Voluntary Health Scotland has published the first ever scoping report of Community Link Worker (CLW) programmes across Scotland, revealing their vital role in supporting mental health while raising concerns around longevity and the way programmes are evaluated to understand CLWs impact.

The research conducted between January and August this year aimed to ‘capture and understand’ the range of CLW programmes in GPs across Scotland.

A first-of-its-kind study, the report looks at how programmes have been designed and implemented and the experiences of individual practitioners involved.

A major concern heard by Voluntary Health Scotland (VHS) from CLWs is about the future of their roles given the short-term nature of funding.

One study participant said: “If we want long-term commitment, it needs to be written into some of the key policy drivers.”

Another explained it feels feel like a Cinderella service but the difference link workers make is an everyday part of general practice and “not just nice to have”.

This comes after additional government funding to protect Glasgow’s link workers was announced two weeks ago, following Glasgow Health and Social Care Partnership plans to cut the service’s funding by a third.

The research, led by Policy and Research Officer Findlay Smith, includes a survey of 60 CLWs working in GP practices and interviews with 18 programme leads and managers.

A programme lead said the current funding system causes staff additional stress:

“Not knowing what’s happening come the end of March causes so much stress on staff that are working with really vulnerable people.

“We are making them [CLWs] vulnerable by not being able to tell them what’s happening with their jobs. I think that’s an absolute tragedy.”

In 2016, the Scottish government committed to recruiting at least 250 CLWs to support people struggling with the social determinants of poor health and reduce pressure on GPs.

There are now thought to be more than 300 CLWs working in GPs across Scotland.

Approaches to support and intervention vary across programmes, with study participants highlighting that this ‘flexibility in support’ is a key strength of CLW programmes.

Despite a range of approaches to delivering care through CLWs, common experiences of patient needs were shared participants from different programmes.

Among the 60 survey respondents, 95% identified mental health as the primary reason for referral to their services.

Social isolation and loneliness, trauma and housing, welfare and financial issues also arose as common concerns among patients referred to CLW services.

CLWs and programme managers shared the reality of multiple issues faced by the people they see in single appointment:

“We have an hour or so with the person, so we can sit and talk. We have often found that people are referred for one thing from the GP, but when they sit down with a CLW there is a whole host of other things that are contributing to the one thing the GP has sent them for.”

Health inequalities

Last year, a CLW and a deep-end GP working in one of Scotland’s most deprived areas gave an insight into link workers’ vital role in tackling health inequalities.

Since then, VHS hosted the first dedicated the Scottish Community Link Worker Network conference which focused on the crucial work of CLWs in tackling health inequalities and outlined that they cannot do this alone.

Now, this report reveals that while link workers agreed they could help on an individual patient basis, tackling health inequalities at a systemic level may be ‘beyond the reach’ of a single programme.

Despite tackling health inequalities recognised as an overarching theme running through most programmes, ‘mixed views’ were expressed on the degree to which this could realistically be achieved.

One interviewee said:

“Originally the programme was brought in to tackle the social determinants of health and support people living in the most deprived areas with those social determinants of health. In reality, there’s a limited amount we can do.”

A programme manager interviewed described this as a “personal struggle”, which they said feels like “patching up the wider political stuff”.

Scotland’s Health Secretary told attendees at the VHS annual conference this year that economic policy change is key to tackling health inequalities.

Meanwhile, this report details the importance of effectively measuring the contribution of CLWs and other programmes of action on health inequalities.

Evaluating success

A lack of standardised reporting tools or coherent national structure around the delivery of services was reflected by survey respondents.

One programme lead explained that programmes were not given set measurement tools. Meanwhile, multiple interviewees suggested the data currently collected could not help meaningfully measure their impact on health inequalities.

Only 13% regularly recording SIMD status of patients and across programmes this was not implemented consistently.

In total, 16 different data collection and management systems were reportedly used to monitor the implementation of CLW programmes – from dedicated and bespoke systems to Excel and Google Suite.

Although flexibility in delivering CLW programmes was welcomed by participants, concerns were raised that this level of local discretion comes ‘at the expense of’ adequate support and coherence across programmes.

Only 35 survey respondents said they used an evaluation tool to measure the impact of their work, with a total of 14 different evaluation tools used in CLW programmes.

The report also highlighted that although better co-ordination nationally could improve evaluation and help programmes become more impactful, it may risk the diversity of CLW provision across Scotland.

Participants discussed the contribution of CLWs to several different wellbeing outcomes but said the understanding around the extent of their impact ‘remains limited’.

Managers said that a common national agenda and evaluation system could support increasing the evidence-base and help “prove that link working support works”.

The Scottish government says it will review the CLW programme in the New Year and VHS and the Scottish Community Link Worker Network hope this report will ‘help guide strategic decisions in relation to the ongoing development and sustainability’ of the programme.

Read more: Inside Scotland's widening health inequalities; Glasgow link workers protected for three years; Working together for climate action and good health; Can Scotland make health fairer?; Money matters for poverty and health

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