Social Prescribing - macrame or medicine?
Dinah’s medical degrees and postgraduate specialty training were done in Cambridge and Oxford, and her Ph.D. is from the University of Cambridge. She obtained her MRCPath in 1991. In 1999, she was awarded the FRCPath and was elected to the Fellowship of the American College of Chest Physicians (FCCP). Dinah has worked as a Senior Lecturer and NHS Consultant where she has held clinical, teaching, research and managerial roles. She has worked in the pharmaceutical industry as a Principal Pharmaceutical Physician and has worked with the BMJ as a Clinical Editor. Dinah has been publishing original peer-reviewed research for more than thirty years and reviews manuscripts for publication for several journals. She now works as a freelance medical and scientific writer, editor and consultant. Her LinkedIn profile and her online website contain details of her clinical and academic experience and publications.
Titrating Tofu?
‘Social prescribing,’ or ‘community referral,’ is a way of linking patients in primary care with sources of support within the community (1). Social prescribing is a non-medical referral option for GPs that can improve health and well-being and may be used alongside conventional treatment [1]).
In developed countries, including the UK, chronic mental and physical illness is associated with other long-term health conditions (co-morbidity), unhealthy lifestyles and an increasingly ageing population. There is recognition that ‘conventional’ medical treatments cannot address these psychological, social and general ‘well-being’ issues, so attention is now turning to the role of ‘civil’ or societal community agencies.
The topic of social prescribing has been in the news recently and has generated some amusing headlines (2,3). The media interest is understandable, given the range of potential prescribed interventions and activities. Some examples of these prescribed activities include (4):
- Fishing clubs
- Gym-based activities
- Exercise and dance classes
- Art classes
- Swimming and aqua-therapy
- Cycling
- Bibliotherapy/self-help reading
- Volunteering
- Self-help groups
- Computerised cognitive-behavioural therapy (CBT)
- Gardening clubs
- Pets as therapy
The medical community seems to accept that people who lead active social lives appear happier and are in better health than those who do not. There is evidence to support the view that people who have good social support are more likely to comply with prescribed medicines, and that exercise can improve recovery from depression (5,6).
In 2013, the results of a survey of more than 1,000 GPs, conducted by Nesta, showed that 90% of GPs thought that patients would benefit from social prescriptions (7,8). However, less than 10% of patients surveyed had received a social prescription (8). More than 50% of patients said that they would like their GP to prescribe these social and community support systems to them (8). When asked, GPs cited healthy eating and weight loss groups, exercise groups, and emotional support as the services they would most commonly refer patients to through social prescribing (8). For patients with long-term conditions, 88% of GPs identified them as a group that would benefit from social prescriptions (8).
Social Prescribing: Now Part of the Government’s Health Agenda
In 2008, the National Institute for Health and Care Excellence (NICE) introduced its guidance (PH9) on Community Engagement and Development for those working in local authorities, the community, voluntary and private sectors (9). At this time, NICE reported that there were ‘gaps’ in the evidence to support community-based health initiatives (9). The NICE guidance noted that the community-based and other activities to promote health were poorly defined or assessed and advised that, for social prescribing, ‘further research is required to determine its contribution to long-term, population-based changes.’
In 2010, the Institute of Health Equity (IHE), University College London (UCL) published its report on a review conducted by Professor Sir Michael Marmot, ‘Fair Society Healthy Lives’ (10). The ‘Marmot Review’ proposed an evidence-based strategy to address inequalities in the health, distribution of health, and social and economic conditions across England (10). In 2010, the Marmot Review gave the following six recommendations for action:
- give every child the best start in life;
- provide education and lifelong learning;
- provide employment and working conditions;
- define and provide a minimum income for healthy living;
- provide safe and sustainable housing and communities;
- and use a ‘social determinants’ approach to disease prevention (10,11).
Between 2012 and 2014, the results of several pilot studies of social prescribing began to emerge (12,13,14). These studies contributed to developing the ways (pathways) in which social and community services could be organised (12,13,14). In March 2014, NHS England responded to the Marmot Review in its Commissioning Toolkit to Reduce Health Inequalities (15). In Section 8 of this report, NHS England specifically included social prescribing pathways to bring together primary care and community care (15).
In September 2014, Michael Dixon, Chairman of the NHS Alliance, wrote an opinion piece in The Guardian newspaper (16). In this article, he raised awareness regarding drug over-prescribing, increasing antibiotic resistance and overspending in the NHS, with the recommendation that alternatives need to be found (16). Following the publication of NHS England’s Five Year Forward View, in November 2014, the Health Secretary supported social prescribing in a speech he gave in the House of Commons (17,18).
Evidence of Health and Cost Benefits
There have been few systematic reviews on the effectiveness of social prescribing on health. The studies that have been done are mainly of poor quality, with small numbers, short follow-up times and a variety of outcomes measured (19, 20).
Evaluation of the South West Well-being Programme involved ten organisations delivering exercise, leisure, befriending, cooking, arts and crafts activities (21). This evaluation consisted of a before-and-after study involving 687 adults (21). Positive changes in self-reported mental health, general health, personal and social well-being were associated with physical activity and improved diet (21). The results supported community-based activities that encourage positive changes in health behaviour (21).
There is little recent evidence to support the cost-effectiveness of social prescribing (22). In 2000, a randomised controlled clinical trial assessed the cost-effectiveness of a social prescribing project based on referral to a voluntary organization from 26 general practices in Avon (23). In the management of psychosocial symptoms, clinically important benefits were found, with fewer symptoms of anxiety and depression, but at a higher cost (23). Patient ‘social prescribed’ care was more costly when compared with routine care and contact with primary care was not reduced. However, this study did not compare the ‘social prescription’ costs with those of a referral to a specialist and secondary care, and it did not include the evaluation of long-term cost-savings (23).
Conclusions
The NICE recommendations from 2008 remain largely unfulfilled (9). Further research is required:
- to evaluate the effects of social prescribing on longer-term health outcomes,
- to learn how to engage with communities to improve their health, and
- to determine how much time and funding are required before community engagement leads to health improvements (9).
The support for social prescribing from GPs and patients indicates that this may be a logical way to the support NHS treatments (4-8).
A recent review of the ‘brave new world of older patients’ in primary care highlights the increasing number of people who live with both chronic disease and social isolation (24). For these patients, social prescribing would seem to be a ‘good thing’ (24). Social prescribing may also improve job satisfaction in primary care at a time when retention of healthcare workers in the NHS, including GPs, is facing such serious challenges.