It is no secret that the government likes “social prescribing”. Last month’s loneliness strategy included proposals for GPs to refer patients to art groups, cookery classes and other activities. And speaking at last week’s King’s Fund conference on the subject, the health and social care secretary, Matt Hancock, announced the creation of an academy to build a research base, train practitioners and champion the benefits of social prescribing. He wants to see a nationwide network of social prescribing projects that encourage individuals to take part in a range of activities including the arts, exercise, and nutritional advice.
It feels churlish to challenge the concept of social prescribing. How can anyone argue with the value of music playlists for people living with dementia? Or dancing for those at risk of falls? Or cookery classes for the lonely? Certainly our conventional medical model can’t solve the growing problems of diabetes, obesity, stress and loneliness. Psychosocial problems underlie around a quarter of consultations that GPs like myself conduct every day. As Hancock says, “We’ve got to stop over-medicalising people. Popping pills and prozac won’t cure all problems.” He sees social prescribing as “fundamental to prevention” of ill-health and wants to harness the “life-enhancing” arts to the “life-saving” medical sciences.
But as ever, funding is key. At last week’s King’s Fund conference, Hancock raised delegates’ eyebrows when he said libraries are great hubs for community services such as smoking cessation clinics. Perhaps he doesn’t realise quite how many local libraries have been closed by cash-strapped local authorities? Youth centres, daycare centres and other community services have also seen massive budget cuts since 2010, with many closing entirely.
The chancellor, Philip Hammond, promised £2bn of extra funding for mental health services and £650m to social care in last month’s budget. But Hancockhas only promised to increase “the overall proportion of funding to primary care”. He wants social prescribing to harness resources that are already out there in the voluntary and community sector. The argument is that participating in social activities will reduce GP consultations and unnecessary hospital admissions, thereby saving the NHS money that can be reinvested in social prescribing. But there are real costs. Who is going to pick up the tab for ensuring patients actually go to these activities? Who will pay to establish new activities where there are none and who will evaluate whether patients are healthier as a result?
Training link workers to act as guides and coaches for patients to access these services, installing digital technology to make it easy for GPs to refer patients and developing robust outcome measures will not be cheap.
Where’s the evidence that this approach is effective, safe, good value for money and accessible to all? Certainly, there are some success stories: the introduction of social prescribing as part of an enhanced model of primary care and compassionate communities in Frome, Somerset is credited with helping cut unplanned hospital admissions by 14% between 2013 and 2017 at the same time as admissions in the rest of Somerset rose by 28%.
But researchers urge caution. Although the evidence for social prescribing’s ability to reduce demand and costs in primary and secondary care is “broadly supportive”, the quality of evidence is “weak” and needs further evaluation. Still, conventional research tools like randomised control trials are unlikely to capture the complex interventions that link workers can make, the positive impact on health and wellbeing and the fact that these schemes are very well liked by patients and GPs alike. And it’s hard to directly compare the cost of social prescribing which may be funded by a mix of NHS clinical commissioning groups, local government, charities and others, with conventional medical care that is wholly funded by the NHS.
In my GP surgery this morning, I had nothing to offer a significant proportion of the people I saw. People with lifelong depression, low self-esteem, agoraphobia and anxiety who have become socially isolated. An elderly man and a young mother, both feeling the effects of loneliness and lack of social support. A man in his 60s who has recovered from a heart attack but is finding it hard to motivate himself to overhaul his lifestyle by stopping smoking and starting to exercise and eat healthily. A young man who has back pain for which no specific diagnosis or treatment can be found despite extensive investigations. An elderly, frail lady who is so scared of falling that she’s become a prisoner in her own home.
The sort of medicine that I was taught to practise was about individuals, illness and disease. It was about diagnosis, investigations and medicines. They still have a place, of course, but as we live longer than ever and want to enjoy good health, rather than just avoiding ill-health, we desperately need a new model of healthcare. The focus of social prescribing on prevention, wellbeing and community has got to be worth a try.