Key figures from The College of Medicine and Social Prescribing Network have come together to produce the article below on social prescribing, offering clarity on everything from current research, to the role of link workers and how effective social prescribing can be in our healthcare systems…
The need for social prescribing:
The Low report demonstrated that 20% of people visit a GP with non-medical needs (The Low Commission). Research by Marmot has shown that the environment a person lives in has a large effect on their health (Marmot 2010; Marmot 2020).
Supporting the wider social and environmental challenges a person is facing is, therefore, critical to supporting their health and reducing demand on the health service. This is particularly so for people in lower social economic positions. A recent systematic and meta-analysis has shown that depression medication is less effective if a person has employment or housing issues (Buckman et al, 2022), notwithstanding some of the side effects caused by long term consumption of anti-depressants (Moncrieff, 2013).
Moreover, inappropriate pharmaceutical prescribing, particularly for older people and those experiencing inequalities was highlighted in the Chief Pharmaceutical Officer’s report (DHSC 2021) as a cause of increased adverse drug reactions and hospitalisation (up to 1 in 5 people over 65yrs+). Social prescribing was cited as one potential solution for a proportion of these people.
What is social prescribing?
Social prescribing is a structure that allows health, allied health and other professionals, including link workers or community navigators, to refer a person to sources of support within the community. The link worker’s role is to listen and identify the needs of an individual, focussing on them as a person, rather than one specific issue.
The link work then efficiently enables a person to get the right support. This may be a benefits review, support for being an unpaid carer, emergency support due to poverty, support to become more physically active, or to connect to community organisation when a person has lost confidence to socialise or get out of their home. When these issues are supported, health can be improved.
The problems with the recent media coverage:
The recent systematic review by Kiely et al (2022) concluded that ‘there is not enough research yet undertaken on the efficacy of social prescribing’ and therefore recommended more research in this area be carried out. Journalists in the media misinterpreted this as ‘there is evidence to disprove social prescribing works’, which is a very different and unsubstantiated conclusion. Further reasons why this systematic review and subsequent reporting is inappropriate to determine the impact of social prescribing are listed below.
- Conflation and misinterpretation by journalists.
It is not possible to separate the effect of a link worker from the effect of a community activity: The review article from Kiely et al., 2022 is entitled “Effect of social prescribing link workers on health outcomes and costs for adults…”. The RCT studies cited in the review collect data at baseline and follow up from a cohort of people who are meeting a link worker and are subsequently referred to a range of community activities. It is not possible to disentangle the effect of the link worker from the effect of community activities on individuals using this method of data collection as data are collected at two time points when the client has been exposed to both link worker and community activity. As a result, the premise of the article is incorrect, the appropriate assessment of the effect of link workers needs a different methodology adopting mixed methods.
- Three of the eight studies are based in USA (n=4053/6500)
Using literature from outside of the UK is inappropriate to determine the impact of the model of social prescribing that is used in the NHS. The mechanisms of identifying, referring, supporting and prescribing activities for a patient are likely to be different to current practice in England compared to research from the USA. The systematic review (Kiely et al) therefore only contains 2 studies (n=1702/6500) that are relevant for current social prescribing practice; note Mercer et al (2019) was carried out in Scotland, not England. Mercer et al (2019) n=900, in particular were able to isolate increased health related quality of life for people who saw the community link worker three or more times. It should be noted that the comparative control group in this study was not matched to the same conditions as the social prescribing cohort. The research by Mercer et al (2019) was carried out in a highly deprived area which reflects the complex social determinants and multimorbidity facing some people. This is important intelligence for optimising the groups of people that social prescribing may be most suited for.
- The articles used were old (n=1067/6500):
Three of the eight studies cited were carried out before 2017 (e.g. 1992, 2000, 2011) before the introduction of the current social prescribing model into the NHS. The field of social prescribing has changed significantly since then, with the development of metrics and outcome measures which show a more positive picture overall.
- Narrow outcomes were specifically chosen
To suit the researcher’s area of interest, they only searched for papers with a primary outcome of health related quality of life or mental health outcomes. This narrow criteria excludes other potential studies that have different primary outcomes further emphasising the inappropriate use of this study by the journalists.
What is an appropriate approach to researching and evaluating social prescribing?
The Medical Research Council guidance on evaluating new and complex interventions provides a roadmap of types of data to be determined before designing a randomised controlled trial (RCT). This involves qualitative data, case studies, proof of concept research and identification of appropriate outcomes to measures. Social prescribing is a relatively new model in the NHS and research strategies have been following the MRC guidance. Much data has now been gathered as proof of concept and pre-post evaluations to understand the breadth of outcomes and the effect size where pre-post change of outcomes occurs.
The National Academy for Social Prescribing’s academic collaborative are compiling rapid evidence reviews and short briefings on priority themes. Those published so far include summaries of what the evidence tells us about the impact of social prescribing on measuring economic impact and health outcomes – you can access these here. Social prescribing: the evidence | National Academy for Social Prescribing (socialprescribingacademy.org.uk) and
Some meta-analysis of small-scale primary studies has also been conducted along with some early phase economic analysis with controlled groups. Examples of knowledge are in the appendix.
The research on social prescribing continues to grow and be published. The next five years will provide deeper insight into the areas where social prescribing can have most impact for the wellbeing of individuals.
Contributors
Dr Marie Polley, Co-Founder Social Prescribing Network; Visiting Reader, University of East London; Honorary Senior Research Fellow, UCL; Co-Lead NASP International Evidence Collaborative.
Prof Helen Chatterjee MBE, Professor of Human & Ecological Health, UCL; AHRC Research Programme Director for Health Inequalities, UKRI; Co-Lead NASP International Evidence Collaborative.
Prof Chris Dayson, Professor of Voluntary Action, Health and Wellbeing, Sheffield Hallam University; core member of NASP’s International Evidence Collaborative.
Dr Marcello Bertotti, Reader in Community Health, Acting Deputy Director, Institute for Connected Communities, University of East London; core member of NASP’s International Evidence Collaborative.
Dr Kerryn Husk, Associate Professor of Health Services (Research), Peninsula Medical School, University of Plymouth; core member of NASP’s International Evidence Collaborative.
Professor Sheena Asthana, Director of the Plymouth Institute of Health & Care Research, University of Plymouth
Dr Daisy Fancourt, Associate Professor of Psychobiology & Epidemiology, Head, Social Biobehavioural Research Group, University College London
Dr Anant Jani, Research Fellow, University of Oxford and University of Heidelberg.
Dr Julian Elston, Senior Research Fellow, University of Plymouth, Consultant in Public Health
References
- Bertotti M, Frostick C and Temirov O (2020a) ‘An evaluation of Social Prescribing in the London Borough of Redbridge: final evaluation report’, July 2020 commissioned by the London Borough of Redbridge and the Redbridge Clinical Commissioning Group, Health and Well-being Fund (DHSC)
- Bertotti M, Temirov O (2020). ‘Outcome and economic evaluation of City and Hackney Social Prescribing Scheme’, commissioned by the City and Hackney Clinical Commissioning Group
- Buckman J, Saunders R and Stott J (2022). Socioeconomic indicators of treatment prognosis for adults with depression. JAMA Psychiatry 79(5):406-416
- Dayson, C., Painter, J., & Bennett, E. (2020). Social prescribing for patients of secondary mental health services: emotional, psychological and social wellbeing outcomes. Journal of Public Mental Health: the art, science and politics of creating a mentally healthy society. https://www.emerald.com/insight/content/doi/10.1108/JPMH-10-2019-0088/full/html
- Kiely B et al (2022). Effect of social prescribing link workers on health outcomes and costs for adults in primary care and community settings: a systematic review BMJ Open 12: e062951. doi:10.1136/ bmjopen-2022-062951.
- The Low Commission. The role of advice services in health outcomes: evidence review and mapping study, June 2015. Available at http://www.lowcommission.org.uk/dyn/1435582011755/ASA-report_Web.pdf
- Liebmann M, Pitman A, Hsueh Y-C, Bertotti M, Pearce E (2022) ‘Do people perceive benefits in the use of social prescribing to address loneliness and/or social isolation? A qualitative meta- synthesis of the literature’ BMC Health Services Research
- Lynch and Jones (2022) Social prescribing for frequent attenders: an economic analysis. Frontiers in Public Health
- Marmot, M (2010) Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-2010. (2010) ISBN 9780956487001
- Marmot M (2020) Health Equity in England: The Marmot Review 10 Years On – The Health Foundation
- Mercer SW, et al (2019). Effectiveness of communitylinks practitioners in areas of high socioeconomic deprivation. Ann Fam Med 17:518–25.
- Moncrieff, 2013 ‘The Bitterest Pills. The troubling story of Antipsychotic drugs’, Palgrave MacMillan, Basingstoke
- Polley M, Seers H and Fixsen A (2019) Evaluation Report of the Social Prescribing Demonstrator site in
- Shropshire – Final Report. University of Westminster, London.
- DHSC (2021) Good for me, good for you, good for everybody -A plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions. Department of Health and Social Care
- Thomson, L.J., Lockyer, B., Camic, P.M. & Chatterjee, H.J. (2018). Effects of a museum-based social prescription intervention on quantitative measures of psychological wellbeing in older adults. Perspectives in Public Health, 138(1), 28–38. https://doi.org/10.1177/1757913917737563
- Todd, C., Camic, P.M., Lockyer, B., Thomson, L.J. & Chatterjee, H.J. (2017). Museum-based programmes for socially isolated older adults: Understanding what works. Health & Place, 48, 47-55. http://dx.doi.org/10.1016/j.healthplace.2017.08.005
- Wildman J and Wildman J M (2021)”Evaluation of a Community Health Worker Social Prescribing Program Among UK Patients With Type 2 Diabetes’, Jama Network Open
Appendix – Examples of social prescribing research findings
Liebmann et al (2022) Qualitative meta-synthesis of the impact of social prescribing on loneliness and social isolation showed an overall positive impact of social prescribing on increased sense of wellbeing, and the factors that engendered an ongoing desire to connect with others.
Drinkwater et al (2021) Ways to Wellness social prescribing service was launched in April 2015 in the west of Newcastle upon Tyne, where deprivation is higher than the average in England, life expectancy is lower and people with long term health conditions experience high rates of unplanned admissions to hospital. The service supports people aged 40-74 years old with specific long term conditions, many of whom have multiple, complex medical, practical and social needs.
Secondary care (hospital) cost impact was measured by comparing the average hospital cost per person for the Ways to Wellness cohort with a matched group of patients that do not have access to the Ways to Wellness service. Patients in both cohorts use the same NHS hospital trust (Newcastle Hospitals) and broadly have access to the same NHS and council services as well as comparable voluntary sector services. In 2019/20, the secondary care cost per patient for the Ways to Wellness cohort was 27% lower than the comparison cohort. Across the full eligible Ways to Wellness cohort (14,652 patients), this equates to an annual secondary care cost reduction of £1.56 million in 2019/20.
Polley, Seers and Fixsen (2019) evaluated the implementation and impact of the Shropshire social prescribing service of n=3600. A pre-post analysis demonstrated a range of positive outcomes in loneliness, activation and wellbeing, where follow up data had been collected. Health service usage for the participants was analysed comparing service usage in the 3 months prior to the first consultation with the social prescribing advisor and over the 3 months between initial consultation and follow-up (n=105). This data was then compared to a case-matched control group for participants extracted from electronic medical records (n=85). A statistically significant reduction was seen in visits to the GP (reduced by 40%, p=0.00) for people who used the social prescribing service. There was no statistically significant reduction in visits to the GP in the control group.
Using this data from the Shropshire study, the National Academy of Social Prescribing’s analysis estimated that NHS England’s social prescribing link worker programme can reduce GP appointments by 4.5 million per year.
Lynch and Jones (2022) very recently published an economic analysis of frequent attenders to GPs services, who were using social prescribing. The results identified a direct cost saving of £78.37 per participant over the 5 months of social prescribing in frequent attenders to GP practices. The authors suggest that targeting of social prescribing to frequent attenders may be the best approach to achieve maximum cost benefit.
Wildman and Wildman (2021). Evaluation of a community health worker social prescribing programme among UK patients with type 2 diabetes. N=8,086 patients aged 40 to 74 with a diagnosis type 2 diabetes were referred to Community Health Workers and observed for 8 years. The control group included patients in the east of the same town where referrals were not available. The study concluded that the intervention group experienced improved HbA1c levels, suggesting that Community Health Worker interventions help to reduce the public health burden of type 2 diabetes.
Thomson et al. (2018) and Todd et al. (2017) showed statistically significant improvements in psychological wellbeing, and reductions in loneliness and isolation, in a mixed methods study involving N=115 older adults aged 65–94 years referred to museum-based social prescribing programmes.
Dayson et al 2020 conducted a qualitative case study of one mental health social prescribing service with three nested case studies of social prescribing providers. Semi-structured interviews were undertaken with commissioners, providers and patients (n = 20) and analysed thematically. Social prescribing was found to make a positive contribution to emotional, psychological and social well-being for patients of secondary mental health services. A key enabling mechanism of the social prescribing model was the supportive discharge pathway which provided opportunities for sustained engagement in community activities, including participation in peer-to-peer support networks and volunteering. A supported social prescribing referral, embedded within a recovery focussed secondary mental health service pathway, offers a valuable accompaniment to traditional approaches. Current social prescribing policy is focussed on increasing the number of link workers in primary care, but this study highlights the importance models embedded within secondary care and of funding VCSE organisations to receive referrals and provide pathways for long-term engagement, enabling positive outcomes to be sustained.
Bertotti M, Frostick C and Temirov O (2020) evaluated social prescribing in the London Borough of Redbridge analysing data at baseline and six months follow up from 182 respondents. The evaluation reported positive statistically significant changes between baseline and follow up were recorded for quality of life, mental well-being and health. Meaningful and statistically significant changes in mental well-being were found. The economic evaluation of social prescribing in Redbridge showed a positive, above average return (£1:£2.30) SROI (£1:£2.86) for the first year. In terms of the healthcare care use cost analysis, the team found a statistically significant reductions in General Practitioner (GP) consultation rates.
Bertotti M, Temirov O (2020). ‘Outcome and economic evaluation of City and Hackney Social Prescribing Scheme’, commissioned by the City and Hackney Clinical Commissioning Group. Baseline, three and six months follow up from 166 respondents. The report found statistically significant improvements in mental well-being. The SROI for Hackney social prescribing scheme was £1: £3.51.
