Changing the conversation about health

‘We have achieved so much but there is so much yet to do…’ Dr Michael Dixon addresses Westminster Health Forum social prescribing Conference

The College of Medicine’s Chair, Dr Michael Dixon, made a keynote address at the Westminster Health Forum Conference on September 17th…here, we share his address in full…

‘I am most grateful to the Westminster Health Forum for organising this third national conference on social prescribing particularly at such a difficult time. I am going to explore some of the pressing issues and challenges now facing us, the effects of Covid and then put forward some thoughts for the future. 

But first of all – where are we today?  It seems almost inconceivable that conversations between a few of us back in November 2016 have already today in 2020 led to almost universal access to social prescription.  This has to be one of the fastest moving social movements in history. 

The College of Medicine’s Chair, Dr Michael Dixon, made the keynote address at the Westminster Health Forum social prescribing Conference on September 17th, telling attendees “primary care, a sense of community and social prescription are now an essential part of the future of all of us”

That success is a factor of the pioneers and enthusiasts that have led this from the frontline and continue to support the National Social Prescribing Network and especially my co-chair Marie Polley. It is also result of the heroic work of GPs, clinicians, link workers and those working in the voluntary sector up and down the country since national roll out.

But none of this would have been possible without the remarkable support that this movement has received at all levels of the NHS from the Secretaries of State and Chief Executive downwards and especially the Personalised Care Team at NHS England especially Bev Taylor, James Sanderson and Nic Gitsham. The UK is now a world leader in this field Southern Ireland is the only other country, I believe, with a national policy on Social Prescription. We have much to be proud of.

“The consequence of this remarkable work is that today almost every Primary Care Network now has or is about to have an NHS funded link worker for social prescription and some will have more than that.   By the beginning of this summer around two thirds were covered and more recently, as you will know, there has been a recruitment drive aiming for universal coverage.”

At the same time we have seen the establishment of the National Academy of Social Prescribing with highly talented leadership , a wide remit to progress this work and substantial funding.  The National Social Prescribing Network grows ever larger in supporting the frontline and the South West AHSN have enabled us to create an Institute for Social Prescribing, which is working hard to fast forward innovation in social prescription.  All this in less than four years and much respect to everyone who has been part of it. 

Inevitably, as in every great movement, there will be bumps and challenges.  With link workers in place, one big challenge has been to expand and extend the volunteer and voluntary sector sufficiently fast and wide to meet the demands of the link workers and their clients.  This has been especially challenging during Covid, when many middle sized voluntary organisations – in particular – have faced overbearing financial challenges and sometimes closure. Two excellent reports have just recently described these challenges and their solutions –  one from National Voices and the other from The Conservation Volunteers. I know that the new Academy sees this area as one of its urgent priorities.

Staying with the voluntary sector for a moment, it has also played a crucial role in  developing the role of link workers with many Primary Care Networks using their funding to contract with a voluntary sector partner, which then provides link workers for use within that Primary Care Network and their member GP practices.  In many cases this arrangement has worked out better than the Primary Care Networks directly employing the link workers and I believe the voluntary sector in this respect now has a major role in ensuring universal coverage and the furthering the rapid development of social prescription.

Another issue that has surfaced during the summer – made more sharply visible by Covid – has been the problem of insufficient support for the link workers.  Not only moral, clinical and personal support but also practical support such as mobile phones, laptops and access to surgery computer systems, which in too many cases were absent.  This appeared to be particularly the case with some link workers employed by some individual Primary Care Networks, whose link workers have often expressed a sense of isolation.

Speaking of  Primary Care Networks, their progress has been extremely variable.  Many have met the challenges with gusto and not only totally revamped the medical offer locally but also raised their profile within their communities and taken on an extended local health role. 

St Austell in Cornwall is an example of this kind – visited by HRH The Prince of Wales a month or two ago and its work – like that of Frome in Somerset – can be seen on the Social Prescribing Institute’s website.  Nevertheless, there are also quite a few PCNs, where progress has been much slower and where a comprehensive vision of a more psychosocial and less biomedical health service does not yet exist.  This was, perhaps, an inevitable problem with the introduction of Primary Care Networks and social prescribing link workers at the same time.

Some PCNs, like my own in Mid Devon, were bringing disparate GP practices together, whose history (often encouraged by the centre) was more one of competition than collaboration. Consequently many PCNs  struggled to agree on communal objectives – initially at least – and were overloaded with all sorts of other issues with relatively scant resources..  So we mustn’t be into the blame game here or bamboozle them but we must inspire and do our best to encourage Primary Care Networks that are struggling and enable their clinical leaders to recognise the enormous benefits to the population and to the workforce, when social prescription is enabled to thrive.

Covid has revealed a number of further issues or, perhaps, I should say, opportunities.  We have seen an extraordinary response from volunteers both nationally and locally and all the goodwill that comes from this. We must work hard now to ensure that this does not disappear, when we all return to work as reasonably normal as we can.  Key to the effective use of volunteers has been the creation of facilitators, who ensure that the right people receive the right sort of voluntary support. 

In Ilfracombe, for instance, this has been mediated by local volunteer facilitators for these volunteers covering discrete areas of the town. This development has put into focus the two crucial roles that need to be connected with that of the social prescribing link worker.  These are the volunteer facilitator making maximum use of local voluntary effort and the community builder, building the volunteer and voluntary sector offers.  In some cases, all three roles are undertaken by a link worker – quite a Herculean task – in others different people are responsible for each of these three functions.  Whatever the form, success in all three functions will be crucial to the future success of social prescription. 

Another issue that has emerged since Covid – ever more starkly following the two Marmot reports – has been the whole issue of inequalities both in terms of those least well off suffering most from Covid and also from the consequences of social isolation that has been designed to prevent it.  This has raised the profile of social prescription, which of course has a prime role in tackling such inequalities. 

Covid has exposed the specific problem of digital inequalities.  Whether it be for the elderly, the less well off or rural populations, social prescription will need to play an important role in future in addressing those digital inequalities especially at a time when so much social prescription has to be digital anyway.

The other thing that Covid has taught us has been the importance of local systems of resilience and the community working together – often catalysed by the success of social prescription locally.  What we have tended to see is social prescription fast forwarded, where the community is pulling together but slightly stuck where it isn’t.  Yet increasingly, where it is working well ,we are seeing social prescription taking on a role in healing sick communities as well as sick patients.

Finally some thoughts for the future.  The worst thing that could happen to social prescription is that it becomes yet just another medical transaction and the link worker just another pair of hands.  Social prescription goes far beyond that.  It is about transformation.  Transforming what we regard as medical care, transforming what we can do for ourselves and what we can do for each other within the community and creating a healthier, happier and more connected local population. 

To achieve this transformation we will need to change things on many levels. Firstly, our education system must train our future doctors, nurses and allied professionals to see social prescription as an intrinsic part of their job and their offer. A new element in medicine itself. The NHS National Social Prescription Champion Scheme brings together Medical Students interested in social prescription. It was led initially by Bogdan, who is speaking today and supported by NHS England and is fighting nobly and successfully to achieve this. 

Secondly, it is important that all the relevant areas of government – from media and sport to transport, from DEFRA to DWP, for instance – see the relevance of social prescription in their areas and support it by providing focus and funding.  This will be a major area of work for the new Social Prescribing Academy. 

Thirdly, Robert Browning observed – “a man’s reach should extend his grasp otherwise what’s a heaven for? It is now time for Social Prescription to extend itself.  To date, it has been largely seen as something for the elderly, the long term sick and those with mental health and psychosocial issues. 

We now need to take it boldly into other areas.  Particularly to children and young people in a nation, where a quarter of 14-16 year olds are harming themselves.  We need to take it to prisons – as in Belfast – and to the homeless, where perhaps the greatest gains are to be made. We also need to take it upstream to stop the one long term disease becoming many and as an agent for improving the health and resilience of the community as a whole. In short, we now need to make social prescribing an intrinsic part of our culture and being. 

Fourthly, to do that, we will need the research and evidence that will tell us where Social Prescription is most effective and in what form . This will require a sophisticated programme  for research, which I know the Academy is developing, which adds as little as possible to link worker workloads with outcomes that are relevant to different patients, problems and interventions and which will hopefully begin to describe the extensive ripple effects within the community where Social Prescription is working well.

Fifthly, the volunteer and voluntary sector will need much support and the Academy will again be crucial in this respect. A significant challenge here will be the inequalities in voluntary and volunteer capacity in different localities and areas of the country.  Each community will need to develop models that include link worker activity, community building and facilitating volunteers.

Six , and on a somewhat more granular level, we will need to revisit what Primary Care Networks are and what they do if we are to maximise the benefits of social prescription.  As I have already said, in some cases, they are part of a revolution of primary care but  too many they are snowed under and are seen simply as a funding mechanism for traditional general practice services at scale and a means of fulfilling central requirements handed down to Primary Care Networks.  All this now needs to change. 

Primary Care Networks must be given far more headroom and encouraged to see and develop their own role .  That means that if they are to be performance managed at all then it should simply be to create a vision of what their local area might aspire to in improving the health and well-being of local people and how. A vision that can be shared with the local authority and VCSE sector. Then to be allowed to performance manage themselves against these aspirations. 

Quite apart from being allowed the headroom and autonomy to do this, they should also be provided with a funding stream for health – however symbolically – just to fully emphasise that general practice and primary care of the future has a local public health role, as part of its bottom line and not simply a fancy add on , and will be paid to undertake this – just as it is paid to provide local services.  Health funding in primary care and communities must not be isolated to the link workers otherwise the danger is that the  link workers themselves will become isolated.

Without some dramatic initiatives of this kind, we will continue to see too much “same old” and too many of my peer GPs will be restrained from meeting their aspirations for the local community with the demoralising affects that are all too visible in daily general practice today.  As PCNs develop this new role, I believe that we will see them working together within localities and able to share experiences and challenges with each other and the outside world.  But I emphasise that his energy and optimism must come from the frontline and its leaders – it cannot be proscribed from the centre.

So my message today is – we have achieved so much but there is so much yet to do.  Social prescription has opened up an enormous seam of goodwill throughout the health service and our local communities and will eventually lead us to the holy grail of enabling health creating communities. 

It is not a policy or an initiative, it is a red blooded revolution still fired by passion and goodwill and, I believe, accelerated by Covid and the recognition that primary care, a sense of community and social prescription are now an essential part of the future of all of us.’

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