And it’s easy to see why it’s a popular response to the challenges faced by general practice. General practice has traditionally been rooted in local communities and GPs are trained to work holistically, which lends itself to taking an ‘asset-based’ approach to improving patient’s lives, building on personal, social community and neighbourhood assets to improve health rather than relying just on medical interventions. Research from the Citizen’s Advice and the Royal College of General Practitioners found that GPs in England reported spending almost a fifth of their time on social issues that are not principally about health. For overstretched GPs additional, non-medical referral options to help improve patients’ wellbeing could seem like a no-brainer.
But how it’s implemented is key and a few concerns have emerged for me.
First, you can only prescribe something that actually exists. Recent work, including from The King’s Fund, suggests that deep cuts to local authority funding and sometimes unhelpful clinical commissioning group (CCG) approaches to commissioning and contracting are harming the very organisations that provide the services that might be prescribed. Many are so small that they can’t absorb uncertainty or variation in their funding, particularly where that funding isn’t enough to cover their overheads or pay their staff. Many of the areas pioneering social prescribing seem to me to be those where commissioners see their role not just to stimulate a market of providers, but to create a strong voluntary sector in their area, investing time and energy in co-producing services with the local community. If social prescribing is going to work, I think leaders of commissioning organisations (and in the future, integrated care systems) need to be serious about their role in supporting a vibrant voluntary and community sector, over and above investing in specific services. It’s not a simple task and requires time, energy, attention and commitment from the top of the organisation. Public health departments in local authorities will be a key ally in this and strengthening the links between general practice and public health which were fractured during the Health and Social Care Act 2012 changes is an important challenge.
Second, I think what sets social prescribing in general practice apart is not just providing a link mechanism but providing access to skilled individuals working in a practice who understand the local community and can build relationships with patients, helping them to the best use of all the potential assets available to them. These link workers, who often come from the voluntary and community sector rather than statutory services, are critical but will also need to be supported – as with all new roles they can’t just be ‘parachuted’ into a GP practice without induction, support and ongoing investment in team building. ‘How’ social prescribing is implemented will be as important as having it in the first place.
And a final question – in my journeys around the UK talking to GPs, I have heard that one of the reasons they need access to social prescribing is because cuts to other services that might have done that linking means the GP practice is the only accessible resource left to help people with wider problems. Should we be addressing that issue too?
Social prescribing clearly has great potential but as Rob Webster said last year at The King’s Fund: ‘Social prescribing on its own won’t solve anything. It has got to be part of a bigger system, which connects the community and the assets to the services and support. And that service and support is bigger than just social prescribing.’
I agree with him.
Comments
Thank you Beccy for these valuable considerations. And to add and move a little further, many would suggest that social prescribing needs to be seen as part of a move towards a 'social model of health', which will require multitude of changes, not least in the training and understanding of clinicians, also the supporting of co-produced approaches to developing 'health creating communities'. For example, whilst General Practice has many merits, for example it serves a community, and has longevity of relationship with its patients, it also has many limitations, not least its focus on illness, rather than on health and wellbeing creation. Which in turn requires a focus on the social determinants of health, which studies suggest are responsible for up to 90% of health outcomes. It also requires General Practice to also work with communities, (rather than solely with individual patients), and to work with a range of organisations that are also supporting health creation within the communities they serve, such a faith organisation, children's centres, housing providers, schools etc, An example that has sought to address this is the Bromley by Bow model, which integrates three General Practice health centres, (120 staff and approx 30,000 registered patients) and a community owned and manged organisation with 150 staff and volunteers delivering community provision to approximately 10,000 people each year. Such provision includes, community outreach and engagement, welfare and legal advice, financial capability, adults skills, employability programmes, a significant arts programme, social care, carers groups, community and outreach health and wellbeing programmes, nutrition and exercise programmes, a social enterprise incubation programme etc. At Bromley by Bow these are brought together in a beautiful in a three acre community managed park. The buildings and their courtyards interlinked by flowing paths, courtyards, complete with ponds, fountains and sculptures, Bromley by Bow forms part of local people's lives, (no appointment necessary!), with regular community festivities and celebrations, a children's playground, homework club, food growing and gardening groups, a social enterprise cafe, internet cafe, arts studios and rooms for community members to run their own activities, We believe that bringing all this together, with general practice, in one community owned and managed venue makes so much more sense than building health centres which are primarily focused on illness rather than working with the community to create health and wellbeing. For more information, please see our discussion paper Stop Building Health Centres https://www.bbbc.org.uk/insights/policy-and-practice-papers/
depends what you mean by 'social prescribing'. The parliamentary all-party report on The Arts and well-being' advocated 'the arts' becoming integrated into the NHS. Where it's happened, the result
has been fewer GP visits and hospital admissions. People's mental well-being has improved.
The 'arts' covers everything under that heading.
I organise a [small] art group for Mental Health carers. It provides 2 hours a week respite from the responsibilities of caring. Those who attend find it invaluable in maintaining their own sanity.
Our pictures will soon be on the walls of the local out-patients clinic.
Funding is a problem: we've had a grant of £100 through our Labour County Councillor from a County scheme. It has to be spent within three months.
We need the NHS to actively promote groups such as ours: Carers are the neglected support for the professional services. The cost is minimal compared to the rewards.
If that what was being proposed you would be right Varsha but my experiences and view is that it is not, to me social prescribing is rooted in locality and connects to a locality infrastructure which can directly provide support, not as you indicated (I think) be bounced around a diverse, often unconnected (however well meaning) efforts across community and voluntary sectors (which on their own are also very different sectors, certainly here in the North of Ireland), the role of the social prescriber as I see it is to provide that connectivity across providers but also crucially put the person who needs/ requires support at the centre of the decision and to navigate on that persons behalf to get the timely and relevant. I also believe that both the community and voluntary sectors are willing to look beyond the numbers game but quite often feel pressured by commissioners et al. to justify in the short term i.e. numbers participating rather than quality interventions, which ironically are also cost effective in the longer term but most interventions are judged on short term, usually financially driven timelines. The opportunity for commissioners is that they can, if they are freed from financial shackles, invest in a longer term process in developing sustainable communities, helping to build capacity for people to do it for themselves rather on costly health service interventions at a later stage.
A vibrant Voluntary and Community sector is also diverse and by just wanting to be commissioners and counting activity rather than value of the work. With the way social prescribing is approached by commissioners is to create infrastructure organisations who are middle persons who then sign post, sometimes the sign posting again sign posts. What is the value in this way of working?
At last, real commentary from someone who both understands the potential benefit of social prescribing ( tbh it's not rocket science, good vcs have always built on strengths), the need to invest in the community and support the vcs. It needs empowered commissioners taking a long view ( more than 12 months!!!) . This message needs to be heard.
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