Social prescribing: holism in action?

Dr Michael Dixon, National Clinical Lead for Social Prescribing, NHS England & NHS Improvement; Chair, College of Medicine

David Peters, Editor-in-chief, JHH

Published in JHH 19.1 – Integrative Medicine

Chair of the College of Medicine Mike Dixon talks to JHH editor-in-chief David Peters about how far social prescribing has come – and how far it still has to go.

‘Biomedicine is fantastic and we have seen that in action with the Covid-19 vaccine. However, because of social determinants we know that biomedicine isn’t going to be the only answer. A recent review into over-medicalisation shows that one in five people over the age of 65 who are in hospital are there not because of the condition they are living with, but because of the medications they are taking. I think social prescribing provides a revolution in health and wellbeing, not just for people living in this country, but globally… A downstream crisis management health system is not going to work any more. We need to be properly investing in prevention and in upstream support.’

James Sanderson, CEO, National Academy for Social Prescribing

DP  Social prescribing has been around for quite some time now. How would you summarise where it is at and where it is going?

MD I just had an amazing meeting with all the people who are doing social prescribing in prisons. It’s been commissioned by the health service and usually with prison staff acting in a social prescribing type role. Some schemes call linkworkers facilitators or community connectors. Down here in rural Somerset [where Mike Dixon is based] they call them village agents! Some primary care networks are making SP a priority, and spending as much money on linkworkers as they are on pharmacists and physios and emergency practitioners. In some other networks, which perhaps take a more biomedical view of primary care, or who see public health as a lesser priority, they aren’t investing in social prescribing linkworkers.

Social prescribing is now UK national policy: there are over 1,000 social prescribing linkworkers and there have been more than 900,000 social prescribing referrals. Most UK primary care networks have one or two SP linkworkers – some as many as three. But things are developing at different rates in different parts of the country. The Oxford University GP Observatory produced some interesting research showing that there are more referrals in deprived areas, which is good news. The bad news is that in deprived areas the actual uptake is less. And so is uptake among ethnic minorities.

SP is designed to advantage those who are least advantaged, and it’s sort of doing its job but probably needs more focus. So much depends on the linkworker spending time with the person to really get to understand them and their hopes and beliefs, and then slowly – possibly starting with welfare benefits or housing or employment advice – giving that person more meaning in life, eventually moving on to other things like green exercise, walking groups or various arts interventions. But those initial deep dives are much harder because of course during the pandemic these crucial connections have had to be made online. So social prescribing and, yes, in parallel online GP (family practice) consultations became more episodic and transactional – less relational. But as the pandemic eases off (fingers crossed) SP is getting back on its feet, along with face-to-face office consultations.

When social prescribing started off it was mostly for elderly isolated people – little ‘knit-and-natter’ groups and book groups. But then we realised these social interventions were helping people who had long-term disease. Soon, the evaluations showed that if you offer people with long-term diseases a social prescription you could reduce their use of GPs and hospitals on average almost 20%: so a very substantial return on investment in that group. And then for the 20% of patients who see the GP because of social problems it’s a no-brainer that a social intervention is going to be more effective that a medical one.

Our young people have suffered intensely throughout lockdowns with restrictions on their social life and loss of access to their schools and colleges. Mental health in young people is an enormous issue at the moment, so children and young people are becoming a further focus for SP. So, huge potential return on investment for social prescribing not just in schools, but also other groups, for example the initiatives for prisoners and army veterans. But I do see SP as being something that’s relevant to everyone; wherever we need to invest in building social capital really. The research questions aren’t about whether it works but rather where and for who is it most effective, which delivery models are most acceptable; and of course, whether it’s ‘efficient’ in sheer economic terms. SP will spread if it delivers a decent return on investment.

DP Michael, you said that there’s a holistic need for this intimate understanding and insightful person-centredness in the linkworker and that this is what makes it holistic rather rather than transactional. But you also said the GPs who see their priority as being to diagnose and treat or refer on the individual patient haven’t taken up the linkworker offer.

MD Yes partly because a lot of GP income depends on getting in fees for meeting targets for defined items – most of them for clinical care. It’s quite a comprehensive list defined by the Department of Health of 57 indicators across 20 clinical areas (eg chronic kidney disease, heart failure, vaccinations, blood pressure, asthma). So that becomes their bread and butter focus, because there’s still no funding stream for GPs to put time into public and community health. So one of my big beefs is that family practice needs to be allowed to spread its wings. Many of our demoralised GPs, if it didn’t cost them, would support social prescribing linkworkers, and engage with local schools, town councils, volunteers and the voluntary sector. The fact that building up local social capital actually builds public health has fired up a lot of family doctors but the funding system works against doing so. So far they’re doing it on their own time because they feel good about it, not because it’s part of the funding system. The GP networks that are really in the know of course see SP as a long-term solid return on investment. What’s emerging from the research is that where local services really are connected then you get a big change in the local culture and health. Frome in Somerset is a prime example.

DP We are just launching the Journal of holistic healthcare in America. I’m thinking readers over there will scratch their heads and wonder what we’re talking about! A national health service (NHS), primary care networks, NHS funding streams and the rest. Actually quite a few of our readers will probably be a bit flummoxed by the intricacies of NHS funding. But on reflection I suspect USA doctors are even more constrained by insurance companies’ complicated fees-for-service system. And I’m sure you’re right, this kind of remuneration encourages doctors to be transactional, to take an episodic approach to care and adopt a narrower, more clinical focus. Do you know whether SP is developing in the States, perhaps through the big managed care organisations?

MD Yes it’s definitely getting traction over there. We’ve got a social prescribing team there in fact and it’s part of a global network of about 22 countries worldwide. Professor Sir Michael Marmot, the leading health inequalities researcher, came to our international conference two weeks ago. He has found that economic inequalities are getting worse and even more so since the pandemic. And we know of course that deprivation of all sorts massively raises the risk of severe Covid and also every type of fatal and long-term disease. With huge inequalities in both our countries, America is on the same trajectory. I asked Sir Michael – somewhat provocatively as I was chairing the conference – whether social prescribing and general practice were irrelevant, just rescuing society’s casualties; that if anything we are just shoring up broken systems. But he thought that on the contrary other than big shifts in national policy, SP is what’s most likely to alleviate some of the real suffering among those that have least. It’s not simply putting a little band-aid over the wound it really is a fundamental change in thinking at the frontline.

DP So the way funding systems operate encourage medical systems to industrialise, and primary care has become more transactional because doctors have to make sure they get the money in and make a profit; but also it’s become transactional because that’s what the primary care day job has become. It’s much less personal and relational than when I trained in family practice in the 1980s. That too was a high demand system, but as often as not the patient wasn’t a total stranger. But then, as now, patients would come in with social problems – one in five on an average day – that clinical medicine wasn’t going to solve. Nowadays given how much more episodic and impersonal a GPs work has become, you might never meet that patient again. So if (as usual) there are 20 folk waiting to see you that morning, rather than to going a bit deeper or getting preventive it might be tempting to use one’s 10-minute appointment to take the easy way out, and prescribe meds or refer to a specialist.

MD That’s right, the great thing about having access to an SP linkworker is that it gives us ways of addressing these ‘non-clinical’ encounters appropriately (some would say more ethically) in ways that just weren’t there for us even five years ago.

DP This – and the evidence backs it up – by allowing doctors to feel better about their work, in turn helps prevent burnout. Happier doctors mean happier patients. Win win!

MD That’s true I’m sure. There are patients who don’t have a reason to get up in the morning and quite a few GPs feel the same way!

DP That’s sadly the case. I meet GPs in the woodland retreats I run. Most of them say they don’t see anybody all day – apart from patients every 10 minutes. They don’t have time for a coffee break.

MD In my practice the coffee break meeting is firmly in everyone’s clinic diary. It’s sacrosanct, and boy does it make a difference! For one thing it means that old-timers like me get a knowledge update from the younger ones, but also we get to talk about how miserable working life can be! Actually it’s incredible, that a half hour makes the whole day good. Most of the team turn up most of the time. It’s a useful thermometer for who is coping with the workload. I hear from other teams that the colleagues who don’t turn up are the ones most overstretched; that repeatedly not turning up could be a warning sign for early burnout.

DP Yes, in our work it’s strangely easy to become isolated in our office and numb to the emotional burden we often carry. So we need to be aware of this and to take better care of each other. But that’s not a sentence you’ll hear in most doctors’ common rooms! So, Michael, what are your blue skies thoughts about where SP could go?

MD Well of course there are a few challenges. A third of UK linkworkers left last year. Some were under great stress because they were being handed mental health problems that should have been dealt with by the local mental health team. Here and there some GPs haven’t been as supportive in terms of giving linkworkers the IT they need: tablets, mobile telephones and online connections. In fact there are quite a few technical issues, yet overall SP developments are going really well. The blue sky for me is a reconfigured local health service. Somewhere like Frome where they’ve got 1,800 community connectors attached to their social prescribing network: all sorts of local volunteers – taxi drivers, hairdressers, students, shopkeepers – who connect through the SP system that can link people to the many things on offer. This truly is creating community, in fact vast social capital! In Ilfracombe on the north Devon coast a volunteer facilitator on every street is checking to see who needs what and then connecting them to the appropriate voluntary help through the trained SP linkworker. So SP systems rely on relatively few trained SP linkworkers and they are not highly paid – much less than a nurse practitioner. But by spreading their influence through volunteers into the community creates this a powerful ripple effect. My blue sky hope for the future is that we will see more and more of this kind of connection at local level.

In a very real sense the National Health Service uses taxes from the better off to make healthcare available free at the point of need to everyone, rich poor alike. But this is eating up more of the GDP every year. The proportion shot up from about 10% in 2019 to 13% in 2020 and no doubt it’s still on the rise. In 2020 it was nearly 20% in the USA. But neither nation fares well in international league table of health outcomes! UK is 13th and USA 18th.

More SP and community interaction at local level has to be part of the solution. We’re not going to have sustainable healthcare systems otherwise: we will always need more GPs, more hospitals, more drugs, more tests, more everything. Somehow all healthcare systems are going to have to stem the tide of evermore technical and secondary care and expensive downstream end-stage disease management. That’s where health service finances always end up when primary upstream healthcare is undervalued because hospital always take priority. This has to change. My blue sky vision is for a revolutionary re-thinking of healthcare.

And as citizens we need to accept that as well as having a right to a health service we have a responsibility to look after ourselves better. In this respect SP is designed to help support those who do need it.

DP I hear you saying that there is such a thing as community; that we are more than just individuals and families. That seems at odds with the mainstream of our politics and society’s neoliberal ideology. I think you’re implying that this kind of individualising technologising industrialising trend could end up bankrupting every western healthcare system. So I’m sure you think people interested in holistic healthcare should get behind the whole social prescribing project.

MD Well on a purely selfish practical level, say a doctor thinks a patient would be best served by a nonclinical intervention and there’s a linkworker available to hook them into a community referral network. This will mean the patient gets holistic biopsychosocial care service and the doc’s time is freed up to do a better clinical work. On an emotional level I suspect people with a holistic vision of practice actually enjoy their work more than those who are stuck in the episodic transactional hamster wheel. The treadmill of transactional episodic medicine burns you out, whereas holistic thinking keeps you curious as to why people are there, and what you can do to help them and to be inventive.

DP So, the technical approach works fine in critical or acute care, but to thrive in the swampy territory of chronic disease where people have to self-manage and can’t be ‘fixed’, doctors have to ask not only what’s the matter with a patient but also to be curious about what happened to them?

MD Yes, but that fundamental curiosity about a person is strained if patients are strangers and more so when we are stressed and overstretched or even burned out.

But it’s early days for SP. So for some of our colleagues it will still seem a step too far to say, ‘I’m not going to give you an antidepressant. Instead, I’m recommending you start walking regularly with the local walking group’. But I find most patients like that option. I wouldn’t have believed that possible even 10 years ago, but something has shifted in the culture. The nature connection idea is all over the media, and the idea of social capital allows people to think in new ways about what makes a community healthy. On the other hand we need national policies to tackle health inequalities, which are huge: 30% of children in the UK live below the poverty line. For the 10% of poorest people in this country to afford the Eat Well Plate recommended by Public Health England they would have to spend 75% of their income! So social and nutritional factors interact to produce increased health risk. Another example: the likelihood of adverse child events (ACEs) increases when people are living in poverty. ACEs are associated with increased chronic disease and more criminality. We know all about this from the American studies.

DP Despite all our problems with austerity and deprivation in this country and inequality, the NHS is still there to pick up the pieces. Is there anything like it in America?

MD Not nearly to the same extent, but some of the providers in America are beginning to realise that social prescribing can be part of a more sustainable approach to treating people and keeping patients healthy than endlessly doling out meds. The latest National Academy of Social Prescribing report has some very good evidence for the social prescribing benefits. Return on investment will be the driver here and internationally. Because frankly we really can’t carry on doing medicine the way we have been.