We live in interesting times. Providing medication to patients, without empowering them to take responsibility for their health, has led to a seemingly unstoppable rise in long-term conditions, many of which are underpinned by diets lacking in nutrients and high in sugar and unhealthy fats. Couple this with low levels of physical activity and you have a recipe for our shockingly high levels of obesity, cancer, diabetes, heart disease and mental health issues (Vos 2016). That’s not all; we have had a massive shift in how ‘community’ is perceived. The extreme development of technology has led to the paradox of being able to connect with anyone almost anywhere in the world instantly, while at the same time social isolation and loneliness are rife in our society. Then add in the austerity measures, the consequences of which are being felt now, particularly in the voluntary and community sector. Finally combine these developments with the worst levels of burnout and disenchantment in the medical profession in modern times. There is a huge cost to this situation – the cost of caring for an ageing population with long-term health needs, the cost to the community and voluntary groups that can no longer get funding, the cost to the health of our healthcare professionals and the organisations that are finding it more difficult to attract the necessary workforce. If you need any more convincing, it is estimated that the amount of time a GP spends seeing people with nonmedical needs is equivalent to £394 million a year (CAB 2015). I could go on…. If someone developed a drug to cure these ‘societal ills’ the drug companies would bite your hand off to produce it. But this article is about exactly the opposite – what we can do when drugs may not be answer.
Many have watched the policy changes in the health sector with baited breath. As William House wrote about the introduction of the Health and Social Care Act (DoH 2012), ‘it has this been a cleverly constructed story about localism, decisions nearer to people and a new culture of social enterprise, all disguising the real plan for a gradual hollowing out of the NHS… or will the NHS be slimmer, fitter, more patient-focused yet keeping the collaborative ethos, the commitment to shared responsibility, social solidarity and the common good?’ (House 2013). William House’s words resonate with me, as over the last couple of years there has been the most unprecedented realisation, arguably at all levels, that something radically different needs to happen with healthcare provision, if the latter version of the NHS is to be realised. Hence the Five Year Forward View and GP forward view documents setting out the ambitions of how the NHS wants to change (NHS England 2014; 2016 respectively). It would only be right and proper to point out that the voluntary and community sector realised this a long time ago. This article is about the many people who are already working outside their comfort zone, doing something radically different. It’s about the vision of unlocking a person’s potential irrespective of their situation, to provide humane healthcare and to empower a person to live their life with meaning, purpose and fulfilment. It’s about the growing movement of people who are coming together and whose collective voice is getting louder.
Social prescribing has existed below the radar for many years as discrete projects, not just in England, but in the UK, the Republic of Ireland, and in the Netherlands too. In 2015, with the support of the Wellcome Trust and College of Medicine, I led the project to set up the Social Prescribing Network, based at the University of Westminster.* We officially formed in January 2016 when we convened the first UK conference for people active in social prescribing. Until that point, there had been no way of knowing who was already innovating new approaches to people care, and therefore no way to of sharing experience and best practice and understanding the collective knowledge. When we began approaching people through word of mouth, we hoped for 60 people at the conference. What happened was amazing – 100 people attended the conference, demand was so high we ran a waiting list, and the buzz in the room on the day was fantastic. The conference was attended by as many stakeholder groups as we could identify, bringing healthcare practitioners together with social care, public health, CCG representatives, citizens, voluntary groups, academics and local authorities. A summary of discussions and priorities can be found in our report which was launched at the Houses of Parliament in March 2016 (Social Prescribing Network 2016). We had lifted the cover off an active underground social movement of the people and hopefully started to build a home for them. One year on, we have 500 members and are rolling out 7 regional network groups; from little acorns, big oak trees grow.
There have been many definitions of social prescribing, which are often associated with an area of health eg mental health, or with the arts. At the conference, we debated this issue of a definition and then proposed the following short one. ‘Enabling healthcare professionals to refer patients to a link worker, to codesign a non-clinical social prescription to improve their health and wellbeing’ (Social Prescribing Network, 2016)
Social prescribing in the NHS
Despite social prescribing often being referred to as the common-sense approach, making social prescribing a reality in the current structures of the NHS is an interesting and, I would say, (as a pragmatist and an optimist) an ultimately achievable challenge, if the collective will is there. This article will now explore how it is possible for social prescribing to reshape healthcare provision.
First, this needs to be underpinned by a shared vision of an NHS which is ‘more patient-focused yet keeping the collaborative ethos’. A challenge here is about communication – communication between just one or two stakeholder groups is an unacceptable way of working. So often people are in their silos, working away completely unaware that knowledge and expertise exists in a different silo; this is a ridiculous waste of time and knowledge (and therefore money). One principle underpinning the Social Prescribing Network is to ensure all meetings and events are attended by as many stakeholder groups as possible. This is not how the NHS generally works, and I would argue that it is only the situation of extreme austerity which is forcing commissioners, healthcare professionals, local authorities, public health and the voluntary and community sectors to talk to each other. It takes some courageous champions in every sector to start these cross-sector conversations and we cannot expect ‘top down’ change to bring it about; this bit needs organic, bottom up activism.
We explored what our social prescribing members (n=180) thought the key ingredients to a successful social prescribing project were. Communication, relationships and feedback loops were three of the themes we identified – which won’t surprise those already employing holistic approaches to promote whole person care. There is a desperate need for a patient/person to be heard, to tell their story without being stopped after seven minutes, to be able to unpack the complexities in their life and then be given the opportunity to choose a positive way forward. This is the role of the link worker. The link worker is the term we currently use to describe the community navigators, health trainers, health champions, health advisors of this world, who listen to a person and match them with the appropriate community/voluntary groups or health resources that they need. It’s a very special form of communication and it is in the liminal space they provide that new paths can be revealed. So, is it possible to engender working practice whereby each stakeholder has equal voice and respect? Absolutely, it is already happening in half the CCGs in England on some scale.
What is the model?
One frequently asked question is ‘what model should we use if we want to commission a social prescribing project?’ This question also exemplifies another unacceptable approach to patient care – the one-size-fits-all approach. There is no one model of social prescribing, which is fortunate as we are not all cloned from one person. Social prescribing projects are commonly set up to build on existing assets. This is often referred to as the ABCD – Asset Based Community Development – approach. What is there that already exists, what expertise is available, what community and voluntary groups exist, what buildings can be used? This means the focus needs to be on the underpinning values. It’s also about building in flexibility in a service to allow for varying needs of a person. Some people are recommended to go to a group, yet lack the confidence to go on their own. So they are accompanied for the first couple of visits. A person who has a lot going on may need many link worker sessions before they are standing on their own two feet again, but that’s OK as there are others who only need a couple of sessions. Flexibility must allow for such varying demands to be managed as its ebbs and flows.
If we come back to understanding how healthcare can be reshaped by social prescribing, then the commissioning of services is an essential element to sustaining this movement. It is crucial for commissioners to commission services that exist locally, and which already have established relationships with people, where possible. Crucial because this supports the local voluntary and community groups, who already have the relationships with people. Crucial because if there are established relationships in the community, local needs are more likely to be recognised and met. Crucial because without the local voluntary and community sector, the NHS would be even worse off than it is now.
There is a real danger that commissioners will only look at the bottom line and fail to appreciate the value of commissioning existing assets. We therefore need to take shared responsibility for educating commissioners on what to look for in a good social prescribing project. That is not all, as we are often asked by commissioners about the evidence – is there enough evidence for social prescribing and what is the return on investment? To answer these two very pertinent questions, many pieces of evaluation have been done on social prescribing projects, and we have been analysing 60 evaluations, as well as some RCTs and qualitative work. This is an emerging field, so there is certainly room for more research, however similar results are being reported around the country and in Europe. Predominantly it’s reported that the demand for GP time reduces, as the frequent attenders find new people to connect with. We also see that A&E attendance often falls in areas where social prescribing schemes have been introduced. Furthermore, healthcare professionals say they like to have more appropriate routes to refer patients to. We have seen many reports where social isolation, for example, is reduced, people are empowered, some people start to volunteer their time, those who felt forgotten find a way to live the life that they want to live. In some cases, people get back into work or set up their own enterprises. We are still analysing the full range of benefits and outcomes, however these benefits match what is needed in our society now to address those societal ills. Furthermore, most if not all the benefits we are identifying have some financial value, hence the potential for saving money and bringing about a ‘slimmer, fitter and more patient-focused NHS’.
This is the beginning of a transformation of the healthcare system. Social prescribing is not the panacea for all ills, but it will make a sizeable contribution to reshaping the healthcare system. We have a unique opportunity right now, and in the Social Prescribing Network we are working hard to link people, share the knowledge and research, provide evidence and influence the ‘great and good’. It is our hope that by bringing many voices together, and by creating the spaces for us to listen to each other, a shared understanding will be revealed and great change will occur. We are an ever-growing number of people and I hope that social prescribing will be seen in future years as a true Movement of the People.
- Citizen Advice Bureau (2015) A very general practice: How much time do GPs spend on issues other than health? Online. Available at: www.citizensadvice.org.uk/Global/CitizensAdvice/Public%20services%20 publications/CitizensAdvice_AVeryGeneralPractice_May2015.pdf (accessed 21 October 2016).
- Department of Health (2012) The Health and Social Care Act. Available at: www.legislation.gov.uk/ukpga/2012/7/pdfs/ukpga_ 20120007_en.pdf (accessed 20 October 2016).
- House W (2013). Sealed with a prayer. Is the NHS up for sale? JHH 10 (1) pp44.
- NHS England (2016) General practice forward view. Available at www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf (accessed 20 October 2016).
- NHS England (2014) Five year forward view. Available at: www.england.nhs.uk/wpcontent/uploads/2014/10/5yfv-web.pdf (accessed 20 May 2016).
- The Social Prescribing Network (2016) Report of the Annual Social Prescribing Network Conference. Online. Available at: www.westminster.ac.uk/patient-outcomes-in-health-research-group/ projects/social-prescribing-network (accessed 17 October 2016).
- Vos T et al (2016) Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 338 pp 1545–602.