Peter Donnebauer, Layperson trustee of the BHMA; pioneering moving image artist and media entrepreneur

Published in JHH15.3 – Social Prescribing

I have been interested in alternative approaches to drug-based ‘treatments’ since being prescribed tranquillisers for random panic attacks in my teens in the 60s. My instinct then told me that this was not treating the cause(s) of my condition; this was verified some five years later when I was one of the first people in the country to be officially diagnosed with hypoglycaemia. A week after the six-hour blood sugar test I had changed my diet accordingly and that was the last time I needed help from the medical profession for my ‘symptoms’. Medical understanding has moved on since then, and the internet is a powerful source of patient information, but my instinct remains to use drugs only as a last resort. I have been a layperson trustee of the BHMA for the past few years as it remains the only organisation committed to promoting a person[1]centred rather than a symptom-centred approach to ‘illness’.

SP is holistic even though its name comes straight out of the medical model Click To Tweet

Social prescribing IS holistic healthcare in practice

An article in Pulse broke the surprising news that health regulator NICE is calling for GPs to signpost patients at risk from loneliness and isolation to local singing, arts and crafts and walking groups, to help them stay healthy and keep living independent lives. General practice could receive an extra £1 per patient towards improving access to social prescribing by 2017/18 according to NHS England’s clinical champion for social prescribing (Wickware, 2016).

Social prescribing (SP) is all about looking at patients’ wider social needs in order to make referrals to community-based non-clinical services, ideally with the GP being supported by liaison staff. So, 35 years after the BHMA was born, it has cause to celebrate this as a sign that holistic healthcare has gone mainstream!

SP is holistic even though its name comes straight out of the medical model in which the dispassionate professional observes, analyses, diagnoses and prescribes. Yet this raises an issue for me, because we ‘patients’ have too easily and for too long accepted that the doctor is someone who knows more than we do about our ill-health or dis-ease, and can diagnose – ie tell us what is wrong, and then prescribe something for us, and then tell us what we need. Thankfully – and SP is a sign of this – there is at last a growing acceptance that the ‘something prescribed’ doesn’t have to be a drug. This is great news for patients, and possibly for doctors too. However, even if the doctor is correct about what we need, the social prescription is going to demand a lot more from the patient than a trip to the chemist and a prescription charge!

No more magic bullets?

The fact is that many problems can’t be solved by money or pills. This is in itself a crucially important message. Instead, SP relies on the possibility that (with help) we can (and should) be more fully engaged with our own health and wellbeing. The social prescription moreover requires us to be actively involved in activities within our local community: a double whammy in that it will probably benefit not just the individual, but the community too, and the NHS as well of course. As a report published by the Social Prescribing Network (a group dedicated to supporting SP at local and national levels) says: ‘Social prescribing could help reduce pressure on health and care services by referring patients seeking help for non-medical issues to community based non-clinical services…since… around 20% of patients consult GPs for problems that are primarily social rather than medical, and dealing with these needs is important because social and economic factors affect health outcomes’ (Torjeson, 2016).

Of course not everyone, including drug companies, will celebrate if doctors are required to push us to live more active and engaged lifestyles. The nation ought to applaud though, because the government exhorting us to eat five a day or to take 10,0000 steps a day has not worked. Is this because the UK population is not yet well-educated and wealthy enough to make health[1]enhancing lifestyle changes? Perhaps we need the leadership and support of a new kind of primary care organisation or emphasis, and less that of celebrity culture and The Daily Mail.

Social prescribing is holism by the back door

Or perhaps it’s via the front door but in disguise! It is holistic in the sense that it does not focus on simply eliminating symptoms. Instead SP is interested in boosting resilience by asking what the individual can do to better manage their own dis-ease and promote wider wellbeing. Even though it might not appear to the doctor, or even the patient themselves, to be holistic, the prescribed activity will probably have improvements beyond symptomatic relief. And there will be other side-benefits if SP allows hard pressed GPs to offer something for those patients who are ‘repeat visitors’ without conventionally ‘treatable’ medical issues. What’s more, SP reinforces the role of GPs as a central part of the local community. Potentially at least, SP supports the financial health of the local community too, by encouraging people to spend time and money locally; and it saves the NHS money on medicines that may not even be taken by the patient, for it is well known many patients do not like to take drugs, or take them erratically.

SP usually depends on secondary advisors and supporters who take some time pressure off GPs, allowing them to use their professional time more effectively for attending to medical issues that they can treat ‘conventionally’. And, in the longer term, it will hopefully discourage passivity from patients and empower them to realise that they can have a positive impact on their own health.

Unspoken aspects of the doctor–patient consultation

Social prescribing illuminates something important about the doctor-patient consultation. I see this as a ‘two person game’ with particular social rules – a kind of play-acting of accepted social roles – where authenticity is probably the exception rather than the rule; the unspoken and assumed conventions contextualise and define the situation. I have known many people who go to doctors for a diagnosis, and leave the consultation with a prescription for drugs that they have little or no intention of ever using, unless their condition was serious or life[1]threatening. It is not authentic for the patient to pretend to accept the doctor’s unspoken rules and conventions where the expected outcome will most usually be the prescribing of drugs.

Perhaps this reluctance to be honest about why they consulted is to do with a misplaced English sense of politeness. But with the necessary feedback loop broken, the doctor has no information about what the patient actually wanted, nor any reason to do things differently. One expensive result is overprescribing, which I tackled in an earlier JHH article about my osteoporosis (Donnebauer, 2015). Researchers found that in 2013 overall, around a quarter to a third of patients either failed to take their prescribed medications or didn’t take them as directed. The estimated cost to the NHS in the UK is more than £500 million every year (Langley and Bush, 2014). One should then add in the potential human loss of an authentic interaction, the unintended side-effects of drugs, the cost pressures on the NHS and the ineffective use of GPs’ time, which is in short supply, with many burning out or retiring early. ‘Knee-jerk’ prescribing undervalues the benefits of GPs’ human-to-human role. With the predicted rise of robot competition in the form of AI diagnosis and prescription one can see many compelling reasons why the GP consultation could do with a fundamental makeover.

Social prescribing is the chink in the armour of evidence-based medicine

Does evidence-based medicine actually underpin current consulting practice and GP action? Research by Peter Gotzsche (2016) referred to in the British Medical Journal blog suggests that prescription medicines are the third largest killer of patients after heart disease and cancer.

This is why I hope SP will be a seed, whether consciously or not, for the practice of holistic healthcare. Whatever its many intrinsic benefits for individuals, it will open up debate about what holistic GP consultations and extended services can achieve. This is clearly important in an ageing population with complex healthcare needs and the ever-increasing financial and resource pressures on the NHS. And surely, in an age when everyone can access so much varied information about medical matters on the internet, SP just feels more ‘modern’.

Are there any downsides?

The only downside I can foresee is that it moves the patient out of the GP surgery environment into potentially unregulated areas. Even so, the kinds of non-medical engagement recommended under SP surely need regulating far less than do doctors and medicines. Presumably doctors will be aware if a patient is vulnerable from reduced mental capacity for example, and good practice would anyway have the patient return for GP review.

It may only be a small beginning, but holistic healthcare is going mainstream.

References

• Donebauer P (2015) Overdiagnoss and osteoporosis. JHH 12(3): 15–18.
• Gotzsche P (2016) Prescription drugs are the third leading cause of death. Available at: https://blogs.bmj.com/bmj/2016/06/16/peter-c[1]gotzsche-prescription-drugs-are-the-third-leading-cause-of-death (accessed 2 September 2018).
• Langley CA, Bush J (2014). The Aston Medication Adherence Study: mapping the adherence. Int J Clin Pharm. 36(1):202–11
• Torjesen I (2016). Social prescribing could help alleviate pressure on GPs. BMJ 352: i1436
• Wickware C (2016) GP practices could receive £1 per patient to fund social prescribing advisor. Pulse, 25 November. Available at: www.pulse[1]co.uk/home/finance-and-practice-life-news/gp-practices-could[1]receive-1-per-patient-to-fund-social-prescribing-advisor/20033219.article (accessed 2 September 2018).