The NHS has pledged to create ‘an army’ of 1,000 social prescribers in a bid to help patients lead fitter, healthier lives and combat increasingly common physical and mental health conditions. Peter Blackburn asks what it might achieve
Sam Everington (pictured below) may work in one of the UK’s poorest areas, but it’s creativity and hope, rather than deprivation, that have made his practice famous.
The Bromley-by-Bow centre in east London (pictured below) has become one of the driving forces for social prescribing, and with it, the idea of treating patients ‘holistically’ – the philosophy that greater emphasis on preventive interventions can dramatically improve the health and wellbeing of the public and save money.
The approach, which Sir Sam and his colleagues have followed for more than 20 years, may at last be about to become more mainstream.
Earlier this year, the BMA GPs committee and NHS England announced plans to fund social prescribing link workers for PCNs (primary care networks) in England, in a bid to help patients find effective alternatives to traditional medicine. It came as part of the English GP contract agreement, which included £2.8bn more funding for primary care by 2023/24.
‘The traditional consultation might be a prescription, a leaflet or a referral to a specialist but there’s a fourth dimension – social prescribing’
In east London, the need for concerted action could hardly be more acute. The borough of Tower Hamlets has some of the widest health inequalities in the country, with the affluence of Canary Wharf and areas where, anecdotally, 55-year-olds have the kind of health expected of someone 20 years older.
In Bromley-by-Bow, there is a scheme that allows GPs to refer patients to a social prescribing link worker who can then get in touch with any of around 1,500 local community organisations, seeking to address the wider determinants of health problems, such as diabetes or anxiety, with supported access to community groups running all sorts of activities and schemes – from singing classes, cookery schools or fishing to debt management, benefits advice or housing help.
It builds on the solid body of evidence, amassed by Professor Sir Michael Marmot and others, that so many of the wider determinants of health, such as poverty, housing and early-years education, are outside the traditional scope of the NHS.
While no GP practice can solve these problems by itself, what it can do is connect patients with relevant services and healthy activities.
‘It has the potential to reduce GP workload by supporting patients and, where appropriate, linking them to other services in the community’
Sir Sam says: ‘We recognise that GPs are under a lot of pressure in a 10-minute consultation – there’s a referral form in the system which takes 20 or 30 seconds to complete, with tick boxes around weight, unemployment, debt issues or repeat attender, for example. The traditional consultation might be a prescription, a leaflet or a referral to a specialist but there’s a fourth dimension, which is social prescribing.
‘The evidence is very clear that actually it is quite often much more powerful than the drugs and the traditional things we do. It’s providing a much better and more holistic health offering. At your fingertips is a much bigger team – it’s the team that creates quality and safety whether in hospital or in general practice – you can be the most brilliant clinician, but this automatically extends your team and that’s where so often the failures in care are.’
Wellbeing on the up
The results of the work in Tower Hamlets have been remarkable.
An evaluation last year said patient wellbeing scores had improved and that every £1 invested in social prescribing locally generated an annual social return on investment of £2.30, which means returns of £864,800 per year for the health and care system in Tower Hamlets.
Local health leaders are confident they will soon have robust evidence of reduced repeat attendance and admission to hospital, too.
GP leaders are enthusiastic about the potential of social prescribing elsewhere.
BMA GPs committee chair Richard Vautrey (pictured below) says: ‘Social prescribing has the potential to reduce GP workload by supporting patients and, where appropriate, linking them to other services in the community that can offer longer-term help.
‘As a result of our contract negotiations in England we have secured funding for an expansion of social prescribing across primary care networks and this should help provide access to this service for all patients who would benefit in England.’
The work in Tower Hamlets is not the only successful existing example to follow. In Rotherham a pilot scheme was launched in 2012 and is now fully operational in the area – with every single GP having access to social prescribing in an area with a population of around 260,000.
Lonely hearts club
The project, run by charity Voluntary Action Rotherham, allows GPs or practice staff to refer patients through one of two schemes, one for people with long-term conditions and another for patients with mental health issues but who do not need acute care, to a link worker who spends time with the patient to ascertain what help would be most suitable for them.
The charity holds contracts with a number of local community groups who can help with finances, loneliness or physical activity, among a whole host of other areas.
‘It could be as simple as sending them to a fishing group or an arts and crafts class,’ chief executive Janet Wheatley (pictured below) says.
‘It’s just common sense really – it’s not replacing clinical intervention, it sits alongside a clinical intervention and provides the missing hole in integrated personalised care about what’s important to you, the patient.
‘It makes people feel they are back in control again rather than their illness being in control of them. In some instances, this is replacing things that are broken down in society, that were provided by charities or family or friends.’
The service has had more than 8,000 referrals and clinicians and local leaders are already seeing the benefits.
An independent review of Rotherham’s mental health service found that just under half of patients (48 per cent) made progress against at least one of the commonly used wellbeing measures and that the service has already created significant social value and return on investment – estimated at £724,000: a social return on investment of £1.84 for every £1 invested in the service. And that is just measuring the savings over one year, rather than the long-term effect of changing lifestyles and reducing reliance on the NHS.
Ms Wheatley says: ‘There’s been a massive improvement in their quality of life and overall feeling of wellbeing and there has been a reduction in service admission. A reduction in attendances, unplanned admissions and length of hospital stay.’
Rotherham GP Richard Cullen says social prescribing improves the lives of patients and the working lives of doctors.
‘It works really, really well,’ he says. ‘It’s a real success because social prescribers are becoming real parts of primary care – they come into our team meetings.
‘The wider determinants of health are most of the reasons why patients come to see us in primary care – a GP appointment can be their only chance of sitting and talking on a one-to-one basis with someone and these patients traditionally just often don’t get better, their needs never end.
‘The system works because I don’t have to remember much – it’s not added workload – it’s a service where the worker can meet the patient, identify their needs and tailor care for them.’
While the evidence seems to support the case for social prescription, making a success of schemes around the country will not be easy.
However, ask those who know and there’s little doubt this is an opportunity to improve patient care, save money and try to fight against the demographic change threatening to engulf the NHS. So what obstacles will need to be overcome?
‘If we get hundreds of thousands of patients being referred into the third sector it will crumble’
The most crucial thing, according to Richard Kimberley, senior research fellow in health and social sciences at the University of the West of England in Bristol, is repairing and boosting the fractured community services expected to help deliver social prescribing.
‘It’s crucial to have a third sector that is well supported,’ he says. ‘This is the anxiety I have got about the scheme in the long-term plan – it hasn’t built in any capacity to sustain the third sector. Having well-supported local services is going to be important and the PCNs need to think about where these link workers and which organisations are best suited to help.
'The key is those link workers have good knowledge and that PCNs look at their third-sector organisations and look to see who can help and advise them rather than expecting to turn it all on themselves.’
Reading GP William Bird (pictured below), who pioneered early examples of social prescribing, by taking walks with his patients, agrees.
He says: ‘If we get hundreds of thousands of patients being referred into the third sector it will crumble. Money has been repeatedly taken away and that is a problem.
‘The only way it will work is if it’s supported – in Newham [in east London, where Dr Bird is assisting with social prescribing work] patients have a smart card and as they are seen by a link worker that patient is referred to a third-sector organisation, and when they attend they touch that card on to the phone of the leader and that sends money to the organisation.
‘It might be £4.50 but it is saying the NHS is transferring money into the community. The NHS has to take the responsibility of the third sector – just as with an NHS physiotherapy clinic. They are providing healthcare, they must be recognised as doing so and they should have a contract and proper support.’
For Dr Bird, who has argued this case for years, the other risk is that the NHS stops here and is satisfied with its efforts when, actually, there is much more to do.
He says: ‘Social prescribing is a stepping stone – it’s not the answer. The numbers going through it are small in the grand scheme of things and you won’t deal with the whole population but it’s an essential move for the NHS to start using community assets and getting people to recognise the causes of all these problems.
‘The next stage has to be that social movement where the culture changes, people take responsibility.’
There may be much more work to do, but positive intent is a start. Dr Bird’s and Sir Sam’s work may have been decades in the making, but it looks like their arguments are finally being heard.
Sir Sam says: ‘It’s here to stay now and that I’m absolutely certain of. There will be problems and it won’t be perfect, and the NHS will get things wrong, but fundamentally now this is mainstream. I think it’s fantastic.’
COMMUNITY SPIRIT: A walking initiative delivered by Dr Bird’s organisation
Find out more about social prescribing
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