Social prescribing: is the good life all it seems?
Health Secretary Matt Hancock thinks social prescribing is the free answer to ‘popping pills.’ It’s written into NHS strategy and people seem to love it. But what is it, and is it a bit more complicated than it seems?
The following is the text of a talk delivered by Mark Brown to medical students at University College London as part of the National Social Prescribing Student Champion programme on March 7th 2019
Social prescribing is certainly picking up interest, despite being a far from new idea. According to the Kings Fund: “Social prescribing, sometimes referred to as community referral, is a means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services. Social prescribing and similar approaches have been used in the NHS for many years, with several schemes dating back to the 1990s, and some even earlier (the Bromley by Bow Centre was established in 1984). However, interest in the model has expanded in the past decade or so. More than 100 schemes are currently running in the UK, more than 25 of which are in London.”
I’m not here to talk to you tonight about how lovely social prescribing is. I’m here to help you to explore some ideas around social prescribing, what it does and what it means. I’m a very nuts and bolts kind of person, despite loving ideas. What’s most important for me are the questions ‘What does social prescribing actually mean? How does social prescribing work in practice? What problem does social prescribing solve?’ and ‘if you were going to design a social prescribing service, what might be the important things to think about?’
The broad idea of social prescribing is decades old now, so the first question we must address is ‘why now? Why is social prescribing in the spotlight?”
‘Initiativeitis’
One of the hallmarks of minority government is what you might call ‘initiativeitis’. Lacking the Parliamentary power to make huge changes to law and to spending; minority governments still need to show that they are making things happen. So they begin initiatives. Social prescribing, the topic of this talk, is one such initiative. The current government is embroiled in brexit after losing a majority in Parliament and is enduring an ever increasing level of turbulence at cabinet level. On July 9th 2018 Matt Hancock MP was appointed Secretary of State for Health and Social Care, replacing Jeremy Hunt, the longest serving health secretary in the history of the NHS who had clocked up nearly six years overseeing one of the most tempestuous periods our NHS has ever seen.
Hancock, famous for once creating an app called ‘Matt Hancock’ in his previous role as Minister of State for Digital, has two things he is really into. One is digital as part of the NHS, the other, surprisingly is social prescribing.
On 23rd July, less than a month into Hancocks’ reign and needing something new to announce, the government announced it would be committing 4.5 million pounds through the The Health and Wellbeing Fund, a part of the voluntary, community and social enterprise (VCSE) Health and Wellbeing Programme to fund 23 social prescribing projects across England, each of the projects receiving “a share of the funding to extend existing social prescribing schemes or establish new ones.”
A diverse range of projects were funded, which were described by the government as referring “patients to local voluntary and community services such as walking clubs, gardening or arts activities. The practice, known as ‘social prescribing’, aims to improve patients’ quality of life, health and wellbeing by recognising that health is affected by a range of social, economic and environmental factors.”
Speaking at his first ever NHS Expo in Manchester on September 5th 2018, Hancock waxed lyrical about social prescribing, saying to the assembled room of NHS bigwigs, journalists and policy and management bods:
“There is a growing evidence base that social prescribing can be better for patients than medicine,” he said. “Of course there will also be medicine prescribed — and rightly so — but I want to see the balance shifted in favour of social prescribing. The nature of social prescribing is that what you’re prescribing is a social activity, so of course, anybody can suggest to somebody that they do a social activity. My wife regularly tells me to do more exercise. But what I really care about is ensuring that within the NHS it is normal practice to consider a formal social prescription and that the growing evidence base for the value of social prescribing is taken on board by practitioners.”
He warmed to his topic later in the year speaking to the health charity The Kings Fund’s annual conference at length about social prescribing. Speaking to a very similar crowd he said:
“I see social prescribing as fundamental to prevention. And I see prevention as fundamental to the future of the NHS. For too long we’ve been fostering a culture that’s popping pills and Prozac, when what we should be doing is more prevention and perspiration. Social prescribing can help us combat over-medicalising people. Of dishing out drugs when it isn’t what’s best for the patient. And it won’t solve their problem.
“Social prescribing is a tool that doctors can use to help them, help patients and help the NHS cut waste. It’s the Goldilocks approach to medication: the right amount at the right time. No more, no less.
“We will create a National Academy for Social Prescribing to be the champion of, build the research base, and set out the benefits of social prescribing across the board, from the arts to physical exercise, to nutritional advice and community classes. A resource which GPs and other frontline health workers can draw on for guidance and expertise. Where they can learn what works, and what’s available in their communities.
“Because social prescription reduces over subscription of drugs. It can lead to the same or better outcomes for patients without popping pills. And it saves the NHS money, because many of these social cures are cheaper or free.
“Now, drug companies may not like that. And you can bet this multi-billion pound industry will use every tool at their disposal to lobby for the status quo and convince us drugs are better than free social cures. That’s why we need a National Academy for Social Prescribing.”
Matt Hancock’s free cures
So there we have it, there’s our narrative from the top man, right there. Picking out the keywords set out on a public platform we hear ‘popping pills’. ‘Free cure’. ‘Prevention’. ‘Reducing over prescription’. ‘Cut waste’ ‘Prozac’. ‘Drug companies’. Playing to the gallery, Matt Hancock paints a picture of a health system that does too much medicine, dishes out antidepressants, wastes money and can’t see the free social cures under its nose. Social prescribing, in Matt Hancock’s framing of it, is the better, healthier alternative to medical treatment. If the community can make people healthier and happier, then the NHS will have less work to do.
Hancock’s enthusiastic endorsement of social prescribing there tilts towards one big concern for the NHS: prevention. If we can stop people becoming unwell, or reduce the effect that being unwell has on their wellbeing, then we can reduce the overall disease burden to the NHS and thus reduce the spending of the NHS which, as Hancock must know, is experiencing greater financial pressures than it has for a generation.
His, unhelpful in my opinion, references to ‘popping pills’ and ‘prozac’ speak to another area of concern for the NHS: the growing amount of unmet mental health need. Therefore social prescribing is a way of putting people together with things that make them happier. This is a kind of hazy way of also thinking out social prescribing as something that might extend healthcare into directly addressing social determinants of health by providing or supporting access to non-medical services that act upon issues such as poverty, poor environment, housing, employment, learning and other areas where exclusion or lack of access or entitlement affects a person’s health.
Less referenced by the enthusiastic Hancock but also a strong theme around social prescribing is the growing number of people in England who live with one or more chronic conditions. The NHS and our social security system in the UK, the fruits of the foundation of our post-war Welfare State, have been amazingly successful at making sure that more of us do not die young than ever before. More of us live longer sharing our lives with chronic conditions and disabilities than ever before. Our ageing population is evidence that we’re better at helping people not die of things that might otherwise have killed them. Far from being something we should see as a problem, we should be high-fiving ourselves daily. Nevertheless, the reality of living with a chronic condition is that you live with it, day-in, day-out.
There is an increasing realisation that the NHS is not necessarily set-up or even particularly good at providing things that help people to live well. Social care, which might at one point have been the NHS’s partner in this has been reeling from decades of under investment only accelerated by a rain of blows from cuts to local authority funding since 2010. So, if social prescribing might help people to live better lives by putting them in touch with activities or opportunities that contribute positively to their overall health, then it may help meet unmet needs presented by people who have illnesses and conditions that do not go away.
Why does social prescribing feel right?
The first thing to say is that I don’t think that anyone is being scammed or robbed or cheated by social prescribing. The idea of a mechanism to put people in touch with things that exist in their community that they might like, enjoy or which might help them with challenges that they might face is lovely. Similarly, the existence of a way that voluntary, community or non-statutory sector organisations might reach out further to people they really wish to make a difference for is great, too.
There is a way in which social prescribing occupies the same space previously occupied by the Big Society, David Cameron’s ill-fated attempt to get local people to provide what had once been provided by public services. But, unlike the Big Society, social prescribing doesn’t set the same alarm bells ringing for people. Why? I think there’s few reasons.
The first reason social prescribing doesn’t put people’s backs up is that social prescribing feels additive; it feel like it is adding something significant to the rage of options that someone might have to meet their wellbeing and health needs. Social prescribing doesn’t feel like it’s taking anything away from anyone; even if Matt Hancock refers to social prescribed opportunities as being ‘free’; which will be news to the community and voluntary sector organisations that provide them. Social prescribing rests on the idea that there is magic out there somewhere in the those boroughs and parishes and suburbs and towns and cities that is just waiting to be put to the right purpose. Even if the argument is in essence that the NHS can use social prescribing save money, we feel different somehow about that proposition than the idea of other services saving money. Perhaps we have been so conditioned to feel that the NHS is on a perpetual knife-edge that we are open to new ideas, as long as they don’t look like cuts.
The second reason is that we really do value our community assets and organisations. I’m development director of a small social enterprise. We do loads of stuff, including publishing three community newspapers in Tottenham, Waltham Forest and Enfield. I’ve spent the majority of my adult working life working around social enterprises, community business, charities and community groups. They’re an incredibly important element of the social fabric of our communities, and arguably have become more so as austerity policies have reduced the level of public spending. It feels nice to be recognising the role that these organisations play in people’s health and wellbeing.
The third reason that social prescribing seems such an attractive idea is that it taps very strongly into our collective sense of what a ‘good life’ looks like, emphasising social and cultural activities as the route to a more healthy mind and body. It’s no mistake that socially prescribed activities that politicians like to talk about are very healthy and wholesome, like gardening or sport or choral singing. There is a kind of embedded moral rightness in social prescribing that speaks to our idea of clean-limbed, cooperative, brightly-lit sunshiney wellbeing. It very much speaks to the same instinct that big hits like Johann Hari’s book on depression ‘Lost Connections’ speak to: the sense that something about modern life has separated us from essentials about ourselves, leaving us isolated and anxious and out of touch with each other and the essential pleasures and requirements for a happy life. Social prescribing as it is often sold is about wellbeing, but as we’ll see in a bit, it doesn’t have to be.
The forth bit that makes social prescribing feel less contentious is the ‘social’ bit. When I’ve been working on stuff around social prescribing, I’ve often said there are two red herrings in the discussion about social prescribing. The first is the word ‘prescribing’. The second is the word ‘social’. We are commonly understood to be living in a period of increasing loneliness and social isolation in the UK, so it follows that any intervention such as social prescribing which might put people in touch with others must be a good thing. People who are generally spoken about as being the target of social prescribing are people who are are often excluded from wider communities activities, so the logic goes that making them part of those community activities will end their exclusion.
How does social prescribing work? The refer, prescribe, enjoy model
At this point it’s probably useful to talk some nuts and bolts. We’ve got what social prescribing is intended to do, but how does it do it? Often when we talk about social prescribing we end up talking about the opportunities prescribed, but really that is just describing community based projects or opportunities. What makes social prescribing special is the actual idea of prescription. And this is where things get a bit murky, because there is real consensus for what social prescribing actually is in practice. There is an evidence base that describes what people have done and called social prescribing, or which researchers or evaluators have named as such, but no real evidence base for what works best and which can predict outcomes arising from decisions made in the design of social prescribing schemes or programmes.
Very roughly, any social prescribing model has three basic working parts:
The first part is a mechanism of referral. People need to get to the actual social prescribing itself. Often this is situated with GPs in primary care who are ‘prescribing’ the social prescribing by referring a patient to a third party, but this is not the only way of doing this. Some social prescribing schemes are self-referral. Others accept referral from a range of sources.
The second part of the mechanism is the social prescribing contact itself. This is where someone is helped by someone, often called a link worker in a nod back to previous iterations of social prescribing, to find suitable opportunities in their local community to meet needs that either they, or their referrer have expressed. Again, there is no one model for this. Some social prescribing programmes focus entirely on this stage with motivational coaching and ongoing contact. Others do it over the phone, in a short meetings or even online. The working part of this is the matching of people to opportunities.
The third working part is the range of available opportunities to which people can be referred. If there is nothing in your area that meets people’s needs, your social prescribing won’t be very effective.
This very simple social prescribing model presumes a number of things. Firstly, it assumes that no money is changing hands between initial prescriber and eventually prescribed opportunity. Someone, say a GP, sends someone to see a social prescribing worker or organisation who are being independently funded, who then refer the person they have seen to one or more community opportunities that are themselves independently funded.
Secondly, it assumes that there is a degree of informality to this process and that evaluation of the outcome, if there is any, will be on the basis of measures of subjective progress or wellbeing of the individual whose has been referred. Basically, the referral will be successful if the person referred actual takes up the offer and likes it.
Thirdly this simple model assumes that the job of social prescribing is to match demand to supply, by fitting people referred to what is available in their locality. This is of course assumes that there are things available in that locality to refer to and that the needs of people people referred are general enough to fit with in them.
You could call this a ‘refer, prescribe, enjoy’ model. It sounds great, especially if you aren’t too worried about where money comes from and how people’s health actually works. Having spent some time interviewing and studying social prescribing models, there are a number of equally important elements required if social prescribing is intended to achieve more than sending people to do nice stuff. Which, don’t get me wrong, is a great thing to be doing, but it might not really deliver either the outcomes or the evidence base required if social prescribing is intended to be an integral part of provision.
Social prescribing might be a bit more complicated: Pauline
Social prescribing exists in the real world where people have real problems. Health is complicated. The voluntary sector is complicated. Local health economies are complicated. Primary care is complicated. Funding is complicated. If we focus for a moment on a hypothetical person in a hypothetical place, you’ll see what I mean.
While we might picture social prescribing as a kind of dating agency for health and wellbeing opportunities, the realities are a bit different. Let’s focus on a potential social prescribee.
Pauline is in her fifties. She’s caring for her wife who has health difficulties. She’s also looking after at least two older parents. Her and her wife don’t have kids. Pauline has health difficulties herself. She has severe arthritis. She has long term anxiety and depression. She has type 2 diabetes and is also obese. She’s had to leave work in the social services department of her local council which she loved to care for her wife. They’re just about scraping by in their flat which they rent from a private landlord. The flat is cold and damp but it’s home. Pauline and her wife don’t live in a big city. They live in a small ex-mining town in the north east. There’s not much going on in the community at the minute. A lot of local charities have had to stop providing much as local authority funds were their main source of income and they’ve dried up over the last decade. She’s unlucky enough to live in an area with a low tax base, meaning the council is desperately trying to balance the books. The library is gone. The high street is mainly charity shops. The area has attracted some funds, but a lot of them are focused on supporting either younger people or older people. Pauline is just about coping, but it’s a close run thing. She might be making her first ever trip to the foodbank soon. Pauline makes a lot of visits to her GP, but there’s very little her GP can do beyond what her GP is doing already. There’s a social prescribing service available, but Pauline’s GP wonders: What could social prescribing do for Pauline?
The answer is: that would depend on how social prescribing was developed, with what purpose and who was paying.
‘Free cures’ aren’t always actually free
When Matt Hancock was speaking about ‘social cures’ being free he was being a little bit disingenuous. If social cures are already being sustained by funds from somewhere else, yes they’re free to the NHS but they aren’t free. A park might be free to visit, but an organised fitness walk will take people’s time and potentially money to organise. A gardening project requires someone to organise it. An advice drop in for people with diabetes requires people to be providing the advice, a venue for it to take place in, other people attending to make it more social. While a simple social prescribing model can link people very well to stuff that already exists, it’s not so useful if the things that are needed aren’t there to be referred to. After all, when a health care professional prescribes you a medication, your pharmacist doesn’t fill your script out of their own pocket. The cost of your prescription comes from somewhere.
One of the elements of social prescribing that might be important is using social prescribing as a mechanism to stimulate the local health economy. Social goods are not evenly spread through our towns and cities. We know that there is a correlation between poor ongoing health and the poor overall social fabric of where we live.
To use social prescribing as a means of stimulating the local health economy requires money to change hands in the form of funding, contracts or other fees between either referrer, like Pauline’s GP, or social prescribing organisation and various bodies or organisations in the community to make something particular happen that hasn’t been happening before. In places where there is little to refer people to that fits their needs, it makes sense that, instead of fitting demand to supply, to work the other way and fit supply to demand.
It’s easy to assume that local organisations and community groups will always be over the moon to be referred a new person with whom to share their opportunity. This assumes two things: capacity and flexibility. I’ve heard of social prescribing projects that have referred people to opportunities without having a relationship with the opportunity in question, which built up a lot of bad blood. A small social knitting group might work because it’s small and voluntary. Without really knowing the group, a social prescribing organisation might prescribe the group to people with greater support needs than the group can meet. It isn’t that the people in the group are being selfish or uncharitable; it’s just that their opportunity isn’t right for the people to whom it’s being prescribed. A poorly chosen prescription might make our Pauline’s anxiety worse, not better. For social prescribing to be able to meet the needs of people with more complex health needs it will require a much stronger relationship, potentially involving funding, between social prescribers and the opportunities they prescribe. These kinds of relationships and strategic thinking and planning take time, trust and often a bit of money to secure.
The Rotherham Social Prescribing model did just that with local partners and local voluntary sector organisations working together to meet the needs of the five percent of patients in primary care most at risk of deteriorating health. Because this model knew the kinds of people which might be referred to it, the local voluntary sector could use public funds to create the kinds of services and opportunities that would really help people while at the same time also being able to also refer to other opportunities. The important thing in this model is that the five percent of people get things that really make a difference for them in ways that can be measured, managed and planned for.
Knowing who you might be referring is also important because it suggests a strong guidance on referral. In one of the large social prescribing projects I spoke with, they found that the majority of their social prescribing referrals came from a couple of GPs within a couple of practices. These were GPs who were already interested and excited in community based provision and reducing health inequalities. The GPs that weren’t that interested, or thought that money was being wasted on social prescribing that could be better spent elsewhere, didn’t refer people. In this circumstance, a firm set of referral criteria and an agreed protocol would be necessary to guarantee referrals. And for that to be agreed would require the social prescribing mechanism as a whole to be able to show that it really did have an effect on the lives of the people who passed through it. ‘Nice to have’ won’t cut it if integration is what is required.
Social prescribing is sometimes argued for on the basis that GPs do not have the time to ‘know what’s happening in their community’ and it is assumed that social prescribing will make things easier for them. There is certainly a strong argument for this, but to argue that GPs ‘aren’t bothered’ about their patients and are just ‘dishing out drugs’ as Matt Hancock suggests is doing a disservice to General Practitioners. GPs in areas with high levels of deprivation and inequality see and deal with the realities of people’s lives every day. They must have confidence in social prescribing to be able to make referrals because, unlike many other forms of health professional, they will see their patients again and will have to pick up the pieces of any ways that social prescribing hasn’t helped people. GPs know about the social determinants of health and they know that gardening won’t cure COPD and that choral singing won’t send type 1 diabetes into remission. They don’t need to be sold the idea of social prescribing; they need to be sold the practical results. They need to know when a referral will help their patient and how.
So, in a practical sense, social prescribing in areas with weak health economies and high health demands needs to be more strategic, more long-term and need to be based on planning, relationships and clear referral pathways and clear assessment of outcomes. None of these things is easy, and none of these things is best done as something that isn’t somehow paid for and managed. This takes social prescribing away from being a simple ‘refer, prescribe, enjoy’ model and into something far more complex.
Of the 23 social prescribing projects funded through The Health and Wellbeing Fund which I mentioned earlier, the majority are looking to build the social prescribing infrastructure to meet the needs of identified groups of people in particular areas. Few are close to Matt Hancock’s vision of ‘free social cures’.
Social prescribing feels like it makes sense: that’s why you should ask questions
On 29th January, in the wake of The NHS Long Term Plan, NHS England announced targets for social prescribing link workers as part of another re-oganisation of Primary Care. It said: “The NHS long-term plan will see GPs surgeries big and small work to support each other in around 1,400 primary care networks covering the country, with each network having access to a social prescriber link worker and NHS England agreeing to fund their salaries in full. ‘By 2023–24, social prescribers will be handling around 900,000 patient appointments a year. NHS England plans to recruit 1,000 social prescribing link workers.”
My advice to anyone who listens to discussion of social prescribing and thinks ‘yes, but’ is to follow their instinct and ask the questions that occur to them. Rotherham is the model I think tells us most about social prescribing in the real world. Ask your questions, because they will be good ones. As the Kings Fund say: “robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative, and relies on self-reported outcomes. Researchers have also highlighted the challenges of measuring the outcomes of complex interventions, or making meaningful comparisons between very different schemes. Determining the cost, resource implications and cost effectiveness of social prescribing is particularly difficult.”
To make social prescribing really work will require going beyond its status as a lovely idea that leaves a lot of energy in the room to getting down to the grimy, challenging and rewarding works of hammering out real world deals and real world relationships. People who have health needs are not fools who don’t know what’s good for them. They’re people living with needs and problems not of their making. Social prescribing must be about what people need, not just saving the NHS money.
In many ways, social prescribing is enjoying its current vogue because it is such an amorphous good idea that is very difficult to disagree with in principle. Social prescribing will survive the current bout of ‘initiativeitis’. It’s a great idea; but it’s also a great idea that has been written into successive five year plans and forward views. There are currently lots of people across the country trying to put flesh on the bones of this lovely idea to make it happen in a way that makes a real difference for people like our fictional Pauline. There were people trying to make social prescribing work before this current day in the sunlight as there will be clever, passionate and committed people trying to make it work after the current excitable Health Secretary is upgraded to a less excitable model.
People do need more than pills, but enthusiasm alone won’t get them it.
@markoneinfour
