Merron Simpson, Chief Executive, New NHS Alliance

Published in JHH15.3 – Social Prescribing

My main professional expertise lies in housing policy and practice but I often describe myself as a sector-bridger since much of what I do lies at the interface between traditional professional domains. My passion is to bring congruence between public services and the reality of people’s and communities’ lives – which requires health, housing, social care and other services to work together and focus on what it is that makes people well. I’ve worked with and advised many organisations including The King’s Fund, NHS England, the National Housing Federation, Housing LIN, the Local Government Association, De Montfort University and the Royal Town Planning Institute.

Health creation is a route to wellness. It comes about when local people and professionals work together as equal partners Click To Tweet Social prescribing is increasingly being recognised as offering health and wellbeing benefits to patients beyond the consultation interaction alone. By recognising that people’s health is primarily determined by a range of social, economic and environmental factors, it seeks to address people’s needs in a more holistic way.

According to The King’s Fund (2017) there are more than 100 social prescribing schemes in the UK – there may be many more. They are supported by the Social Prescribing Network and NHS England’s national clinical champion for social prescribing which advocates for this more holistic intervention.

Another approach to addressing the unmet health and wellbeing needs of people and their communities is through the practice of health creation. This is being championed by New NHS Alliance and its members.

Simply put, health creation is a route to wellness. It comes about when local people and professionals work together as equal partners and focus on what matters to people and their communities. Health creation is complementary to, and can enhance, social prescribing. However, there is still some confusion as to how health creation fits within the overall scheme of things.

Wellness is an active process of becoming aware of, and making choices toward, a healthy and fulfilling life. Wellness is more than being free from illness, it is a dynamic process of change and growth.

University of California (undated)

Health creation and social prescribing

New NHS Alliance was recently asked, on twitter, to clarify the relationship between social prescribing and health creation – as espoused by the alliance and its members.

We felt that the best way to respond might be to set out not just one but several illustrations of how the relationship works. We expect different perspectives to be helpful to different people depending where they sit within the health and care system. And we value your feedback – so please feel free to tweet your thoughts @nhsalliance.

The first thing to say is that social prescribing is an excellent first step in the journey to adopting health creating practices. If you’re a general practitioner, a practice manager, a practice nurse or anyone else supporting general practice, and you’ve not already adopted social prescribing, then the emerging evidence for its benefits indicates that you should seriously consider doing so. Adapt and respond.

Social prescribing opens up a wide-range of possibilities for social interventions, alongside medical ones. It is a move away from the biomedical approach to a holistic person-centred partnership and it starts the process of culture change among the workforce and patients. Having a community navigator who can spend more time listening and working with individuals to find appropriate solutions to their ailments or troubles will certainly help more people to better health than the traditional model of the 10-minute consultation.

Health creation is a route to wellness

To be well, people need sufficient

Control over the circumstances of their lives and the things that affect them.

Contact with other people that is enjoyable, meaningful and purposeful.

Confidence to see themselves as an asset able to have a positive impact on their own and others’ lives.

The second point is that, while any general practice that is adopting health creation is likely to have social prescribing as part of the mix, it should not be assumed that they are therefore ‘doing’ health creation. Among the many social prescribing models some are going to work better than others in terms of enhancing wellness. Our community informed framework suggests that the most health creating forms of SP would be characterised in abundance by these five features – listening and responding, truth-telling, strengths-focus, self-organising and power-shifting. (For more information about the five features of health creating practices. Those that have two or three of these five features will offer benefits although they may not be meeting their full potential.

The third point is that general practice can adopt a wide range of practices that can be health creating, not just social prescribing. Group consultations are a good example. Where they are done well, peer learning and support (aka self-organising) becomes a bigger part of the patient experience. In one study in Croydon, type 2 diabetes patients reported learning more compared with one-to-one consultations. This included improved understanding of their diabetes and how to manage it. Supportive friendships that are forming through the group sessions come with more acceptance of the need for lifestyle change. Not only that but having attended such meetings patients then engage with local social prescribing and report they wouldn’t have gone to SP events on their own. New NHS Alliance recently found evidence of high levels of health creating practices in hospital discharge schemes, initiatives that support people with mental health difficulties within the community and social clubs for older people, to name just a few.

And finally, social prescribing is a specific practice, albeit one with many variations. It is ‘a means of enabling GPs and other frontline healthcare professionals to refer patients to a link worker – to provide them with a face-to[1]face conversation during which they can learn about the possibilities and design their own personalised solutions, ie ‘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’ (defined by the first Social Prescribing Network conference in 2016).

Health creation is, by contrast, a way of working at the front line that is not the preserve of healthcare professionals. It requires asset-based skills characterised by the five features of health creating practices. When these five features are working, it provides the conditions for people to gain control, make meaningful contact with others and build confidence. People need enough of the 3Cs of health creation to be well.

It is the equal partnership and the ability of people to work together with others to address the long-term issues that matter to them and their community that makes for lasting change in people’s and communities’ lives. Communities play roles, professionals play roles, and what gets done revolves around what matters to the communities. If done well, there is a positive impact on the workforce as well as on the community.

The five features of health creating practices

Listening and responding: effective, genuine listening to the reality of people’s and communities’ lives is essential. As is acting differently on what is heard, and not just reverting to the established systems. Listening can also enable truth-telling when there is sufficient trust for people to open-up about matters they might find it difficult to face up to.

Truth-telling: when people and practitioners face the truth and can identify and acknowledge what holds them back from creating health, rather than treating illness, they can start to get to the root causes of problems.

Strengths focus: health creation happens when attention is paid to what people can do for themselves or others. Making people aware of their strengths, and finding opportunities for them to employ them, unlocks their potential and builds confidence for creating health.

Self-organising: putting people in touch and helping them to connect meaningfully with others makes it possible for them to find solutions and take actions together.When people start to value, trust and help each other and work together, they are more likely to find purpose in their lives and this drives wellness. Over time, people become less reliant on health and care services.

Power-shifting: lasting health creation happens when the features above result in a power shift from practitioners to people and communities.When people’s expertise and strengths are recognised and valued, they can make good decisions about things that affect them and their environment. Services can then adapt and respond.

The route to health creation

Social prescribing is one route into health creation. As well as providing a connection between the medical and social models of health, it also helps to create a bridge between primary care, other local services and communities. Those who adopt community-led versions of social prescribing and continue to develop them by fully embedding the five features of health creation practice within them have the greatest potential to improve population health. Other sectors and parts of the health system will take different routes into health creation. For many, making every contact count (MECC) is part of the journey. For others the adoption of reflective practice and psychologically informed environments is the route to take. What is most important is that we all go on the journey, that we all recognise the efforts of others who may be taking different routes, and that we are all open to learning from each other along the way.

General practice can adopt a wide range of practices that can be health creating, not just social prescribing

It is heartening to see that social prescribing has been widely taken up by general practice despite the lack of a robust evidence base. This is unusual. It is also absolutely necessary if we are to stand a chance of embracing either social prescribing or health creation. Trying new practices, incrementally building the evidence base, sharing our learning and strengthening our collective confidence as we go along are all essential to bring new practices to the mainstream. This needs to become the new normal, applying as it does as much to health creation as to social prescribing.

References

• The King’s Fund (2017) [Online] Available at: https://bit.ly/2POUMW2 (accessed 15 August 2018).
• University of California Davis Campus (undated) Student health and counseling services. Available at: https://shcs.ucdavis.edu/wellness/ what-is-wellness (accessed 15 August 2018).