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Are you afraid of being sued? Do you have sleepless nights worrying about the legal consequences of misdiagnosing a patient?

If you do, then you are not alone – a survey earlier this year found that 67% of GPs in the UK are fearful of being sued. The survey was conducted by the Medical Protection Society (MPS) among 600 GPs. And it seems that GPs’ fears are not without foundation! MPS’s analysis of medical claims shows that GPs are more likely to be sued now than ever before, with 35% of respondents having received a claim and 58% knowing a colleague who has. In fact, UK GPs are twice as likely to receive a claim related to their work this year as they were seven years ago.

The fear of litigation is having serious repercussions on GPs themselves and on their practices. Those GPs who had received a claim stated in the survey that it had an impact on their stress/anxiety (89%), morale (86%), confidence (74%) and health and wellbeing (63%).

When the results of the survey were announced, Dr Rob Hendry, Medical Director at the Medical Protection Society said that GPs were facing immense pressures, including increasing demand, more complex guidance, rising patient expectations and negative media coverage. His message was clear: “If we are to recruit and retain GPs then we must tackle the culture of fear that GPs are currently working in. We must give them back the confidence in their abilities and allow them to do what they do best – providing patients with excellent care.” [1]

Does this matter? What is the impact of this fear of litigation?

The short answer is that it takes a huge toll on the lives of the doctors. A second MPS survey of 600 UK members revealed that 85% have experienced mental health issues, with common issues being stress (75%), anxiety (49%) and low self-esteem (36%). A third of respondents (32%) have had depression during their medical career, while one in 10 (13%) stated they had experienced suicidal feelings. And these feelings have an impact on their day-to-day work with 60% saying that their mental health affects their concentration [2].

How do doctors deal with the situation?

Even though mistakes happen and nobody can be expected to be infallible it cannot be right that doctors have to work in fear of litigation when they must make increasingly difficult decisions in an era of rising patient expectations.

According to a recent systematic review of the literature on malpractice claims [3] the primary causes of malpractice claims are failure in diagnosis (or delay in diagnosis) and medication error. The most commonly cited missed or delayed diagnoses in adults were cancer and myocardial infarction, while in children the main diagnosis issue was meningitis. Wallace and co-workers also examined the literature for possible cognitive causes of misdiagnoses and found that the primary causes were GPs misattributing the symptoms to an ‘obvious’ or readily available diagnosis, and an issue referred to as ‘anchoring heuristics’ where GPs tend to maintain their initial diagnostic decision instead of looking for alternative explanations [3].

Physicians have a number of ways of responding to the fear of litigation. The primary strategy is the adoption of ‘defensive medicine’. We can think of defensive medicine as a doctor’s deviation from his or her usual behaviour (or good practice) in order to reduce or prevent complaints or criticism from patients or their families. Osman Ortashi and colleagues conducted a survey recently to assess the prevalence of defensive medicine among hospital doctors in the UK. 78% of the 202 doctors surveyed reported practicing some form of defensive medicine. The most common form of defensive medicine was ordering unnecessary tests (59%), unnecessary referral to other specialities (55%). Only 9% refused to treat high risk patients, but twice that number (21%) would avoid high risk procedures altogether. Ortashi noted that the NHS has been working for many years to create a blame-free culture in UK healthcare, but the results showed this has not been achieved, with 86% of the doctors in this study believing that they are not working in such an environment [4].

The additional tests and unnecessary referrals that characterise defensive medicine will inevitably add to the overall national costs of healthcare. Ortashi called for further research to more clearly define the cost of defensive medicine to the NHS.

The saddest reaction of all to the pressures of possible litigation would be the gradual draining away of talented doctors from the health system. A 2010 survey of nearly 3000 primary and secondary doctors in Australia found a depressing 33% considering giving up medicine and 40% thinking about retiring early as a result of medicolegal concerns! [5]

To find out more about the cost of litigation see our previous article ‘The law is an ass’: How to avoid clinical negligence.

 

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. Medical Protection Society. 67% of GPs are fearful of being sued by patients [Internet]. [cited 2015 Sep 13]. Available from: http://www.medicalprotection.org/uk/about-mps/media-centre/press-releases/press-releases/67-of-gps-are-fearful-of-being-sued-by-patients
  2. Medical Protection Society. 85% of doctors have experienced mental health issues, reveals Medical Protection survey [Internet]. 2015 [cited 2015 Sep 13]. Available from: http://www.medicalprotection.org/uk/about-mps/media-centre/press-releases/press-releases/85-of-doctors-have-experienced-mental-health-issues-reveals-medical-protection-survey
  3. Wallace E, Lowry J, Smith SM, Fahey T. The epidemiology of malpractice claims in primary care: a systematic review. BMJ Open. 2013;3(7).
  4. Ortashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics. 2013 Oct 29;14:42.
  5. Nash LM, Walton MM, Daly MG, Kelly PJ, Walter G, van Ekert EH, et al. Perceived practice change in Australian doctors as a result of medicolegal concerns. Med J Aust. 2010 Nov 15;193(10):579–83.

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While we all know how our moods can affect gastrointestinal activity, recent evidence shows that changes in the gastrointestinal activity can also affect brain function. The high co-morbidity between gastrointestinal diseases, such as irritable bowel syndrome (IBS), and psychological symptoms such as anxiety and depression has lead many researchers to focus on the pathogenic role of stress. This emerging concept – the gut-brain axis – also involves the bacteria in our gut; for the most part, interactions between commensal microbiota and its host (our gut) are beneficial. Studying the microbes in the gut and how their modification can influence the CNS could aid advancement of new therapeutic strategies for complex CNS disorders.

In mammals, commensal microbiota colonise the gut in early postnatal life and thus remain throughout life. Their presence is crucial for processing nutrients, immunological functioning, and also brain development and function; they communicate with the CNS bi-directionally to influence the brain using neural, immune and endocrine pathways; and seems that the gut-brain axis is hard-wired during early life and adolescence.

How can the gut microbiota change the brain’s wiring to affect behaviour?

The use of germ-free animals has facilitated the evaluation of the role of the microbiota on many aspects of gastrointestinal physiology. Germ-free mice are born without, and protected from commensal microbiota, and show a number of effects distinct from normal mice. By observing what happens when the microbiota are removed, researchers can investigate the role of normal gut flora. Initially germ-free mice demonstrate heightened levels of stress hormones, suggesting that alterations in gut microbiota during early development can influence the wiring of the stress axis (1).

Research published last week indicates that stress-induced changes can lead to intestinal dysbiosis, a key determinant of the aberrant behaviour that characterises early-life stress (2). Clinically this is interesting because psychological problems are common in adolescents, and these could be linked to early life events, as well as diet and microbiota early in life.

Although germ-free mice have a longer lifespan and appear to thrive, when they are exposed to stress they show exaggerated responses compared with normal mice. Furthermore, behavioural traits of donor mice can be transferred into adult germ-free mice of a different strain via the gut microbiota, although little is known about how these microbes could impact brain plasticity and behavioural responses.

IBS & depression are often experienced together

Irritable bowel syndrome (IBS) is characterised by abdominal pain and change in bowel habit and is the most common functional gastrointestinal (GI) disorder, accounting for up to 50% of visits to general practitioners for GI complaints (3).  Mood disorders are common across a diverse array of GI disorders. The gut-brain axis is not limited to gastrointestinal and neurological function, the gut microbiota also interact with the immune system, contributing to its development. Sensors in the gut respond to many mediators including cytokines and inflammatory mediators, produced by gut microbes; the gut microbiota also have a strong influence on the diversified production of protective immunoglobulins by B cells (4). Inflammation is a feature of depression, and gastrointestinal dysregulation may exacerbate neuroinflammation leading to dysfunction in brain regions that are associated with mood regulation.

Evidence suggesting a microbial link between IBS and CNS disorders

  • IBS patients with clinically significant depression and anxiety were correlated with a particular microbial composition ratio (5)
  • IBS patients and healthy controls with higher anxiety scores were associated with lower faecal microbial diversity (6)
  • Evidence has implicated microbial diversity in other neurological disorders, such as autism where significant differences in bacterial phyla were observed (7)

Because of the close interaction between diet and immune system, probiotics (the “good” bacteria that help keep the digestive system healthy by controlling growth of harmful bacteria) and prebiotics (non-digestible fibre substrates for probiotics)

may have roles in personalised diets and disease prevention. Consequently there is considerable commercial interest in the gut microbiota as demonstrated by the expanding probiotics markets. This field shows great promise for treatment based on an individual’s microbiome and it may be possible to stratify patients for the best treatment. Some prebiotics and probiotics have shown significant benefits in the preclinical and clinical settings:

  • Probiotics may prevent the development of brain activity changes in mice in after exposure to chronic stress (8)
  • Probiotic strains may have anxiolytic potential after deleterious infection of the GI tract in mice (9)
  • IBS patients with clinically significant anxiety who received daily treatment with a (galactooligosaccharide) prebiotic for 4 weeks showed reduced anxiety scores and this had a significant positive impact on quality of life (10)

There has been growing interest in the therapeutic potential of faecal microbiota transplantation (11) This has largely stemmed from the demonstrated efficacy of donor faecal infusions in the treatment of recurrent C. Difficile. In the future it may be possible to screen for therapeutic intestinal bacteria and already stool banks like OpenBiome (12) have emerged to provide screened, filtered, and frozen material ready for clinical use in the treatment of C. difficile.

With an eye to future research in the clinical setting, a potential tool for linking mood and food is neuroimaging: it can be performed in vivo, giving a good spatial and temporal profile of changes in the brain. Using neuroimaging in humans, Tillisch et al showed that consumption of fermented milk product with probiotic affected activity of brain regions that control central processing of emotion and sensation (12). These data suggest that certain organisms may prove to be useful therapeutic adjuncts in stress-related disorders, although well-designed controlled human trials are needed to further evaluate these ideas.

Using this bidirectionality, an interesting mechanistic line of investigation is that of the behavioural therapies such as cognitive behavioural therapy, relaxation therapy or hypnotherapy. These therapies could potentially modify the gut microbiome via efferent vagal and/or hypothalamic–pituitary–adrenal axis function. Therefore, demonstrable differences in gut microbiota have important implications regarding the development of a disease-specific biomarker(s) as well as treatment and, hopefully, prevention. More studies considering the role microbiota in clinical populations with anxiety disorders, mood disorders, and comorbid psychiatric symptoms are needed.

 

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. Collins J, Borojevic R, Verdu EF, Huizinga JD, Ratcliffe EM. Intestinal microbiota influence the early postnatal development of the enteric nervous system. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society. 2014;26(1):98-107. Epub 2013/12/18.
  2. De Palma G, Blennerhassett P, Lu J, Deng Y, Park AJ, Green W, et al. Microbiota and host determinants of behavioural phenotype in maternally separated mice. Nature communications. 2015;6:7735. Epub 2015/07/29.
  3. Wilson A, Longstreth GF, Knight K, Wong J, Wade S, Chiou CF, et al. Quality of life in managed care patients with irritable bowel syndrome. Managed care interface. 2004;17(2):24-8, 34. Epub 2004/03/25.
  4. Hapfelmeier S, Lawson MA, Slack E, Kirundi JK, Stoel M, Heikenwalder M, et al. Reversible microbial colonization of germ-free mice reveals the dynamics of IgA immune responses. Science. 2010;328(5986):1705-9. Epub 2010/06/26.
  5. Candela M, Biagi E, Maccaferri S, Turroni S, Brigidi P. Intestinal microbiota is a plastic factor responding to environmental changes. Trends in microbiology. 2012;20(8):385-91. Epub 2012/06/08.
  6. Quigley EM. Small intestinal bacterial overgrowth: what it is and what it is not. Current opinion in gastroenterology. 2014;30(2):141-6. Epub 2014/01/11.
  7. De Angelis M, Piccolo M, Vannini L, Siragusa S, De Giacomo A, Serrazzanetti DI, et al. Fecal microbiota and metabolome of children with autism and pervasive developmental disorder not otherwise specified. PloS one. 2013;8(10):e76993. Epub 2013/10/17.
  8. Ait-Belgnaoui A, Colom A, Braniste V, Ramalho L, Marrot A, Cartier C, et al. Probiotic gut effect prevents the chronic psychological stress-induced brain activity abnormality in mice. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society. 2014;26(4):510-20. Epub 2014/01/01.
  9. Bercik P, Park AJ, Sinclair D, Khoshdel A, Lu J, Huang X, et al. The anxiolytic effect of Bifidobacterium longum NCC3001 involves vagal pathways for gut-brain communication. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society. 2011;23(12):1132-9. Epub 2011/10/13.
  10. Silk DB, Davis A, Vulevic J, Tzortzis G, Gibson GR. Clinical trial: the effects of a trans-galactooligosaccharide prebiotic on faecal microbiota and symptoms in irritable bowel syndrome. Alimentary pharmacology & therapeutics. 2009;29(5):508-18. Epub 2008/12/05.
  11. Smits LP, Bouter KE, de Vos WM, Borody TJ, Nieuwdorp M. Therapeutic potential of fecal microbiota transplantation. Gastroenterology. 2013;145(5):946-53. Epub 2013/09/11.
  12. Tillisch K, Labus J, Kilpatrick L, Jiang Z, Stains J, Ebrat B, et al. Consumption of fermented milk product with probiotic modulates brain activity. Gastroenterology. 2013;144(7):1394-401, 401 e1-4. Epub 2013/03/12.

 

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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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