Although the interviews came from a variety of stakeholders with different roles, unequal power and diverse skill sets, the 12 participants had similar thoughts on SP for families, and SP practice in general. There was an overwhelmingly positive view on SP for young families with children 0-3-years-old, although all of the participants also acknowledged the weaknesses of this type of intervention. There were three main themes identified in the corpus of data all pertaining to both families and the stakeholders themselves; 1) A New Offer: Getting it Right the First Time, 2) Barriers to Socially Prescribed Family Intervention and 3) Social Prescription for Complex Families. The second and third theme also had one sub theme each 2a) Complexity of Evidence and 3a) Covid-19 and Peer Support. Stakeholders postulated on how families might use the SP play provision and also spoke about themselves, so each theme also resulted in perspectives on service users and stakeholders.
1) A New Offer: Getting it Right the First Time
This theme encompassed the presentation, normalization and the meaning of SP programmes for families. It featured stakeholders’ perspectives on what SP was, is and could be in terms of both their viewpoint and the families that would use the services. All 12 participants unanimously viewed SP initiatives as valuable and needed, although they voiced this from their own perspectives. For example, MP1 explained, “What’s not to like about something that is going to help kids, help the families, help the parents?” knowledge may be limited about the intricacies of SP, but he was sold on the idea.
The early help development officer adds her perspective about the need for SP for families on the ground, “We definitely, definitely feel like it’s something that is worthwhile continuing and actually adds a lot of value to the offer of children’s services.” This viewpoint echoes in other stakeholders. For example, the social prescriber 1 doesn’t hesitate to say, “I think there’s actually like a massive gap for it and I think it is necessary and I think it’s definitely needed.”
Promotion and how SP was presented to the families was one area many interviewees believed was integral to the success or failure of the initiative. GP2 spoke about how she introduces the concept to her patients, ensuring she presented the programme she would send them to in a positive way:
“I try to explain to them that mind and body don’t go separately, they go together and wellbeing goes together with mind and body and that social prescribers, what they do is look into other forms of wellbeing that, they are not purely medical.”
While the specialist health visitor uses another strategy that has worked for her consistently suggesting that “‘This would normally cost.’ And I said, ‘but it’s just available at the minute, and hopefully and see what you think.’”
The consensus among the stakeholders was that normalizing SP in general and for families was one way forward. SP for families with 0-3-year-olds is a very new practice and, “we’re essentially six years behind because it’s very, very new to us in children’s services.” (early help development officer). Some stakeholders mentioned that families may feel there was a stigma while others did not feel the families they worked with would feel any differently about a SP play experience specifically. The acting service manager reported, “the more social prescribing there is out there and the more there is available actually becomes more normal, less scary and that stigmas then removed.” The mental health commissioning manager added that one of the things that play on prescription may have going for it is thatplay groups already “so normalized for young children.”
Although stakeholders themselves found SP valuable, these concepts were also discussed in terms of interviewee’s opinions on how families may understand SP. Many spoke about families not knowing what SP was or that it could be available to them for no cost. The public health portfolio lead explained, social prescribing is a bit of a well-kept secret that’s not meant to be a secret. While social prescriber 2 talks about how, “obviously not many people know what social prescribers are, and the children and family seems new.” While the maternity voices representative agreed, “the barriers are they don’t know they are there.”
Some stakeholders postulated that once SP is more mainstream and normalised one of the worries would be expectations of outcomes that are above and beyond what is realistic in their minds because of the medical implication of the word prescription. For example, MP1 pointed out that he’d be worried people would be misled into thinking the intervention would, “be the solution to all problems…I think expectations should be managed that this intervention with this opportunity, this play MAY help, rather than will.” While there were others that opposed this and thought play was not medicalized inherently, so did not fear this outcome. The health visitor explains, “a play intervention it’s not sort of seen as medicalized. Or yes because a lot of the things that we do refer to are a very medicalized or hospitalized.”
Finally, stakeholders themselves warned that when carrying out a programme, everything done from promotion to the quality of the intervention itself would need to be done right the first time. The acting service manager pointed out, “it is an amazing option as long as it’s done in the right way.” and as MP 2 states, “You may only have one crack at this.”
2) Barriers to Socially Prescribed Family Intervention
This theme encompassed a range of structural issues and sustainability worries which were voiced by the stakeholders. It was agreed that infrastructure needed to be well organized and specialized for real buy-in to SP for families with infants. The disconnect between stakeholders’ own roles also falls under this theme and their own thoughts about what families of 0-3-year-olds need in SP as well as how families might feel about the infrastructure and even government on a whole while engaging in a SP programme for families with very young children.
One of the standout infrastructure issues, no matter what perspective the stakeholder was coming from, was that of funding infrastructure which would make SP more sustainable. The maternity voices representative explained community services are trying to provide mental health wellbeing for new families, but, “they haven’t got funding to provide it, they are looking at other ways to provide it and social prescribing has come up as a possibility.” While GP1 worried about play on prescription being just another initiative coming across his desk explaining, "what you learn as time goes by, very often this initiative fails, but you’ve created a number of expectations”. Coming in from a policy and sustainability angle, MP2 warns:
“Clearly having a strategy to sustain it is absolutely crucial or else you’re just throwing money down the drain. And I think there is too much of that which goes on. It’s like let’s put some money in. Let’s invest. And then you move on, you’ve ticked that box.”
The mental health commissioning manager pointed out that one way to sustain SP being its unique place within the system. She told the researcher, “its got a huge role in children and young people’s lives, but it has to tie into the wider system.”
Another issue that came up in many discussions was the strain of healthcare work and how this makes everything harder for stakeholders and thus new family SP programmes. The public health portfolio lead describes this strain in her interview saying, “everybody’s too busy and at capacity all the time.” She goes on to explain the work environment where social prescription might be viewed as “fluffy” because of the holistic nature of the initiatives concluding, “I think sometimes clinicians, it- we all work differently don’t we, and they don’t- some of them will see it like that, and others just see as, no that’s how- we prescribe that, that’s the answer, that’s what we’ll try first.”. Social prescriber 1 acknowledges the workloads on healthcare workers looking at the benefits of her job. “It takes pressure off GPs and everything because we’re able to give them constant meetings that some people need.” Even the GPs themselves talked about their workload where GP1 reminds, “I don’t have 20 minutes. I don’t have- I sometimes have 7 minutes and that’s what I have.” The GPs also spoke about disconnect with SP for families as GP2 states, “usually young children are managed by the health visitors.”
While time constraints and money were readily spoken about, one topic that some of the stakeholders seemed to know little about was infancy. This was most likely because for many, this stage of life was not in their remit. For example, GP1 explained he couldn’t speak to issues faced by 0-3-year-olds. Many of the stakeholders reverted to talking about “young people” and those of school age when discussing SP for families. The first 1,001 days were only mentioned in the interview with the early help development officer who later went on to tell a story about trying to find research around, “social prescribing, but for children…At the time we had that done, there was very little.” This disconnect could be one reason why SP for families of very young children is not understood by all stakeholders and even families themselves.
Another infrastructure issue which came up was the trust that families with infants might or might not have in the system. The mental health commissioning manager saw this as a potential issue with uptake explaining, “families, especially in areas of high deprivation, have a general mistrust of the council.” This mistrust also was mentioned by almost every one of the interviewees explaining families were afraid of the council taking their children. As an intervention to improve this trust, the acting service manager described how provisions like play on prescription have worked well for families that don’t trust the system, because usually when being referred into services this is a negative, but with a programme like play on prescription, “they got education going through and they also got a positive experience of working with professional agencies.” She believes SP of this sort could really improve those fears and mistrust.
2a) Complexity of Evidence
One of the inherent problems with the rollout of SP around the world has been that there is a lack of evidence base. The funding and rollout of health initiatives are usually grounded by an evidence base. Talking about the expectation of measurable change for a play on prescription initiative brought out opinions on the quantifiability of the intervention. For example, social prescriber 2 spoke about seeing a confidence in families that have gone into SP but not being able to note down a numeric change, “There’s always a lot of change in sort of behaviour themselves. When they know they’ve got support, they’re happier.” While MP2 argued that, “I think data is important and looking at that, but that comes through, often stories rather than just hardcore data.” The mental health commissioning manager agreed saying that yes, there are standardized measures that can be used because “NHS England is really driving for measurable things, but actually there are other things we can’t capture.” She gave an example of a woman with an increased risk of crisis put into a SP programme explaining, “we can’t prove that it stopped her from going into a hospital bed.” One thing that stakeholders agreed on was the idea set forth by the public health portfolio lead about the quantifiability of SP for families of infants, “even if we can’t measure it, it’s still important, isn’t it?”
3) Social Prescription for Complex Families
The final theme was that of the complex profile of needs in many families. The family system and spectrum of different needs must be taken into account in this type of SP where there is not only one person coming into the programme. To have utility there needs to be an extra layer of having a bespoke nature for each family. The complex needs of the parents and families coming into the SP programmes was spoken about by many stakeholders. Around this issue is the idea of severity. Where stakeholders explained that parents have to have very acute issues usually to be given intervention. The maternity voices representative explained,
“It’s the severe end of depression that is targeted with perinatal health and the groups that are set up, but it’s that low to moderate depression that is, I think increased particularly over covid. There is a great big gap.”
GP2 also talked about the complex nature of her patients that are new parents explaining, “many of these patients they don’t only need the social prescriber, they need mental health, they need CAMHS.” In order to facilitate SP for all of these different families, the early help development officer explained how they actively tailor programmes to meet needs of specific families, “it’s completely bespoke. It is quite difficult to explain exactly what they do because it is very different for every family.”
Because the interviews were based around a play on prescription model, almost all of the interviewees touched on play itself and its therapeutic nature There was also discussion on families being taught how to play. It was acknowledged that every family’s circumstances and relationship with play would be different. The acting service manager’s dialogue around play shows how imperative she thinks playing is for families, “Play, it’s really important and we’ve got so many kids who are…sat with a tablet, generally in a highchair or if they’re out in a buggy so development’s delayed. And that importance is missed, that understanding is missed.” The health visitor agreed, “a lot of parents don’t necessarily know how to play.” She later commented on watching parents with children in a creative practice saying, “the kid would do a beautiful picture and they’d go, ‘what’s that? Doesn’t look like anything.’ And you think (pause) but to the child-.” And the public health portfolio lead also spoke about the ability for a play on prescription programme to be able to;
“provide their role in play going forward, as well. So to understand how to maybe structure play or enable play in their home…I know a lot of the demographic, and I think sometimes they just don’t know.”
After consideration of how a play on prescription model could help parents who have gone through Covid-19 and are beginning to return to activities with their infants, MP2 states, “if people can divert into more creative spaces, more therapeutic spaces either in the school environment or outside that is a place of recovery.”
3a) Covid-19 and Peer Support
One of the events that has made family systems even more complex, is the Covid-19 pandemic. This subtheme involves the concept of SP as an intervention for families recovering from the pandemic. Every stakeholder saw isolation as a major issue in the pandemic, but one that hit new parents particularly hard as much of new parenting is made easier through family and community peer support. MP1 explains how play on prescription might foster peer support;
“developing their own community network, you know, that whole kind of mumsnet kind of playgroup, mums kind of thing. There might be some incidental benefits that come from that incidental networking of people with shared problems.”
While the mental health commissioning manager explained that new parents need that peer support whether it is coming from inside the house or somewhere else. Later talking about how “during lockdown, they didn’t have this opportunity to make peer group support. And, you know what if there’s no one else their age that’s having children or that they know?”