Just what the doctor ordered?

Social prescribing is the new big thing in health. So what is it, why is so much money being ploughed into it, does it represent good value for money and what difference does it make?

There is an awful lot more to good health than the work of doctors and nurses. In fact only around 20% of health indicators are related to the work of health professionals.

Poverty, poor housing, inadequate education, environmental pollution and limited access to affordable healthy foods are all examples of factors that can impact negatively on health.

Many of these are related to policies of other government departments. The provision of clean drinking water, effective sewage systems and reducing environmental pollution have been just as important in improving health than breakthroughs in medical treatments.

In fact there is a very strong argument for compelling departments to assess the impact on health of policies before implementing them – after all if they already have to carry out equality impact assessments the basic methodology is already in place.

That, however is a debate for a different day. The point is that improving health is not just the business of the health service.

It’s not just the business of government either. How we lead our lives is every bit as important to promote good physical and mental health. Physical activity, for example is good for both and we also know of factors that can be very bad for your health: loneliness and isolation, for example.

It therefore follows that the remedy for many ailments is not a bandage or a pill, but lies outside the health system.

And this is where social prescribing comes in.

The term itself, like so much jargon, is both ugly and misleading not least because it means different things to different people. There is no agreed definition. It is yet another example of people using and repeating terms without troubling to find out what they mean. Scope has written about this before in the context of “Wellbeing”. This is all too common and it is not pedantic to point it out. It is counterproductive for people to introduce a concept as the “next big thing” if they are incapable of saying what it means. Health policy is complex enough as it is for the general public.

There was an attempt to do this at the Social Prescribing Network conference in 2016. A workshop was held with participants to see if they could come up with anything, and this was the group-think definition agreed:  ‘A means of enabling GPs and other frontline healthcare professionals to refer patients to a link worker - to provide them with a face to face conversation during which they can learn about the possibilities and design their own personalised solutions, i.e. ‘co-produce’ their ‘social prescription’- so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary, community and social enterprise sector’.

This is a very complicated jargon-studded way of expressing something that is essentially simple and very powerful.

It is probably best illustrated by an example.

Mrs X is 79 years of age. Last year her husband of 50 years died after a long illness during which she cared for him. She is anxious, lonely and feeling very low so she visits her doctor. The doctor recognises that her problems are related to her bereavement and isolation. There are no pills or bandages for that. So instead the doctor is able to put her in touch with a professional who meets her, discovers her love for walking and is able to put her in touch with a local rambling club which she then joins. She goes on weekly rambles and meets new friends who she then socialises with. She still mourns the loss of her loved one, but her life has got meaning and purpose again.

That, in essence, is social prescribing.

And it is important. This example was around loneliness. And Loneliness and isolation are major drivers for poor mental and physical ill health.

Studies show that acute loneliness and social isolation can impact gravely on wellbeing and quality of life. It has a significant and lasting negative effect on blood pressure; is associated with depression and higher rates of mortality.

Recent research shows that the overall negative effects are comparable to well-established risks such as smoking and alcohol usage. Clearly, as the population ages, so too will loneliness and it is therefore an important public health issue which doctors are in no position to tackle.

So Mrs X was helped by sitting down with a “link worker” who talked to her about why she felt sad, what she enjoyed doing and was able to come up with a “social prescription” to help her. The worker might have met her in the GP’s surgery or else in Mrs X’s home and, if she felt nervous about attending the group on her own would have offered to go along with her for her first walk.

Another simpler way of describing social prescribing is that it recognises that peoples’ health is affected by social, environmental, economic and other factors and seeks to address their needs in the round (or holistically for those who like jargon). And in doing so it supports people to take greater control of their own health.

Most of the activities that are prescribed are run by community and voluntary groups and so therefore their importance in delivering good health is central to this process.

In the UK it all started in the early 1990s in what is now the Bromley By Bow Centre, the vision of the local vicar which has gone on to deliver a full range of community and health services. Today it helps  people in the area access more than 30 different local services ranging from swimming to legal advice. The first social prescribing initiative there is one run by Macmillan which helps people to live through and beyond cancer diagnoses.

The £3 million Big Lottery Funding is going to the Bogside and Brandywell Health Forum in Derry/Londonderry. It follows a pilot project which worked with older people in Derry and Strabane. The money will be used to expand the service to provide three social prescribers across Northern Ireland and a similar project in Scotland. Loneliness and isolation will be a key focus.

It looks like a good investment but what is the evidence?

Sadly, to date, there isn’t very much of it. A report from the King’s Fund which was published last year, concedes that “robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model.”

This is not surprising as it is difficult to compare the respective impacts of complex interventions or compare often very different schemes.

However  what evidence there is suggests that they do have positive impacts on both mental and physical health and that they reduce pressures on NHS services.

It is important to stress that the absence of evidence about effectiveness does not mean that social prescribing is not effective, just that there is insufficient evidence to date.

The same applies to its value for money, here the evidence is even thinner on the ground. One scheme in Bristol was deemed to be more expensive than regular GP care but produced better outcomes. The cost was only measured over a 12 month period though – which begs questions about whether more positive findings would have been made over a longer period.

Further research is needed but common sense tells us that helping address the non-medical factors that affect peoples’ health is a good thing and needs to be rolled out and that it will, over time, reduce pressures on the health service.

But wouldn’t it be nice if those behind it could agree on a simple, sensible jargon-free definition that everybody else can understand?