Involving citizens in integrated care. Monitoring the implementation of positive health and social prescribing in twenty-five GP-practices in the Netherlands.

Background: The demand for healthcare is rising in many countries, while the simultaneous shortage of healthcare workers creates an overburdening of healthcare professionals. Also, non-medical issues like loneliness, low literacy, and financial struggles increasingly contribute to health problems that lead people to consult general practitioners (GPs). To address this, alternative care models involving collaboration with welfare professionals and community initiatives are needed. In the Netherlands, social prescribing (Welzijn op Recept) has emerged as an approach where GPs refer patients to welfare coaches, aiming to bridge healthcare, social work, and in particular community support.

Approach: We monitored the implementation of the positive health concept and social prescribing (in Dutch, Welzijn op Recept) in twenty-five GP-practices in the south of the Netherlands. The objective was to establish whether collaboration between general practitioners (GPs) and welfare coaches, as well as between welfare coaches and citizen initiatives, was established, and to identify which factors influenced this collaboration. Questionnaires were sent to all relevant collaboration partners (GP-practices, welfare coaches, community support workers, and citizens) at baseline and after 12 months, and twenty semi-structured interviews were conducted with professionals and citizens in seven purposively selected locations out of the twenty-five included in the study.

Results: Questionnaires revealed that collaboration between the welfare coaches and the GPs was established. However, better agreements on referral criteria were needed, and GPs wanted to be informed about the patient after referral. GPs appreciated having the welfare coach as a single point of referral instead of a variety of citizen initiatives. However, with the presence of the welfare coach, direct contact between the GPs and citizens (e.g. informal caregivers) decreased. At 12 months, collaboration between welfare coaches and citizen initiatives was limited. Community support workers, who are strongly connected to the community, were hardly recognized as collaboration partners. The number of referrals was 1-2 patients per GP per month but decreased to 0-1 patients between 12 and 24 months.

Interviews showed that GPs often did not apply the concept of positive health during consultations and, consequently, may have missed non-medical factors. Overall, self-efficacy regarding the application of positive health was moderate. Additionally, due to daily routines, they regularly forgot about the possibility of social prescribing. Welfare coaches need to develop a network with citizen initiatives but do not automatically possess networking capabilities. Many welfare coaches also combined this role with a profession as social workers or as community support workers. This dual role was sometimes confusing for themselves and for the patients.

Implications: GPs need to feel competent and require support in applying positive health to recognize underlying non-medical problems. Active implementation strategies based on a needs assessment are required. The possibility of social prescribing should be regularly brought to their attention to make it a routine. To involve citizens in the provision of care and support, welfare coaches need help to develop networking capabilities and should present themselves to GPs to strengthen their position. If available, community support workers are valuable partners in the collaboration.