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See your GP and leave with a prescription for a pet or a new hobby?

Original illustration for Healthcare-Arena by Fran Orford
Original illustration for Healthcare-Arena by Fran Orford

Social Prescribing: What is it?

‘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).

Social Prescribing: 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).

Social Prescribing: 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.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) Kimberlee R. What is social prescribing? Advances in Social Sciences Research Journal. 2015;2(1). http://eprints.uwe.ac.uk/24818/1/808-2245-1-PB.pdf Accessed June 25, 2015

(2) Chan S. GPs prescribe gardening to help mental health patients. A GP who has been prescribing gardening to isolated patients has said he has seen an ‘enormous’ improvement in their confidence and happiness. GP Online. May 26, 2015. http://www.gponline.com/gps-prescribe-gardening-help-mental-health-patients/mental-health/article/1348669 Accessed June 25, 2015

(3) Pati A. Why GPs are prescribing animal handling sessions for older people. The Guardian. October 7, 2014. http://www.theguardian.com/healthcare-network/2014/oct/07/animal-handling-sessions-reduce-isolation-older-people Accessed June 25, 2015

(4) Brandling J, House W. Social prescribing in general practice: adding meaning to medicine. The British Journal of General Practice. 2009;59(563):454-456. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688060/ Accessed June 25, 2015

(5) Heywood PL, Blackie GC, Cameron IH, Dowell AC. An assessment of the attributes of frequent attenders to general practice. Fam Pract. 1998;15(3):198–204. http://fampra.oxfordjournals.org/content/15/3/198.long Accessed June 25, 2015

(6) Grayer J, Cape J, Orpwood L, et al. Facilitating access to voluntary and community services for patients with psychosocial problems: a before-after evaluation. BMC Fam Pract. 2008;9:8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2390561/ Accessed June 25, 2015

(7) Nesta. People Powered Health website: http://www.nesta.org.uk/project/people-powered-health Accessed June 25, 2015

(8) Nesta. Social prescriptions should be available from GP surgeries, say four in five GPs. November 5, 2013. http://www.nesta.org.uk/news/social-prescriptions-should-be-available-gp-surgeries-say-four-five-gps#sthash.d7pfamra.dpuf Accessed June 25, 2015

(9) Community Engagement and Development. National Institute for Health and Clinical Excellence (NICE) Guidelines (PH9); London, UK: Feb 2008. https://www.nice.org.uk/guidance/ph9 Accessed June 25, 2015

(10) University College London (UCL) Institute of Health Equity. ‘Fair Society Healthy Lives’ (The Marmot Review). Strategic Review of Health Inequalities in England, post 2010. Published Feb 2010. http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review Accessed June 25, 2015

(11) Marmot M. What kind of society do we want: getting the balance right. Lancet 2015;385:1614-15. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60784-X/fulltext Accessed June 25, 2015

(12) Courtenay M, Carey N, Stenner K. An overiew of non medical prescribing across one strategic health authority: a questionnaire survey. BMC Health Services Research. 2012;12:138. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3420322/ Accessed June 25, 2015

(13) Sheffield Hallam University. Centre for Regional and Economic Research. From dependence to independence: emerging lessons from the Rotherham Social Prescribing Pilot. Published Dec 2013. http://www.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/rotherham-social-prescribing-summary.pdf Accessed June 25, 2015

(14) Williams R. Why Social Prescriptions are Just What the Doctor Ordered. The Guardian. Nov 5, 2013. http://www.theguardian.com/society/2013/nov/05/social-prescribing-fishing-group-doctor-ordered Accessed June 25, 2015

(15) NHS England. Commissioning to Reduce Health Inequalities: Outline Plan for Toolkit . Published March 2014. http://www.england.nhs.uk/wp-content/uploads/2014/03/outline-plan-ca-hi-toolkit.pdf Accessed June 25, 2015

(16) Michael Dixon, Chairman, NHS Alliance. How social prescribing is cutting the NHS drugs bill. The Guardian. Sept 17, 2014. http://www.theguardian.com/healthcare-network/2014/sep/17/social-prescribing-cutting-nhs-drugs-bill Accessed June 25, 2015

(17) NHS England. Five Year Forward View. Published October 23, 2014. http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf Accessed June 24, 2015

(18) Roberts N. Health secretary backs GP social prescribing. GP Online. December 10, 2014. http://www.gponline.com/health-secretary-backs-gp-social-prescribing/article/1326032 Accessed June 25, 2015

(19) Washburn RA, Lambourne K, Szabo AN, Herrmann SD, Honas JJ, Donnelly JE. Does increased prescribed exercise alter non-exercise physical activity/energy expenditure in healthy adults? A systematic review. Clinical obesity. 2013;4: 1-20. http://onlinelibrary.wiley.com/doi/10.1111/cob.12040/full Accessed June 25, 2015

(20) Milton B, Attree P, French B, Povall S, Whitehead M, Popay J. The impact of community engagement on health and social outcomes: A systematic review. Community Dev J 2011; http://cdj.oxfordjournals.org/content/47/3/316 Accessed June 25, 2015

(21) Jones M, Kimberlee R, Deave T, Evans S. The Role of Community Centre-based Arts, Leisure and Social Activities in Promoting Adult Well-being and Healthy Lifestyles. International Journal of Environmental Research and Public Health. 2013;10(5):1948-1962. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709358 Accessed June 25, 2015

(22) Hunter B., Neiger B., West J. The importance of addressing social determinants of health at the local level: The case for social capital. Health Soc Care Community. 2011;19:522–530. http://www.ncbi.nlm.nih.gov/pubmed/21595772 Accessed June 25, 2015

(23) Grant C, Goodenough T, Harvey I, Hine C. A randomized controlled trial and economic evaluation of a referrals facilitator between primary care and the voluntary sector. BMJ. 2000;320:419-23. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27287/ Accessed June 25, 2015

(24) Bonney A, Phillipson L, Jones SC, Hall J, Sharma R. The brave new world of older patients: preparing general practice training for an ageing population. Primary Health Care Research & Development 2015; Jan 29. 1-11. http://www.ncbi.nlm.nih.gov/pubmed/25631546 Accessed June 25, 2015

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Original illustration for Healthcare-Arena by Fran Orford