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BackgroundCommon mental health disorders are especially prevalent among people from socioeconomically disadvantaged backgrounds. Non-pharmaceutical primary care interventions, such as social prescribing and collaborative care, provide alternatives to pharmaceutical treatments for common mental health disorders, but little is known about the impact of these interventions for patients who are socioeconomically disadvantaged.AimTo synthesise evidence for the effects of non-pharmaceutical primary care interventions on common mental health disorders and associated socioeconomic inequalities.Design and settingSystematic review of quantitative primary studies published in English and undertaken in high-income countries.MethodSix bibliographic databases were searched and additional grey literature sources screened. Data were extracted onto a standardised proforma and quality assessed using the Effective Public Health Practice Project tool. Data were synthesised narratively and effect direction plots were produced for each outcome.ResultsThirteen studies were included. Social-prescribing interventions were evaluated in 10 studies, collaborative care in two studies, and a new model of care in one study. Positive results (based on effect direction) were reported for the impact of the interventions on wellbeing in groups that were socioeconomically deprived. Inconsistent (mainly positive) results were reported for anxiety and depression. One study reported that people from the group with least deprivation, compared with the group with greatest deprivation, benefitted most from these interventions. Overall, study quality was weak.ConclusionTargeting non-pharmaceutical primary care interventions at areas of socioeconomic deprivation may help to reduce inequalities in mental health outcomes. However, only tentative conclusions can be drawn from the evidence in this review and more-robust research is required.

Background Link worker social prescribing enables health-care professionals to address patients’ non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking. Objectives To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement. Data sources Quality Outcomes Framework and Secondary Services Use data. Design Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April–July 2020). Study population and setting Community-dwelling adults aged 40–74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK. Intervention Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions. Participants (1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients. Main outcome measures The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score. Results Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (–1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to –£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval –0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems. Limitations The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise. Conclusions This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances. Future work To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts. Trial registration This trial is registered as ISRCTN13880272. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

The concept of intergenerational fairness has taken hold across Europe since the 2008 financial crisis. In the United Kingdom (UK), focus on intergenerational conflict has been further sharpened by the 2016 ‘Brexit’ vote to take the UK out of the European Union. However, current debates around intergenerational fairness are taking place among policy makers, the media and in think-tanks. In this way, they are conversations about, but not with, people. This article draws on qualitative interviews with 40 people aged 19–85 years and living in North-East England and Edinburgh, Scotland's capital city, to explore whether macro-level intergenerational equity discourses resonate in people's everyday lives. We find widespread pessimism around young people's prospects and evidence of a fracturing social contract, with little faith in the principles of intergenerational equity, equality and reciprocity upon which welfare states depend. Although often strong, the kin contract was not fully ameliorating resentment and frustration among participants observing societal-level intergenerational unfairness mirrored within families. However, blame for intergenerational inequity was placed on a remote state rather than on older generations. Despite the precariousness of the welfare state, participants of all ages strongly supported the principle of state support, rejecting a system based on family wealth and inherited privilege. Rather than increased individualism, participants desired strengthened communities that encouraged greater intergenerational mixing.

Healthcare systems in many countries are enthusiastically adopting link worker social prescribing interventions that aim to tackle the social determinants of health by linking patients to voluntary and community sector activities and sources of support to address their social needs and improve condition management. Social prescribing interventions aim to improve health and reduce healthcare spending. However, despite the diversion of healthcare budgets to fund social prescribing, we still lack robust evidence for its effectiveness. In this study we evaluate whether participation in a social prescribing intervention reduced non-elective admitted patient care use and costs for 8283 patients aged between 40 and 74 years, with a diagnosis of type 2 diabetes and living in an area of high socioeconomic deprivation in north-east England. Patients were followed for a total of 6 years: 2 years pre-intervention and 4 years post intervention. Exploiting a natural experiment, we used a two-part difference-in-differences regression model to estimate costs conditional on healthcare use. We also estimated intervention effects across several intervention and control groups and sample subgroups. Participation in the intervention resulted in reductions of up to -£77.57 [95% CI: -152.30, -2.84] (for high engagement patients) per patient, per year, in non-elective care costs. Reductions were greater for patients with higher levels of engagement with the intervention. Sub-group analyses showed greater cost reductions for non-White patients, older patients, and patients without additional co-morbidities. Our findings suggest that engagement with a link worker social prescribing intervention may reduce non-elective healthcare spending, perhaps through enabling better condition management that results in fewer avoidable health crises.

Common mental health disorders (CMDs) disproportionately affect people experiencing socioeconomic disadvantage. Non-pharmaceutical interventions, such as ‘social prescribing’ and new models of care and clinical practice, are becoming increasingly prevalent in primary care. However, little is known about how these interventions work and their impact on socioeconomic inequalities in health. Focusing on people experiencing socioeconomic disadvantage, this systematic review aims to: (1) explore the mechanisms by which non-pharmaceutical primary care interventions impact CMD-related health outcomes and inequalities; (2) identify the barriers to, and facilitators of, their implementation in primary care. This study is a systematic review of qualitative studies. Six bibliographic databases were searched (Medline, ASSIA, CINAHL, Embase, PsycInfo and Scopus) and additional grey literature sources were screened. The included studies were thematically analysed. Twenty-two studies were included, and three themes were identified: (1) agency; (2) social connections; (3) socioeconomic environment. The interventions were experienced as being positive for mental health when people felt a sense of agency and social connection. The barriers to effectiveness and engagement included socioeconomic deprivation and underfunding of community sector organisations. If non-pharmaceutical primary care interventions for CMDs are to avoid widening health inequalities, key socioeconomic barriers to their accessibility and implementation must be addressed.

The COVID-19 pandemic and ‘lockdown’ restrictions have affected people's health and wellbeing globally. Those who are clinically vulnerable to COVID-19 mortality due to living with long term conditions (LTCs) are at greater risk of negative impacts on their health and wellbeing, and of disruption in management of their LTCs. This study explores how people with LTCs managed their health and wellbeing under social distancing restrictions and self-isolation during the first wave of the COVID-19 pandemic, and examines why some people were more able to manage than others. Interviews were conducted between May and July 2020 with people (n = 44) living in North East England, who had one or more LTCs and were recruited via a social prescribing intervention. Data were analysed using a social constructivist thematic analysis. We present our analysis of the possibilities afforded to people to manage the impacts of lockdown on their health and wellbeing. We find that while some people deployed a range of capitals and/or etched out ‘tactics’ to make life ‘habitable’, others experienced ‘zones of impossibility’ requiring that they rely on contingent events or formal support. Our analysis highlights inequalities amongst people with LTCs, particularly regarding access to and deployment of important resources for health and wellbeing under COVID-19 social distancing restrictions, including outdoor space or greenspace, exercise and social connection. The study is novel in showing the mechanisms for coping with a significant period of disruption in the life-course whilst highlighting that although resilience was common in people with LTCs, this was sometimes at detrimental costs to themselves.

BackgroundFrom their Scottish origins in 2009, Deep End GP networks are being established all over the UK and further afield in Ireland and Australia. Formed of primary care practitioners in areas of high blanket socioecocomic deprivation, their common goal it to mitigate health inequalities and champion the cause of primary care. As the North East is the most deprived region in England, it was important to set up a network that was sustainable and reflected the priorities of those who worked in it. The network currently consists of the 34 most deprived practices in the region. Deep End NENC is affiliated with the Newcastle University Applied Research Collaboration’s (ARC) ‘inequalities and marginalised communities’ strand and this work will also be used to direct the ARC research priorities. This project aims to use co-design methodology to gather information from practitioners in the region that could be used to guide the initial steps of the Deep End NENC network. Co-design interviews would also serve to improve engagement and disseminate information about the network.MethodsParticipants were recruited using purposive and snowball sampling, as well as a blanket communication to all Deep End practices. Fifteen semi-structured interviews were carried out with health professionals (11 GPs, 2 social prescribing link workers, 1 nurse practitioner and 1 district nurse) from Deep End practices in the NENC. Due to Covid-19 these were carried out over Zoom before transcription and thematic analysis. Findings from the interviews were communicated to the members of Deep End NENC via webinars and they also formed the part of the Deep End Steering Group spending prioritisation protocol.ResultsA coding framework was used to consider findings at patient level, practice/network level and ‘upstream’ political level. Themes identified were the specific clinical and social challenges in the Deep End;barriers to patient care and access to services;training and recruitment;the need to connect with others who worked in these communities to share best practice;and the need to advocate for the Deep End. The COVID-19 pandemic itself brought challenges that were felt more acutely by Deep End patients and those who cared for them.DiscussionThese interviews were successful at identifying priority areas that will form the basis of the work that Deep End NENC will focus on over the coming years. They also add to the literature around challenges facing staff who work in deprived communities.

Background COVID-19 is disproportionately impacting people in low-income communities. Primary care staff in areas of high blanket deprivation (also known as the ‘Deep End’) have unique insights into the challenges posed by the pandemic. We aim to explore the impact of the COVID-19 pandemic from the perspective of Deep End primary care practitioners in North East England, the most deprived region of the country. Methods Semi-structured interviews followed by thematic analysis. 13 participants were interviewed (11 GPs, 1 nurse practitioner and 1 district nurse) with Deep End careers ranging from 3 months to 31 years. Participants were recruited via purposive and snowball sampling. Semi-structured interviews were conducted using video-conferencing software. Data were analysed using thematic content analysis. Participants were interviewed between September-December 2020, at the start of the UK second wave of the COVID-19 pandemic. Results Our results can be categorised into three broad themes: the immediate health risks of COVID-19 on Deep End general practices and patients; factors likely to exacerbate the effects of existing socioeconomic deprivation; and wider implications for remote consulting. Discussion Deep End practitioners have valuable insights into the impact of social distancing restrictions and remote consulting on patients‘ health and wellbeing and on the delivery of primary care in areas of deep deprivation. Their experiences should guide future pandemic response measures and any move to ‘digital first’ primary care to ensure that existing inequalities are not worsened.

Background COVID-19 public health restrictions, such as social distancing and self-isolation, have been particularly challenging for vulnerable people with health conditions and/or complex social needs. Link worker social prescribing is widespread in the UK and elsewhere and is regarded as having the potential to provide support to vulnerable people during the pandemic. This qualitative study explores accounts of how an existing social prescribing service adapted to meet clients’ needs in the first wave of the pandemic, and of how clients experienced these changes. Methods Data were collected in a deprived urban area of North East England via remote interviews with clients (n = 44), link workers (n = 5) and service provider managerial staff (n = 8) from May–September 2020. Thematic data analysis was conducted. Results The research found that service providers quickly adapted to remote intervention delivery aiming to serve existing clients and other vulnerable groups. Service providers experienced improved access to some existing clients via telephone in the first months of remote delivery and in some cases were able to engage clients who had previously not attended appointments at GP surgeries. However, link workers also experienced challenges in building rapport with clients, engaging clients with the aims of the intervention and providing a service to digitally excluded people. Limited link worker capacity meant clients experienced variable contact with link workers with only some experiencing consistent support that was highly valued for helping to manage their conditions and mental wellbeing. Limited access to linked services also adversely affected clients. Clients living in less affluent circumstances and/or with worse health were more likely to experience negative impacts on their long-term condition. Some found their health and progress with social prescribing was ‘on hold’ or ‘going backwards’, which sometimes negatively affected their health. Conclusions Social prescribing offered valued support to some during the pandemic, but remote support sometimes had limited impact for clients and findings highlight the vulnerability of social prescribing’s success when linked services are disrupted. Findings also show the need for more to be done in the upscaling of social prescribing to provide support to digitally excluded populations.

COVID-19 is disproportionately impacting people in low-income communities. Primary care staff in deprived areas have unique insights into the challenges posed by the pandemic. This study explores the impact of COVID-19 from the perspective of primary care practitioners in the most deprived region of England. Deep End general practices serve communities in the region’s most socioeconomically disadvantaged areas. This study used semi-structured interviews followed by thematic analysis. In total, 15 participants were interviewed (11 General Practitioners (GPs), 2 social prescribing link workers and 2 nurses) with Deep End careers ranging from 3 months to 31 years. Participants were recruited via purposive and snowball sampling. Interviews were conducted using video-conferencing software. Data were analysed using thematic content analysis through a social determinants of health lens. Our results are categorised into four themes: the immediate health risks of COVID-19 on patients and practices, factors likely to exacerbate existing deprivation, the role of social prescribing during COVID-19, wider implications for remote consulting. We add qualitative understanding to existing quantitative data, showing patients from low socioeconomic backgrounds have worse outcomes from COVID-19. Deep End practitioners have valuable insights into the impact of social distancing restrictions and remote consulting on patients’ health and wellbeing. Their experiences should guide future pandemic response measures and any move to “digital first” primary care to ensure that existing inequalities are not worsened.

Combining feminist political economy and life-course perspectives, this mixed-methods study critically examines the extent to which extended working life policies take account of women’s experiences of paid and unpaid work. I explore how decisions to extend working life are shaped by gendered social structures and norms across the life course among women in the Newcastle Thousand Families Study, a UK early baby-boom birth cohort. Among this cohort of women currently transitioning into retirement, analysis of longitudinal survey data identifies a range of mid- and later-life factors that impact on the likelihood of women working beyond state-pension age. In-depth life-course interviews identify further complex and interacting gendered life-course experiences, not captured in the survey data, which act to necessitate, encourage, enable or constrain extended working. I conclude that, if women are to extend their working lives, ‘joined-up’ policies are required, addressing gendered inequalities across the life course.

In this journal there has been considerable discussion regarding the development of tools for valuing the multiple attributes that arise from complex interventions with benefits beyond health. Nevertheless, unlike the rigorous underpinnings of cost-utility analysis, much of this work has been taking place in fragmented research communities and without theoretical underpinnings, leading to a call for better and more comprehensive frameworks. We discuss the challenges faced by economic evaluation using as our example a "social prescribing" intervention, a novel health intervention based on the social model of health. We suggest a mixed-methods approach to uncover important attributes and then combine tools from health economics and economics to provide measures of benefit in a common money numeraire. This approach provides the theoretical underpinnings necessary for deliberate, transparent, and structured decision-making processes. It also enables the correct allocation of costs within complex payment systems. We suggest that, because of the complexities of randomized controlled trials, interventions should be introduced in a way that allows the application of causal analysis for evaluation. In the short term, such evaluations may be challenging and expensive. Nevertheless, as has happened with health economics evaluation and the quality-adjusted life-year, when a common set of attributes is agreed upon, the expense will fall and these methods can become embedded in interventions with diffuse outcomes.

The effectiveness of immunization is widely accepted: it can successfully improve health outcomes by reducing the morbidity and mortality associated with vaccine-preventable diseases. In the era of pandemics, there is a pressing need to identify and understand the factors associated with vaccine uptake amongst different socioeconomic groups. The knowledge generated from research in this area can be used to inform effective interventions aimed at increasing uptake. This umbrella systematic review aims to determine whether there is an association between socioeconomic inequalities and rate of vaccine uptake globally. Specifically, the study aims to determine whether an individual’s socioeconomic status, level of education, occupation, (un)-employment, or place of residence affects the uptake rate of routine vaccines. The following databases will be searched from 2011 to the present day: Medline (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane CENTRAL, Science Citation Index (Web of Science), DARE, SCOPUS (Elsevier), and ASSIA (ProQuest). Systematic reviews will be either included or excluded based on a priori established eligibility criteria. The relevant data will then be extracted, quality appraised, and narratively synthesised. The synthesis will be guided by the theoretical framework developed for this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Equity extension (PRISMA-E) guidance will be followed. This protocol has been registered on PROSPERO, ID: CRD42022334223.

IntroductionInternationally there is pressure to contain costs due to rising numbers of hospital admissions. Alongside age, socioeconomic disadvantage is the strongest risk factor for avoidable hospital admission. This equity-focussed systematic review is required for policymakers to understand what has been shown to work to reduce inequalities in hospital admissions, what does not work and where the current gaps in the evidence-base are.Methods and analysisAn initial framework shows how interventions are hypothesised to reduce socioeconomic inequalities in avoidable hospital admissions. Studies will be included if the intervention focusses exclusively on socioeconomically disadvantaged populations or if the study reports differential effects by socioeconomic status (education, income, occupation, social class, deprivation, poverty or an area-based proxy for deprivation derived from place of residence) with respect to hospital admission or readmission (overall or condition-specific for those classified as ambulatory care sensitive). Studies involving individuals of any age, undertaken in OECD (Organisation for Economic Co-operation and Development) countries, published from 2000 to 29th February 2020 in any language will be included. Electronic searches will include MEDLINE, Embase, CINAHL, Cochrane CENTRAL and the Web of Knowledge platform. Electronic searches will be supplemented with full citation searches of included studies, website searches and retrieval of relevant unpublished information. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Narrative synthesis will be conducted and also meta-analysis where possible. The main analysis will examine the effectiveness of interventions at reducing socioeconomic inequalities in hospital admissions. Interventions will be characterised by their domain of action and approach to addressing inequalities. For included studies, contextual information on where, for whom and how these interventions are organised, implemented and delivered will be examined where possible.Ethics and disseminationEthical approval was not required for this protocol. The research will be disseminated via peer-reviewed publication, conferences and an open-access policy-orientated paper.PROSPERO registration numberCRD42019153666.

Key Points Question Is a community health worker social prescribing program associated with improved glycemic control among UK patients aged 40 to 74 years with type 2 diabetes? Findings In this cohort study with difference-in-differences analysis of 8086 patients in the UK National Health System, a holistic community health worker intervention was associated with improvements in hemoglobin A1c levels. The association increased over time and was greater for White patients vs non-White patients, those with fewer additional comorbidities, and those living in the most socioeconomically deprived areas. Meaning The community health worker social prescribing program was associated with improved glycemic control, suggesting that these types of interventions may help to reduce the public health burden of type 2 diabetes., This cohort study examines whether a UK National Health Service community health worker social prescribing program was associated with improved hemoglobin A1c levels among patients with type 2 diabetes, Importance Despite lacking robust evidence of effectiveness, health care systems in developed countries are funding holistic community health worker (CHW) social prescribing programs that address social needs and health behaviors as adjuncts to clinical care. Objective To determine whether a UK National Health Service (NHS) CHW social prescribing program was associated with improved hemoglobin A1c (HbA1c) levels among patients with type 2 diabetes. Design, Setting, and Participants This cohort study with difference-in-differences analysis was conducted among 8086 patients (4752 in the referral program, 3334 in the control group) in 24 NHS primary care practices in a city in North East England. Patients aged 40 to 74 years with a diagnosis of type 2 diabetes were observed for 8 years, from 2011 through 2019. The statistical analysis was conducted between June 1, 2019, and January 31, 2021. Interventions A social prescribing program, launched in April 2015, enabling primary care staff to refer patients to CHW support to identify condition management and social needs goals and access voluntary and community sector support to address these goals. Intervention referral was only available in primary care practices in the city’s west. The control group included patients in the city’s east where referral was unavailable. Main Outcomes and Measures HbA1c level, a marker of glycemic control. Results A total of 8086 patients were included in the analysis (mean [SD] age, 57.8 [8.78] years; 3477 women [43%]; 6631 White patients [82%]). Mean (SD) baseline HbA1c levels were 7.56% (1.47%) in the referral program group and 7.44% (1.43%) in the control group. Following introduction of the social prescribing referral program, the referral group experienced an HbA1c reduction of −0.10 percentage points (95% CI, −0.17 to −0.03 percentage points) compared with the control group. The association increased over time: after 3 years the estimated association was −0.14 percentage points (95% CI, −0.24 to −0.03 percentage points). The association was stronger for White patients compared with non-White patients (−0.15 percentage points [95% CI, −0.26 to −0.04 percentage points] after 3 years), those with fewer additional comorbidities (−0.16 percentage points [95% CI, −0.29 to −0.04 percentage points] after 3 years), and those living in the most socioeconomically deprived areas (−0.19 percentage points [95% CI, −0.32 to −0.07 percentage points] after 3 years). Conclusions and Relevance In this study of UK adults with type 2 diabetes, a social prescribing program with referral to CHWs targeting patients’ social needs and health behaviors was associated with improved HbA1c levels, suggesting that holistic CHW interventions may help to reduce the public health burden of type 2 diabetes.

Objectives While a large body of evidence exists in support of outcomes associated with cumulative dis/advantage (CAD), individual-level experiences of the systemic processes that generate unequal outcomes have received far less attention. This study explored experiences, among members of an early baby-boom birth cohort, of CAD-generative processes within the education and housing systems and the mechanisms by which they interacted with initial social position to perpetuate inequalities. Methods The author conducted in-depth interviews (n = 27) with members of the Newcastle Thousand Families Study, a UK 1947 birth cohort. Longitudinal survey data enabled participant sampling on the basis of gender, occupational social class at birth and age 50, educational attainment and homeownership status at age 60. Qualitative data were analyzed using thematic analysis. Results Analysis identified two themes: Firstly, the sorting and funneling mechanisms by which the “meritocratic” education system interacted with initial social position, progressively narrowing aspirations and opportunities; and secondly, the creation in later life of winners and losers in the property market, resulting in legitimization of inequalities through a deservingness narrative. Discussion CAD has proved persistent, even among the supposedly “lucky” early baby-boom cohort. Policies to ameliorate CAD generation through education and property systems act instead to entrench advantaged social positions. Later-life outcomes can be naturalized as the product of effort-plus-ability if not seen in a whole-life context. Disruption of CAD processes requires challenging vested interest inherent in social systems.

Background Social prescribing enables health-care professionals to address non-medical causes of ill-health by harnessing the resources of the voluntary and community sectors in patient care. Although increasingly popular in the UK, evidence for the effectiveness of social prescribing is inconclusive and longer-term studies are needed. This study aimed to explore experiences of social prescribing among people with long-term conditions one to two years after their initial engagement with a social prescribing service. Methods Qualitative methods comprising semi-structured follow-up interviews were conducted with 24 users of a link worker social prescribing service who had participated in an earlier study. Participants were aged between 40 and 74 years and were living in a socioeconomically-deprived area of North East England. Results Participants reported reduced social isolation and improvements in their condition management and health-related behaviours. However, many participants had experienced setbacks, requiring continued support to overcome problems due to multi-morbidity, family circumstances and social, economic or cultural factors. Findings indicated that, in this sample of people facing complex health and socioeconomic issues, longer-term intervention and support was required. Features of the link worker social prescribing intervention that were positively appraised by participants, included a highly personalised service to reflect individual goal setting priorities and a focus on gradual and holistic change dealing with issues beyond health. The important role of a strong and supportive relationship with an easily-accessible link worker in promoting sustained behaviour change highlights the importance of link worker continuity. A lack of suitable and accessible voluntary and community services for onward referral acted as a barrier to involvement for some participants. Conclusions This study highlights issues of interest to commissioners and providers of social prescribing. Engagement with social prescribing for up to two years was examined and continued involvement was identified for those with complex issues, suggesting that a long-term intervention is required. The availability of onward referral services is an important consideration for social prescribing in a time of constrained public spending. From a research perspective, the range of improvements and their episodic nature suggest that the evaluation of social prescribing interventions requires both quantitative and qualitative data collected longitudinally.

IntroductionSocial prescribing enables healthcare professionals to use voluntary and community sector resources to improve support for people with long-term conditions. It is widely promoted in the UK as a way to address complex health, psychological and social issues presented in primary care, yet there is insufficient evidence of effectiveness or value for money. This study aims to evaluate the impact and costs of a link-worker social prescribing intervention on the health and healthcare use of adults aged 40–74 with type 2 diabetes, living in a multi-ethnic area of high socioeconomic deprivation.Methods and analysisMixed-methods approach combining (1) quantitative quasi-experimental methods to evaluate the effects of social prescribing on health and healthcare use and cost-effectiveness analysis and (2) qualitative ethnographic methods to observe how patients engage with social prescribing. Quantitative data comprise Secondary Uses Service data and Quality Outcomes Framework data. The primary outcome is glycated haemoglobin, and secondary outcomes are secondary care use, systolic blood pressure, weight/body mass index, cholesterol and smoking status; these data will be analysed longitudinally over 3 years using four different control conditions to estimate a range of treatment effects. The ranges where the intervention is cost-effective will be identified from the perspective of the healthcare provider. Qualitative data comprise participant observation and interviews with purposively sampled service users, and focus groups with link-workers (intervention providers). Analysis will involve identification of themes and synthesising and theorising the data. Finally, a coding matrix will identify convergence and divergence among all study components.Ethics and disseminationUK NHS Integrated Research Approval System Ethics approved the quantitative research (Reference no. 18/LO/0631). Durham University Research Ethics Committee approved the qualitative research. The authors will publish the findings in peer-reviewed journals and disseminate to practitioners, service users and commissioners via a number of channels including professional and patient networks, conferences and social media. Results will be disseminated via peer-reviewed journals.

Debates around intergenerational relations, framed in terms of conflict, exchange, solidarity and equity, proliferate in policy and public arenas in ageing societies. Internationally, we are witnessing the re-emergence of discourses of generational conflict over political settlements and attempts to forge a new moral economy of welfare in economically straitened times. Increasingly, issues such as social care, employment, retirement, housing, welfare provision and pensions are crystallising around the concept of intergenerational equity. Yet, surprisingly little academic work has examined this in the UK. This qualitative study aimed to explore intergenerational relations across the life course in two locations; Edinburgh in Scotland and Tyneside in North East England, to allow exploration of intergenerational relations in different policy contexts brought about by devolution, austerity and Brexit. Forty interviews (20 in each locality) were undertaken with participants ranging from 19 to 85 years, and including unemployed, employed, retired and low, middle and high income individuals. A sense of anxiety and pessimism for the future pervaded participant discourses. Disquiet about the pace of change with respect to housing, employment and pensions proliferated. Resentment about generational differences in the potential to achieve financial independence was more apparent amongst younger people; whilst resentment about the need to provide resources to younger generations for longer than anticipated characterised older people’s narratives, although strong inter-familial support was commonplace. We conclude that continued austerity compels families to provide support for longer than previously and that this negatively influences how citizens think about ‘give and take’ across the generations.

Polices to extended working lives into older-age are a response to population ageing. Extended-working policy discourse most often targets a generic individualised ‘adult worker’; however, women’s lives differ in a variety of ways to men’s, with later-life outcomes embedded in gendered experiences of social institutions such as education, work and family. This study adds to the scarce literature on ‘baby-boomer’ women’s life-course experiences of paid and un-paid work and their influences on later-life employment and retirement. Drawing on data from a UK birth cohort (n=1142) born in 1947 and now in its eight decade, this study takes a mixed-approach: prospective quantitative survey data provides evidence on life-course predictors of women’s employment at ages 62–64; qualitative data from in-depth life-history interviews (n=14) with a sub-sample of the cohort’s women explore, in greater depth and in the women’s own words, the ‘messy realities’ of the decision to retire or remain in employment. Quantitative analysis indicated a range of factors were associated with extending working life, with mid-life labour market inactivity and having a retired spouse both strongly negatively associated with later-life employment. Interviews revealed a gender-imposed ‘glass corridor’ acting throughout these women’s lives. Structural constraints acting at all stages of the life-course on their experiences of education, employment and family caring responsibilities acted at all stages of the life course, heavily influencing both the choice and ability to extend their working lives. This study highlights the importance of acknowledging the gendered nature of the life course in policies to extend working lives.

For a social prescribing intervention to achieve its aims, clients must first be effectively engaged. A ‘link worker’ facilitating linkage between clients and community resources has been identified as a vital component of social prescribing. However, the mechanisms underpinning successful linkage remain underspecified. This qualitative study is the first to explore link workers’ own definitions of their role in social prescribing and the skills and qualities identified by link workers themselves as necessary for effective client linkage. This study also explores ‘threats’ to successful linked social prescribing and the challenges link workers face in carrying out their work. Link workers in a social prescribing scheme in a socioeconomically deprived area of North East England were interviewed in two phases between June 2015 and August 2016. The first phase comprised five focus groups (n = 15) and individual semi‐structured interviews (n = 15) conducted with each focus group participant. The follow‐up phase comprised four focus groups (n = 15). Thematic data analysis highlighted the importance of providing a holistic service focusing on the wider social determinants of health. Enabling client engagement required ‘well‐networked’ link workers with the time and the personal skills required to develop a trusting relationship with clients while maintaining professional boundaries by fostering empowerment rather than dependency. Challenges to client engagement included: variation in the volume and suitability of primary‐care referrals; difficulties balancing quality of intervention provision and meeting referral targets; and link workers’ training inadequately preparing them for their complex and demanding role. At a broader level, public sector cuts negatively impacted upon link workers’ ability to refer patients into suitable services due to unacceptably long waiting lists or service cutbacks. This study demonstrates that enabling client engagement in social prescribing requires skilled link workers supported by healthcare referrer ‘buy‐in’ and with access to training tailored to what is a complex and demanding role.

Promoting quality of life (QoL) in later life is an important policy goal. However, studies using prospective data to explore the mechanisms by which earlier events influence QoL in older age are lacking. This study is the first to use prospective data to investigate pathways by which a range of measures of life-course socioeconomic status contribute to later-life QoL. The study uses data from the Newcastle Thousand Families Study cohort (N = 1142), an early ‘baby-boom’ birth cohort born in 1947 in Newcastle upon Tyne, an industrial city in north-east England. Using prospective survey data collected between birth and later adulthood (N = 393), a path analysis investigated the effects and relative contributions of a range of life-course socioeconomic factors to QoL at age 62–64 measured using the CASP-19 scale. Strong positive effects on later-life QoL were found for advantaged occupational status in mid-life and better self-reported health, employment and mortgage-freedom in later adulthood. Significant positive indirect effects on QoL were found from social class at birth and achieved education level, mediated through later-life socioeconomic advantage. Experiencing no adverse events by age five had a large total positive effect on QoL at age 62–64, comprising a direct effect and indirect effects, mediated through education, mid-life social class and later-life self-reported health. Results support a pathway model with the effects of factors in earlier life acting via later-life factors, and an accumulation model with earlier-life factors having large total, cumulative effects on later-life QoL. The presence of a direct effect of adverse childhood events by age five on QoL suggests a ‘critical period’ and indicates that policies across the life-course are needed to promote later-life QoL, with policies directed towards older adults perhaps too late to ‘undo the damage’ of earlier adverse events.

The ‘baby boomers’ are ideal candidates for extended working due to better health and less physically-demanding employment than previous cohorts This study investigated how circumstances across the life course influence retirement decisions and what it means to have an extended working life in a UK ‘baby boom’ birth cohort, born in 1947 (n=1142). Mixed-methods were used: prospective quantitative survey data provides evidence on earlier-life predictors of employment at ages 62–64; qualitative data from in-depth interviews (n=28) with a cohort sub-sample explore the ‘messy realities’ of the decision to retire or remain in employment. We found that socio-economic characteristics throughout the life course influenced retirement decisions and our interviews shed light on inequalities arising from freely-chosen extended employment as part of active ageing and involuntary extended employment (or unemployment) among those without the means to choose. The extending working lives agenda risks amplifying inequalities in later life.

This article considers the relationship between income inequality and health. Recent research has suggested that absolute income does not explain the existence of health inequalities in developed countries and that income inequality is a more important determinant of health. This article discusses the theories and evidence linking income inequality to health, and explains the difficulties and challenges any future research needs to address.