Signposting services for people with health and care needs: a rapid realist review

Article history

The research reported in this issue of the journal was funded by the HSDR programme or one of its preceding programmes as award number NIHR130588. The contractual start date was in July 2022. The draft manuscript began editorial review in January 2023 and was accepted for publication in September 2023. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HSDR editors and production house have tried to ensure the accuracy of the authors’ manuscript and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article.

Copyright statement

Copyright © 2024 Cantrell et al. This work was produced by Cantrell et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

2024 Cantrell et al.

Experimental report format

This report uses an experimental format to optimise its usefulness to its target audiences. This audience-centric method of presentation seeks to minimise ‘academic formatting’ as requested by policy/decision-makers. 4,5 It starts by introducing the problems and then covers the findings from each of the three questions that the report is addressing. Each of the questions is introduced together with any subquestions. Information is then provided about the perspective the questions is being answered for, for example service user, provider of a signposting service and commissioner/funded of a signposting service. Findings from the literature are then presented together with the initial conclusions specific to that perspective supported by data extraction tables. The report then finishes with an overall conclusion and references.

The report appendix provides supporting detail for the methodology. This experimental format thus seeks to optimise usefulness to the intended audience by providing the findings much earlier in the report. It recognises that a detailed research methodology is of comparatively less interest to primary audiences. Nevertheless, full methods are still provided for researchers with the time or methodological interest to require more from the report. Further details of the methodology can be found in Appendices. Appendix 1 covers the report methodology, the MEDLINE search strategy is reported in Appendix 2 and the document flow diagram for the review is detailed in Appendix 3, Figure 1. Appendix 4.The full date extraction of context-mechanism-ouctome (CMO) configurations in the programme theory signposting table, Report Supplementary Material 1.

Appendix 4, Table 12 provides details of the consolidated programme theory, and the data extraction tables are in Appendix 5, Tables 13–15. Full details of the realist review questions can be found in Appendix 6, and public and patient involvement in Appendix 7.

Subquestions

To address this overarching question, the following subquestions were formulated:

• What do people with health and social care needs require from a signposting service to believe it is a valuable and useful service?

• What do people with health and social care needs require to be confident in accessing a signposting service?

• Which aspects of signposting services help people with health and social care needs to engage with signposting services?

• Which aspects of signposting services enable people with health and social care needs to be satisfied with the service provided?

Summary for value and usefulness of signposting: service user perspectives

Interpretation of the review brief became more challenging as our review team became sensitised to the nuances of signposting provision. Should we literally focus only on the signposting component in isolation? In which case, we could reasonably conclude that beneficiaries from signposting in isolation are likely to represent only a small proportion of service users, for whom the referral target is simply the missing piece in their route to self-management and resolution. In such a situation, a 2- to 5-minute intervention may be viewed as sufficient. Or is signposting to be considered as an adjunct that must always be backed up with more extensive social prescribing that provides for those for whom signposting will not be enough?

Two further complexities were identified. First, where signposting is prolonged beyond its brief 2- to 5-minute ‘dosage’, it may offer an opportunity to elicit more information on user need; therefore, increasing the likelihood that referral to more intensive services is required – effective, rather than efficient, signposting thereby potentially subverts its own programme theory of brief contact and referral onwards. This tension plays out against the two driving and competing narratives for signposting, namely the driver to deflect inappropriate non-health-related demands away from the health service, particularly primary care (‘to free up GPs’ time by directing patients to other sources of help’), and the driver to use signposting as a way to improve the quality of care through better integration and linking of services (‘to enable patients to be signposted at the first point of contact, to the “right” professional or service’). 12

Second, where signposting cannot be extended beyond its 2- to 5-minute duration, it may represent an inappropriate response to more profound needs, thereby functioning to cloak levels of actual need. This links to the need identified in a qualitative metasynthesis9 to evaluate potential harms of social prescribing which can be extrapolated to encompass equally the briefer interventions delivered by signposting.

Conceptually, the challenges presented by signposting services mirror, albeit on a wider scale, those posed by the creation of the NHS111 service as an alternative to urgent primary and secondary care. Service users require reassurance that the response that they are receiving is not of inferior quality, that the operatives with whom they are dealing are proficient, that the response is appropriate and that the eventual outcome that they receive is the best possible for their current situation. Similarly, signposting services may be seen to be equally vulnerable to high-profile accounts of occasional inappropriate response, evidenced in concerns from signposting staff about ‘stepping into clinical areas’ and patient safety. Such concerns may require that specialist signposting for high-risk groups, for example, for patients with psychosis, receive additional safeguards (whether this be training, expertise or procedures) for both signposting staff and their service users.

Front-line providers of signposting services require training

Training is important to help front-line providers offer an effective signposting service. Numerous training courses, either generic or tailored to support particular populations, are currently available. One recent qualitative study12 found that some reception staff felt insufficiently trained to take on a role of active signposting as a CN. Receptionists may either lack formal training or have to wait for care navigation training, making them feel even less prepared for their role:

Receptionist 4 (CN): Well, whenever we started the care navigating, me and my colleague didn’t go on the course till a long time after, like months after…12(p5).

There were some receptionists who were excited to develop their role. Receptionists can potentially have a key role in signposting, but there is a need for adequate training and support from the practice team. Receptionists already have an important role within their practice; a high workload and their location in the waiting area are all issues that could make it difficult to fulfil a signposting role. An observational study in seven urban general practices in the north-west of England involving 45 receptionists explored the complexity of the receptionist role. 18 The study found that receptionists had the difficult role of prioritising patients for which they had limited time, training and information. Receptionists felt it was important for them to protect the patients who were most vulnerable, but that was not always possible due to the procedures they had to follow and also some patients knowing how to ‘play the system’. The knowledge that receptionists have of patients from living in the community could be helpful but could also mean that receptionists could get asked about work by patients they meet when not at work. To help GP practices to manage workload, receptionists ask each patient their problem to record on the booking system. From the information added, the GPs can then determine each patient’s level of need for an appointment. One practice in the study required the receptionists to ask each patient why they wanted to see a doctor. The receptionists’ response in the study indicated that they found it difficult. The study concluded that while more training is often suggested for receptionists, the challenges they encounter cannot always be addressed by training. These challenges may be exacerbated or improved by the actions of other staff in the practice and the organisation, structure and context of the individual practice. The situation can be improved by providing receptionists with the opportunity to give feedback on how policies can impact on their job and getting the wider practice team to consider the full role of the receptionist and the challenges that they are facing. The study was published in 2013 and the observations were conducted in 2009–11 and may be out of date, but the pandemic has potentially intensified some of these issues.

In addition, some reception staff felt that active signposting was a form of clinical triage leading to their concerns about patient safety when they as non-clinicians were undertaking the role. 12

Pharmacists can also be involved in signposting and are well placed in the community for this role. A qualitative study explored the view and attitudes of pharmacy support staff on the Healthy Living Pharmacy (HLP) initiative. 30 Pharmacy counter-based roles were found to be more suited to this public health role than dispensing roles. Initial training on the Royal Society of Public Health training programme was needed to become a Level 1 HLP; some described the training as useful, but many did not feel that the training had helped them to develop the skills that they required to work with clients. Offering advice or signposting about smoking was seen as easier than proactively delivering public health advice on topics they found difficult to bring up, for example, obesity, alcohol consumption or sexual behaviour, indicating the need for training on delivering advice in these areas. Nineteen facilitators and barriers became apparent from the interview data which included training as discussed above. Another barrier or facilitator was access to information, whether they knew of services they could refer patients to and how much information to give to clients. Additionally, confidential conversations could be difficult due to the availability of space and facilities. Pharmacies are often busy and there might not be a consultation room or quiet area available for confidential conversation. Time and competing priorities was another barrier, for example, pressure to focus on other services for which the pharmacy received financial rewards. Increased engagement with HLP required other staff to be involved from the introduction of the HLP initiative.

Training for community health workers (CHWs) working with patients with addiction and obesity prevention was developed using the Extension for Community Healthcare Outcomes (ECHO) model33 and included initial face-to-face skills training followed by weekly teleECHO sessions providing mentorship and community of practice. The training programme was tailored to the needs of the community and the CHWs but could be adapted to other settings. Two linked studies investigated the development and evaluation of a training programme for navigators34 and then a case study used reflective journals to document the navigator’s journey. 17 The researchers developed the Access to Resources in the Community (ARC) patient navigator training programme. The ARC training programme34 was structured around key competencies determined by undertaking an initial educational need assessment. The training course consisted of 12 learning modules and used a blended learning approach. Additionally, navigators had access to discussion forums and a navigator journal as part of the training course. Each navigator had weekly meetings with an experienced multicultural health navigator and support and mentorship from the research team; this continued for the 2 years of the evaluation study to support the navigators’ practice. 34 The training was generally well received. Experience suggested that navigator education programmes should include learning opportunities from experiences of primary care, which could be testimonials from patients during training or initial supervised patient interactions. 17 Qualitative data from mentorship meetings and journals revealed that the training programme was effective in preparing them for practice.

Front-line providers of signposting services require ongoing support and supervision

Ongoing support and supervision is important to enable front-line providers to provide successful signposting services The NOTEPAD trial13 offered two ways of supervision for the support workers, group meeting with two members of the research team and other support workers to discuss practicalities and share experiences and local resource knowledge or individual supervisory support for support workers with one of the research team. This model of supervision was acceptable to the support workers. Usual and ongoing support was also received from support workers’ nominated manager at Age UK. Support workers highlighted how important the supervision was at the final group meeting for reflection on their sessions with the older people and to help them decide how to support them. Training developed using the ECHO model included weekly teleECHO sessions,33 whereby CHWs could discuss their work and receive support and advice from ECHO specialists and other CHWs providing mentorship and a community of practice which were found to be important for CHWs development. The teleECHO session did not include CHWs’ supervisors as when used previously their presence could make CHWs feel less comfortable in discussions. However, including supervisors could help with team integration and teaching CHWs about the resources within their own community. To help community addiction recovery specialist (CARS) CHWs learn about resources within their own community, part of their training was to create a resource directory for their community. A training programme evaluation highlighted that mentorship and additional professional development were needed to support learning in the field. 34 The case study17 using reflective journals of patient navigators that had attended the ARC training programme found the need for ongoing support from peers and supervision. The case study also found that navigators were learning from their peers, the other navigators, suggesting the potential to have community of navigators to learn from each other. Supervision or support from their line managers could help navigators with managing expectation, confidence building and help them start developing skills to apply person-centred care.

Front-line providers of signposting services need to be flexible to meet individual needs

A qualitative study,15 considering patient and health professionals’ views on connecting primary care patients to community resources, found that some patients would have liked a buddy to attend with or someone to meet and greet them to help them attend for the first time. This indicates again that different patients need different things from a signposting service but also that health professionals could be spending time referring patients who feel unable to attend without the extra support in place. A scoping review10 investigated the relationship that LWs developed with participants. The following characteristics of facilitators that were identified in the included studies were ‘skills in tailoring activities to the needs and preferences of participants and the ability to encourage attendance and flexibility in their approach’. 10 Four of the included studies found that the relationship that facilitators developed with participants encouraged their engagement due to the facilitators ‘being flexible, trustworthy, empathetic and accessible’. 10 In the NOTEPAD trial,13 it was intended that support workers would tailor the intervention to the specific participant by being flexible with the number of sessions, if delivered face to face or by phone, and at the initial interview, patient preference was explored. Support workers need skills to do this properly.

Two navigators who had attended the ARC programme documented their experiences as navigators using reflective journals. 17 The journals demonstrated the importance for navigators of gaining and building their patients’ trust. Navigators needed to develop relationships with patients by actively listening and digging deeper to understand what patients needed and their individual preferences. Before a patient shares their health and social care needs, they might want to build up trust with, be listened to by their navigator or LW. 6,17

In the case study,17 the navigators worked with the patients for 3 months and some patients indicated that they needed support for longer. This suggested a variability of support that different patients need and the need for navigators to be flexible in their interactions with individual patients determining the level of support they need (some might need a navigator to attend a service with them initially) and the length of time that patients might require support for. Patients requiring support over different periods of time were also identified in another qualitative study23 where LWs were meant to be providing short-term support. Ideally, clients would have an initial appointment where they describe their problems and what they need help with, the LW would then refer and signpost them and then there would be a follow-up call. However, many clients required more and LWs needed to have skills to realise when this was the case. With complex cases, workers needed to build relationships, find services that meet their needs and then help them with accessing the appropriate service. Sometimes, clients needed help with contacting the service or perhaps attending initially, although this did not necessarily mean that they engaged long term with the service.

Front-line providers of signposting services need knowledge of good-quality available services for referrals

The quality of the resources and services to which patients are referred is clearly important. This was reflected by a Child and Adolescent Mental Health Services (CAMHS) Support Time and Resilience (STAR) worker whose service would only signpost young people to services that they had visited so they know that the services actually exist, are financially viable and able to support the needs of their young people. 31 This qualitative study also found a lack of community resources to refer patients to. People signposting need resources to meet the needs of referrals. A GP interviewed in a qualitative study6 on supporting self-management for patients with different health conditions said that he did not feel confident referring patients as he was unsure of resources or services available as they change over time. To help primary care staff feel confident referring or signpost patients to community services, they need greater and current knowledge of these services. To provide more effective self-management support to patients, many of the participants, from primary care, thought that they needed ‘a “signposting directory” of information resources and local clinical and non-clinical support services’. 6 The qualitative study found that, in the area of mental health, GPs had more knowledge of online services or self-referral services and so would feel more confident referring patients to these services.

A realist evaluation of social prescribing highlighted an important point about voluntary and community services. 11 Representatives from the third sector involved in the evaluation felt that there was an expectation that their services had spare capacity to accommodate extra referrals from social prescribing. However, their services had actually experienced extensive funding cuts, which was a major problem for continuing to deliver social prescribing services. Receptionists acting as CNs found it dissatisfying when they referred patients to services that did not have the capacity to accept them. 12 Another qualitative study15 found that health professionals were reticent to refer patients to physical activity opportunities as they were unsure if the opportunities were current. The study suggested that health professionals could benefit from resources such as a community resource with current community opportunities or an intermediary person to refer patients to. Navigators could experience feelings of helplessness when signposting patients to services due to challenges of barriers to access, cost and waiting times and lack of response from patients;17 navigators, therefore, need available services to refer their patients to and skills in encouraging patients to access services.

Online signposting

Recent years have witnessed increased interest in online or hybrid signposting services. 35 An initial evaluation of GENIE, an online social network intervention for people with type 2 diabetes, was positive. 32 Facilitators, who were local health trainers and CNs, worked through the process with participants. Facilitators received two training sessions on how to use the tools needed to deliver GENIE. A database of community resources was created for GENIE which links to the preference questions and selects potentially appropriate resources for participants. Facilitators worked through GENIE once with participants to create their social network map and prioritise three activities or forms of support. Facilitators understood GENIE and what their role was in delivering the intervention. The facilitators had an important role in the process: they were recruited from local populations, and this meant they could work together and collaborate at each stage of the process which might not have happened if there had been a sense of difference in status. Facilitators often took the lead but encouraged participants to play an active role. Training and skills are needed to enable a facilitator to help the participant play this active role. The study found that having the facilitator’s human presence helped participants to focus, stay motivated and persevere with the process. This indicates how important the facilitator’s role was and how even if a web tool has great promise, a facilitator can help participants to fully engage and complete the process. Facilitators did have ongoing working relationships with some of the participants, but the idea was that GENIE was completed just once with a facilitator. Facilitators spent much time on network mapping, and future training could place emphasis on discussing preferences and options. This would ensure that adequate attention is given to establishing that activities and resources are appropriate for service users. GENIE is a promising intervention that could be adapted for other conditions and is useful for lay health trainers or CNs to use with new or existing service users or to for use by service users who are health literate to help them identify activities.

Equality, diversity and inclusion

As a secondary data study, coverage of populations within the review is determined by the samples of included studies. Study authors did not focus on population variables such as ethnicity or religious belief. Indeed, coverage of any protected characteristics was very limited. The review team has identified a need to explore in a structured and systematic way aspects of diversity already shown to be important when accessing health and care services, particularly information-based services comparable to signposting. For example, a systematic review of social prescribing services found little emphasis on cultural appropriateness. 7

Of particular importance might be cultural differences in question asking behaviour and the practical need for translation or interpretation services, both in promoting and in delivering services. Although we found that personal characteristics were critical in the delivery of signposting services, issues such as matching service providers and service user groups by ethnicity or other similarities remain to be explored. It is not known whether particular ethnic minorities, gender or other protected characteristics are more or less likely to use signposting services; evidence from other health services such as ambulance services suggests a need for caution in assuming underutilisation. Recruitment processes for service providers may offer structural barriers to delivery of an ethnically and language-diverse service.

The literature did not highlight issues of diversity as they relate to setting up a service; theoretically, we might hypothesise that it is easier for a service commissioner to profile population needs for a specific service rather than provide a culturally appropriate generic service. For the latter, training may be targeted more at delivering a culturally appropriate service rather than on the cultural content of the signposting services required by the former.

Methodological limitations/lessons from experimental format

As previously mentioned, the review authors have intentionally re-engineered an experimental report format in an attempt to avoid the academic AMRAD (Abstract Methods Results and Discussion format) and to acknowledge current understanding of policy-maker report preference. However, acknowledging that this format may carry certain limitations in addition to providing an opportunity for lessons learnt, the review authors observe that:

• Researchers might not understand the methodology used and any assumptions on which the findings are based.

• Readers may not be able to navigate the report format.

• The review team have identified a need for feedback and evaluation for the report once published to determine the extent to which it meets the requirements of different target audiences.

• In future, earlier discussions on experimental formats with the NIHR Health and Social Care Delivery Research Programme staff and the editorial team could facilitate timely publication of report findings.

Research priorities/gaps

• There is a need to evaluate different levels of intensity of service provision and their differential benefits and value for money.

• Productive comparison and evaluation (through benchmarking and audit) of similar services is required (i.e. signposting services to be compared with similar brief services and services providing more intensive and sustained to be compared with similar).

• Further comparison and evaluation of signposting services could explore levels of service provided by different staff roles.

• Specialist services may particularly benefit from evaluation tailored to the needs and objectives of each specific service.

• Issues of diversity are particularly absent from the literature particularly as they relate to setting up a service; thus, we have identified a need for research around setting up and providing services for diverse populations.

• Research examining the impact of economic constraints on informal social provision would be potentially informative.

• Further consideration of the extent to which each service developed should prioritise and manage brief interactions with large numbers of generic users or sustained, and even prolonged, support to a targeted user group with complex health and social needs.

Contributions of authors

Anna Cantrell (https://orcid.org/0000-0003-0040-9853) (Research Fellow) was the lead reviewer and carried out proposal development, information retrieval, study selection, data extraction, and report writing.

Andrew Booth (https://orcid.org/0000-0003-4808-3880) (Professor in Evidence Synthesis) was the methodological adviser and lead proposal developer, conducted study selection, data extraction, taxonomy development, and report writing, and was the guarantor of the review.

Duncan Chambers (https://orcid.org/0000-0002-0154-0469) (Research Fellow) carried out study selection, data extraction, and report writing.

All authors commented on drafts of the proposal and report.

Disclosure of interests

Full disclosure of interests: Completed ICMJE forms for all authors, including all related interests, are available in the toolkit on the NIHR Journals Library report publication page at https://doi.org/10.3310/GART5103.

Primary conflicts of interest: Andrew Booth is a member of the NIHR Health Services and Delivery Research (HS&DR) Funding Committee and the NIHR Systematic Reviews Advisory Group, and Convenor of the Cochrane Qualitative and Implementation Methods Group.

Data-sharing statement

Any additional data not included in this report and its appendices are available on request. All queries should be submitted to the corresponding author.

Ethics statement

This review did not involve the collection or analysis of any data that were not included in previously published research in the public domain. Therefore, it was exempt from formal ethical review by the University of Sheffield Ethics Committee.

Information governance statement

National Institute for Health and Care Research is committed to handling all personal information in line with the UK Data Protection Act (2018) and the General Data Protection Regulation (EU GDPR) 2016/679. Under Data Protection legislation, NIHR is the Data Processor; the Department for Health and Social Care (DHSC) is the Data Controller, and we process personal data in accordance with their instructions. You can find out more about how we handle personal data, including how to exercise your individual rights and the contact details for DHSC’s Data Protection Officer here www.nihr.ac.uk/documents/nihr-privacy-policy/12242#how-we-protect-your-personal-data.

Department of Health and Social Care disclaimer

This publication presents independent research commissioned by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, MRC, NIHR Coordinating Centre, the HSDR programme or the Department of Health and Social Care.

This monograph was published based on current knowledge at the time and date of publication. NIHR is committed to being inclusive and will continually monitor best practice and guidance in relation to terminology and language to ensure that we remain relevant to our stakeholders.

Disclaimers

This article presents independent research funded by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care.

Rationale for using realist synthesis

Several considerations determined the choice of realist synthesis as the preferred review method. The original request from the commissioner of the review had suggested, based on initial scoping, that a realist synthesis would be justified by the type of question and characteristics of the data. This was confirmed by the review team following their own review of the commissioning documents based on their experience of multiple realist reviews. The commissioner of the review suggested a broad line of inquiry, and this was then explored through multiple candidate programme theories which were then prioritised to represent one for each of the patient/carer, service provider and commissioner of services perspective.

Although some researchers prefer to use the label of ‘rapid realist review’, the review team privileges the label ‘focused realist review’ together with its implication that the number of programme theories to be explored would be limited by time and resource constraints. The scattered, elusive and fragmented nature of the evidence meant that the ‘bricolage’ required to explore and test programme theories would be appropriate in piecing together an evidence trail.

Scoping the literature

An exploratory search was conducted to find terms and related concepts for signposting in early June 2022. The initial searches guided the development of the searches to identify programme theory(ies). The search for theories was developed on MEDLINE and adapted for the other databases. The search included synonyms and related terms for signposting combined with terms for programme theory and relevant study types. The searches were conducted in June 2022.

Sources searched:

• MEDLINE via OvidSP.

• Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost.

• Social Sciences Citation Index (SSCI) via Web of Science.

Searches were limited to research published in English from 2016 to current. In 2016 signposting was discussed in NHS England 2016. General Practice Forward View. www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

The MEDLINE search is provided in Appendix 2. Search steps 1–2 and 4–6 are the terms and concepts associated with signposting. Search steps 8–11 are broad terms around theory and then search step 15 relates to focused theory terms.

The broad search retrieved 716 unique references and the focused search retrieved 31 references. Both searches were used to explore the programme theories. However, the broad search was used to privilege an understanding of the contexts for signposting services, whereas the focused terms prioritised the identification of mechanisms.

One reviewer (AB) reviewed the results of the focused and then the broader search and selected 22 core studies to use for theory identification. The three reviewers divided these studies between them and extracted initial programme theories in the form of IF (context) – THEN (mechanism) – LEADING TO (outcome) statements (CMO configurations). Extracted data related to IF (WHO? DO WHAT? FOR WHOM?) THEN (THE RESPONSE IS) LEADING TO (WHAT OUTCOMES? FOR WHOM?) followed by the reference source.

Complete configurations were prioritised, whenever possible, although a limited number of two element configurations were included when they provided unique insights, for completeness. Appendix 4, Table 12 shows the signposting programme theories identified.

All CMO configurations were checked by a single reviewer experienced in realist synthesis to ensure that they were complete, in a common format and that agency (i.e. who was the agent for action) could be identified. The review team then met to discuss the initial programme theories and identified a need to address three complementary perspectives: those of the service user, service provider and commissioner. Identification of programme theory led to the development of a priority question constructed to match each perspective.

Searching processes

Exploratory scoping of the literature was accompanied by creation of a reference management (EndNote) database across multiple databases. In August 2022, the team’s information specialist revisited the EndNote database to run targeted searches in order to identify key items relating to the service user, service provider and service funder or commissioner perspectives from their titles and abstracts. Simultaneously another information professional conducted ‘context sensitive’ searches of article full text using the scite tool and Google Scholar (via Publish or Perish), as is evidenced from the tables of included studies papers could relate to more than one of the prioritised questions, thereby covering multiple perspectives. Each question lead researcher would cross-refer studies to other lead researchers where it was apparent that multiple perspectives had been addressed within an individual study,

Selection and appraisal of documents

Selection of documents for full analysis was prioritised to optimise richness, rigour and relevance. Formal quality appraisal was not undertaken. All documents that made specific reference to ‘signposting’ in their title were included as a core set of data sources. In addition, evaluations or qualitative research studies on social prescribing and care navigation were included where ‘signposting’ featured multiple times in the full text. Documents with only an isolated mention of signposting were not included unless supported by a substantive data extract. A purposive sample of documents describing specialist services that include a substantive signposting function was created to reflect condition-specific variations (e.g. people with dementia, those with autism, frail elderly etcetera). The concentration of signposting functions within the receptionist function in primary care required inclusion of documents describing qualitative studies of receptionist–patient interactions, particularly where signposting was either explicitly mentioned or where the functions of signposting (e.g. referral to other health, social or community resources was clearly identifiable).

Data extraction

Data for supporting or refuting the prioritised programme theories were extracted from papers prioritised for relevance, rigour and richness. Due to the interpretative nature of the review question and the time constraints under which the review was performed, no attempt was made to assess the methodological limitations of each study. Instead, studies were considered to be less susceptible to methodological limitations if they employed recognisable research methods of data collection and data analysis, whether quantitative or qualitative. Similarly, richness was judged according to the pragmatic nature of the extent of data relevant to the phenomenon of interest (signposting services) rather than through application of an arbitrary and unvalidated richness scale. Relevance was achieved by ensuring an exclusive focus on the UK, except in the case of more generalisable systematic reviews, and by considering whether findings related to a signposting service or to signposting within a larger service and by considering whether findings related to signposting for a specific population or a generic service open to all who are entitled to health and/or social care services.

Analysis and synthesis processes

Extracted data were tabulated against relevant headings for both review level evidence (Review ID; Author; Review year; Included country/countries; Type of review; Number of included studies; Review findings; Review implications) and for primary studies (Study ID; Author; Study year; Study country/countries; Study design; Study sample; Sample size; Population age; Population gender; Health condition; Signposting context; Setting; Generic or specialist; Signposting features; By whom; Type of resources required; Length of interaction; Outcomes measured; Main findings; Key messages including limitations); see Appendix 5, Tables 13–15.

The data extraction table is provided in Appendix 5.

In addition, qualitative findings were extracted and mapped against the most relevant question or subquestion. A narrative summary was then produced that summarised data from the data table and additional qualitative data where available.

Data synthesis was undertaken either by AC, DC or AB and synthesis results were regularly shared and discussed within the team as a way to ensure validity and consistency in the underlying inferences. The review team sought to identify prominent recurrent patterns of contexts and outcomes (demi-regularities) in the data. We then sought to explain these through the means (mechanisms) by which they occurred. For example, we noted that included articles often characterised the information-seeking behaviours of those who required only ‘light-touch’ navigation to appropriate services and those who required more intensive support. Data synthesis enabled us to explain differential reporting of processes and outcomes through the identification of contrasting mechanism(s) that presuppose instant fulfilment of information needs or more sustained relationship building and trust. Further examination of included articles, and expanding these to other contexts and services through purposive searching, allowed us to understand that while the case for signposting was often articulated around assumptions of minimal necessary contact those requiring signposting often presented with complex needs that could not be addressed speedily. We interpreted these within two contrasting rationales for service provision; first, in a context of service substitution where a signposting service seeks to divert or deflect patient and carer needs from established medical or care services and, second, within a context of service enhancement whereby services of which patients or carers were initially unaware or unlikely to use where presented within an integrated coherent response. When additional studies were sought to enable programme theory testing, such as in relation to social prescribing, which more closely resembled the more intensive form of signposting, data handling processes, synthesis and analysis were repeated.

Document characteristics

Details of the characteristics of documents included in the review are given for each review question.

Question 1 (value and usefulness of signposting) considers the service user perspective

What do people with health and social care needs require from a signposting service to believe it is a valuable and useful service?

To address this question the team formulated the following subquestions:

1. What do people with health and social care needs require from a signposting service to believe it is a valuable and useful service?

2. What do people with health and social care needs require to be confident in accessing a signposting service?

3. Which aspects of signposting services help people with health and social care needs to engage with signposting services?

4. Which aspects of signposting services enable people with health and social care needs to be satisfied with the service provided?

Question 2 (required resources) considers the perspective of the front-line provider of the signposting service

What resources (training, directories/databases, credible and high-quality services for referral) do providers of front-line signposting services require to confidently deliver an effective signposting service?

Question 3 (specification, monitoring and evaluation) considers the viewpoint of the commissioner/funder

Under what circumstances should commissioners commission generic or specialist signposting services?

Purposive searching was undertaken for each of the three questions to find a sample of rich relevant studies to answer each of the questions. The searching included forward and backward citation searching of relevant studies from the theories searches, focused searches and searching for UK initiatives.

Where possible we predominantly included UK studies to optimise the usefulness of the synthesis findings with a UK context. Studies from other comparable countries were included where relevant.

Several studies supplied data to address more than one question and were therefore included in multiple sections.