Social prescription: A trojan horse for a health creating community?

Source: NHE Nov/Dec 16

Dr Michael Dixon, social prescribing lead at NHS England, discusses the opportunities and challenges facing social prescribing.

Social prescription is an idea whose time has finally come. It was virtually unspoken of a year or two ago, and is now poised to become national policy and part of the furniture of every GP consultation within the next few years.  

The idea is elegant and simple. The prescriber will meet with the person to understand their hopes, needs, challenges and obstructions. They then choose from a menu of non-biomedical interventions which range from voluntary services, to local authorities and the private sector to offer them an effective intervention. These non-biomedical interventions ultimately reduce the load on the health service. For example, patients who see their GP for social problems like benefits or housing advice, occupation experience or befriending may need social rather than medical intervention. 

Less intuitively, social prescription can vastly reduce the use of health service resources in patients with long-term conditions who use it most. It can motivate patients to care for themselves better and thus need interventional care less. 

The move towards social prescription is rapidly developing in every part of the country. From the original seeds of development in Newcastle, Burnley, Bromley by Bow and Devon there are now eight CCGs that offer universal access to social prescription for GPs and patients, and 49% offering some support. Our national network of those leading social prescription increased from 100 to 500 between January and September. 

National commitment 

Social prescription is also mentioned both in the FYFV and the GP Forward View. It has even become one of NHS England’s 10 high-impact changes for general practice, and the national steering group established early this year is now being asked by NHS England to lead its development and roll-out. In my personal life, I have seen a change from colleagues calling me ‘the vicar’, whose work had dubious relevance to real general practice to becoming the national clinical champion for social prescription, NHS England. 

This concept is a beast that can no longer be put back in its box. It is not part of some transitory government policy or initiative, nor is it part of a cunning plan to do the NHS on the cheap. It’s something that has been developed by frontline clinicians and their patients all over the UK, who are recognising the limitations of our current health service model and want to do something that makes a meaningful change to the lives of our patients and the health of our communities. 

It represents a reduction in oppressive workload and a change in job description for GPs, a new hope for patients, who really want jobs, social support and meaning rather than antidepressants. It represents a Trojan horse for developing community resources and capital – the holy grail of a health-creating community rather than, as present, communities that make us ill. 

ThinkstockPhotos-85447332 edit

Challenges to social prescription 

Two things stand in the way of social prescription. The first is a cry for ‘more evidence of effectiveness’. There is evidence in Rotherham CCG and more recently Gloucestershire CCG – both of whom have embraced social prescribing for all patients and are showing real savings for the NHS. To others it is ‘just plain common sense’. If the NHS wants to wait for definitive double blind placebo-controlled evidence, then this can only be a means of delay and a hypocritical one at that, because the NHS has never really proceeded along these lines anyway, when it didn’t want to. 

Research is important, but mostly to find out what aspects of social prescription work best rather than whether it is itself a viable concept. The other problem concerns risk and, with the NHS owing half its annual income in litigation, this is understandable. Nevertheless, if we are going to hand health and healthcare to patients and communities and involve a vibrant volunteer and voluntary sector, then we will need to get our act together in terms of trusting non-professionals and non-clinicians to help co-produce a financially sustainable NHS.  

The progress of social prescription should be seen as a litmus test of whether the FYFV is rhetoric or reality. It will test patients, clinicians and policymakers alike and challenge the vested interests of a visibly ineffective status quo. It could represent the last open battle between the peasants and patients of the frontline of the NHS and the barons of professional and organisational self-interest. New hope versus stick in the mud.  Where do you belong?

Tell us what you think – have your say below or email [email protected]


Dr Pete Sudbury   13/01/2017 at 08:11

This is absolutely right. The social and behavioural determinants of health are far more powerful than any medical ones. The most powerful interventions are almost always public health ones. When we know that walking briskly for 10 minutes a day reduces your chance of dying by 20%, but sitting still for 11 hours a day increases it by about the same amount, we need to be intervening positively to change the way people live. The combination of right amount of exercise, the right diet, are as powerful as stopping smoking in the prevention of disease. We need to do that not only on an individual basis, but societally. One of Kaiser's mottos is "make it easy to do the right thing": streets need to be easy to walk in, and healthy food easy and cheap to find. That's going to be controversial, with a government that removed all reference to junk food from the public health strategy, presumably after intense lobbying from the sugar, salt and saturated fats lobby. The fear of practitioners will be that it extends the role of "healthcare" way beyond what we conventionally think of as "medicine". In reality, we have spent decades medicalising behavioural and social problems, (mass prescription of statins being a great example), and we should see social prescription and a way of addressing the cause rather than just the symptom.

Mona Sood   06/02/2017 at 13:10

Social prescribing is a no-brainer: apart from its intrinsic value it can challenge the patient perception that there is a pill for every ill, and encourages people to take control of their own health. There is however a question about sustainability of the intervention if there is not extended open-access to a service once referred, and this is where the inverse care law rears its ugly head once more (gym schemes that come to an abrupt end after a given number of sessions, for example). NICE has issued guidance on individual behaviour change (the reviewed version is expected in August) so we know how to build quality into a system. A national commissioned suite of interventions from PHE would be manna from heaven. Perhaps extend the DPP to all, eventually?

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