowers CYP and helps wellbeing
All participants thought that SP was beneficial to the CYP as it helped empower them. This was often via connecting them with their peers who had similar interests and activities:
I think it can really be life changing, sometimes lifesaving as well, with how low some of the young people are feeling, then it can really make a difference. Having that support from other people around them, their peers. And just being able to speak to other people, finding new hobbies, new interests can be fantastic for them (Link Worker 1)
These interactions and shared interests resulted in positive impacts to CYP’s self- esteem and resilience, meaning they were better equipped to face and manage their difficulties:
[Social prescribing results in] children who know themselves, who are resilient, who are realistic about life and about their own ability to overcome challenges because they’ve got that innate now strength (Social Prescribing Co-ordinator 1)
- CYP getting attached
Around half of Link Workers discussed that without clear boundaries, it was possible that CYP could become too attached or dependant on the support that they were providing:
Sometimes they [young people] might become very reliant on the person who is helping them, in the way that they struggle to continue on without that person guiding them and giving them advice, or signposting them to relevant services. So it’s really, really important for the social prescriber to not just give advice, but also give them the encouragement to be able to, I guess, handle things on their own (Link Worker 5)
Link Workers were mindful of possible attachment risks, particularly when they were not far off the age of the CYP, and worried about the distinction between being social support and peer support being blurred.
- Social prescribing is not a fix all for everyone
Link Workers and those involved in the setting up or running of SP for CYP, cautioned against it being seen as a panacea for treating all difficulties. As the evidence base is still in its infancy, it was posited whether certain types of difficulties may be less suited to SP, such as for individuals that do not like making decisions or that are severely shy:
I guess, would be that some kids are really shy, and they wouldn’t want to do it, because they wouldn’t want to be part of a group, or doing something like that (Link Worker 9)
Optimism
- Social prescribing helps
The majority of Link Workers and those involved in the setting up or running of SP for CYP were optimistic that it was effective in helping them achieve their goals and improve their mental health:
Oh very optimistic…within most goals we kind of rate how happy they are with that, with where they are on the scales. And there’s notable differences sort of before and after engaging with a social prescriber (Link Worker 4)
However, given the novelty of social prescribing with this population, it was acknowledged that more evidence was needed to confirm this, beyond small-scale, anecdotal experiences:
We believe, but we haven’t proved it yet…I think there’s a lot more potential outcomes for young people than there are for adults in a way, but yet to be proven (Social Prescribing Organisational Head 1)
- The system is not working as well as it could be
A few individuals in management positions were less optimistic about the implementation of SP. This was particularly around whether current pathways and systems were working as well as they could:
…Only 20% of these referrals were actually coming through GPs and link workers anyway. So, I was looking at that other 80%, where are the children? Where are they? And how do we reach them, so that they can access this in the best way, the easiest way they can (Social Prescribing Co-ordinator 1)
Others outlined how SP needed to be inclusive and that if it was not implemented as such, then certain marginalised communities, who could benefit from SP, may feel alienated and excluded:
…[If] we inadvertently exclude certain communities from it. So it starts to take off and becomes a thing that only certain sections of the youth population feel is for them…we have to take care to make sure it’s fully inclusive from the start. (Social Prescribing Head 1)
Thoughts on overcoming these difficulties were to embed Link Workers in locations where CYP are situated or frequent, such as schools and places of worship.
Motivation/Goals
- Giving the CYP new opportunities and experiences
One motivation around SP with CYP, outlined by some Link Workers and Co-ordinators, was being able to provide them with opportunities and experiences that they may not otherwise have:
We just want young people to have opportunities, really. Like a lot the young people we work with in schools, particularly, are very isolated…we want to just provide opportunities for people, and spend the money as well (Social Prescribing Co-ordinator 2)
- Improving outcomes for CYP
Linked to above, a motivation for all involved was to improve the outcomes of CYP they came into contact with. Whilst the exact goal or outcome the CYP wanted to achieve depended on their specific circumstance, those involved in SP spoke of being strongly motivated to helping them achieve these and see the associated difference it would make:
I think that I enjoy seeing that change in young people and knowing that I've made a difference to them. And being able to go and make a change in their life (Link Worker 1)
Reinforcement
- Job satisfaction from helping others
The majority of Link Workers and those involved in the setting up or running of SP for CYP, spoke of their role in SP as rewarding and satisfying, as they made a difference to individuals who were struggling:
You feel good when you help someone, and you want to keep helping other people, and that’s a really big positive (Link Worker 6)
The results of seeing the positive impact on CYP acted like a catalyst, motivating and spurring those working in the field to go on and help others.
Emotion
- Social prescribing can be draining and stressful
Link Workers discussed how working with CYP who needed mental health support could impact on their own emotions and mental health. In particular, complex and challenging cases could leave Link Workers feeling overwhelmed and spent:
Social prescribing, it’s tough, it’s a tough job, it really is. It’s so emotionally draining and intense and you have so much to do and so much to think about. So if you’re having a rubbish day or you’ve had a really bad case and you just need to vent or cry, you need to be in an environment that will allow that and not kind of tell you off for getting upset (Link Worker 9)
Support from others and supervision, where available, were ways that Link Workers were able to decompress these built-up emotions:
I have access to line management, I can contact the surgery that the child or young person is under to speak to their GP. Which can sometimes take a little while, but is always helpful. I have six-weekly meetings with the safeguarding lead …Oh I attend a [group] every eight weeks (Link Worker 7)