Background Link worker social prescribing is increasingly accessed and delivered through UK NHS primary care, with plans to refer 900,000 patients to link workers by 2023. However, learning is still needed about models of delivery and embedding of link workers. We present the results of an ethnography aimed at exploring how a social prescribing intervention in North-East England was becoming embedded locally from the perspectives of the link workers delivering it. The intervention, established in 2015 and funded via a Social Impact Bond (SIB), supported patients with Long Term Health Conditions (LTCs) using two local provider organisations.

Methods Ethnographic fieldwork was conducted between August 2019 and June 2020. Link workers consented for the ethnographer to undertake participant observation at their provider offices (n=24). Link workers were then invited to participate in interviews (n=5) and one of three focus groups (n=17). The ethnographer also shadowed eight link workers. This included accompanying them seeing clients in GP surgeries, provider offices or in homes, and whilst they completed administrative tasks and attended staff meetings and training. Data included field notes and interview and focus group transcripts which were coded using thematic analysis in an iterative approach that engaged with complexity, context and existing knowledge.

Results Link workers operated in the liminal spaces between the intervention, primary care and the local community. These spaces were shaped by their own social location as well as that of their clients and the health and community workers they encountered. The subtle hegemony of primary care shaped experiences of working within these intersections, requiring link workers to negotiate a space and work hard securing referrals. Completion of the patient recorded outcome measures required for payment through the SIB also shaped work routines. The combined effect was to obstruct some routines, such as face to face meetings, whilst encouraging others, such as telephoning clients to secure referrals and complete PROMs. These routines contributed to a high staff turnover.

Conclusion As the NHS rolls out social prescribing it is crucial to consider different models of delivery and how to embed them. Shared understandings and strong relationships with primary care will be needed to ensure link workers receive referrals. Understanding that performative pressures to record specific outputs can shape the link worker role will also be important, not only in determining the nature of social prescribing being delivered, but in helping support link workers to stay in the role and become embedded in local teams.