Social prescribingBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1285 (Published 28 March 2019) Cite this as: BMJ 2019;364:l1285
- Chris Drinkwater, emeritus professor of primary care1,
- Josephine Wildman, research associate2,
- Suzanne Moffatt, reader in social gerontology2
- 1Ways to Wellness, Business Innovation Facility Biomedical Research Centre Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK
- 2Institute of Health & Society, Sir James Spence Institute, Newcastle upon Tyne, UK
- Correspondence to C Drinkwater
What you need to know
Emerging evidence suggests that social prescribing can improve people’s health and wellbeing and reduce workload for healthcare professionals and demand for secondary care services
In England social prescribing is part of the NHS Long Term Plan. Primary Care Networks will be funded to employ a social prescriber from 2019
Social prescribing is targeted at a range of patients, including those who are socially isolated and those with long term physical and/or mental health conditions
Social prescribers have a variety of names that include link worker, community connector, community navigator, and health trainer. The role varies from simple signposting to activities to more intensive and sometimes longer term individual support
Further research is needed to identify who is most likely to benefit from social prescribing and what type of intervention is most cost effective
Non-medical interventions are increasingly being proposed to address wider determinants of health and to help patients improve health behaviours and better manage their conditions.12 This is known as social prescribing. In England, the NHS Long Term Plan states that nearly one million people will qualify for referral to social prescribing schemes by 2023-24.3 Primary care networks, announced as part of the 2019 GP contract, will be funded to employ one social prescriber each from 2019.4 The social prescribing approach is also attracting interest in North America,35 Australia,6 and Scandinavia.7 This clinical update outlines what social prescribing is, the evidence behind it, and offers some tips for embedding social prescribing within healthcare systems.
What is social prescribing?
Socioeconomic factors have consistently been found to have a greater impact on health than healthcare.8 In addition, frailty and long term conditions can negatively affect social and physical activity, finances, and relationships, which in turn can lead to a further decline in health and wellbeing.49 The underlying hypothesis is that addressing these factors through providing a range of social activities and interventions is as important as addressing biomedical issues (box 1).11 Social prescribing does this by linking traditional clinical practice with activities and support services within the community. A “social prescription” is a referral to one or more of these activities, which are typically provided by the local voluntary and community sectors. Referral mechanism, target groups, activities offered, and the intensity and duration of support provided vary.
Why social prescribing is gaining support
We need to rethink the balance between the biomedical and the social and psychological model of care in clinical practice.10
Interest is growing in a more personalised approach to healthcare delivery, with more effective partnerships between patients and professionals.10
Social prescribing is presented as an effective way of addressing social determinants of health while potentially reducing healthcare demand and costs.3
Is there evidence that social prescribing works?
A systematic review indicated current evidence is insufficient to provide definitive guidance on what works.12 Evaluating social prescribing schemes can be challenging because of the complex and wide ranging issues it seeks to address, wide variations in the nature of interventions, the wide range of additional influences on individual health and wellbeing, the time taken for benefits to emerge, and the expense of thorough evaluation.13 Many current evaluations are small scale, short term, poorly designed, lack standardised outcome measures, and fail to account for wider influences on health and wellbeing.12
However, the lack of robust evidence of effectiveness does not mean social prescribing is ineffective. Findings from qualitative studies suggest that patients are satisfied with social prescribing schemes, particularly valuing a trusting and supportive relationship with their link worker, the time and space to address social problems, and link workers’ extensive knowledge of the range of community support services available.14151617 Recent systematic reviews of non-clinical community interventions identified evidence, albeit weak, of a further range of patient benefits.1218 These include improvements in mental wellbeing and in physical health and health behaviours; reductions in social isolation and loneliness; and reductions in primary and secondary care usage. Systematic review evidence from the United States on patients’ social and economic needs supports the effectiveness of interventions aimed at identifying and addressing families’ resource needs and of programmes providing linkage to employment support for certain vulnerable groups.19
How could the evidence be improved?
To aid evaluation, social prescribing programmes need to be underpinned by a clear understanding of the intended impacts, the mechanisms by which impacts are achieved, and how each programme fits into wider health and social care systems and the communities in which it operates.16 The Choice and Personalisation Team at NHS England has recently produced a draft common outcomes framework for discussion.20 This proposes a common approach to measuring outcomes for the person (for example, being better able to manage their own care), for the health and care system (a change in the number of GP consultations or hospital episodes), and for local community groups (capacity to manage referrals). Measuring these outcomes is not straightforward and will require further work if a robust evidence base is to be developed. Mixed methods research that integrates qualitative and quantitative approaches is likely to capture the context and range of outcomes necessary to develop evidence and learning about social prescribing services.21
What are the risks and harms of social prescribing?
There is a risk that social prescribing is treated as a panacea for complex problems and social issues such as loneliness, poverty, and increasing inequalities. While social prescribing is likely to be of benefit to many patients, it may not be appropriate for people with end stage disease or severe mental illness. Social prescribing also risks being viewed as a “silver bullet” to fix the pressures of growing demands facing health services. The primary driver needs to be benefit to patients.22 In addition, if the link worker model (described below) is to be rolled out, some critical issues need to be addressed. For example, what are the role’s core competencies, and should there be an accredited qualification?23 Should the role always be paid, or could it be performed by volunteers or by a mix of both? Should link workers be managed within the health or the voluntary sector? Finally, it is important to recognise wider social policy contexts within which social prescribing is delivered, specifically the constraints on the UK’s voluntary and community sectors imposed by a prolonged period of austerity and the impact of reductions in local authority budgets between 2010 and 2018.24 This, coupled with growing demand for services, may make it more difficult to refer patients into community activities because of limited local capacity. Against this backdrop, balancing funding for link workers and activities requires planning by commissioners, service designers, and the voluntary and community sectors. Giving link workers a brief to generate local activities and a limited budget to spot purchase some activities is an option, but local circumstances will dictate the best model.
Social prescribing in practice
Who are the target groups for social prescribing?
A key target group is patients who may require a greater level of social and emotional support to improve wellbeing and health than is available in routine care. The social prescribing scheme that we have developed, “Ways to Wellness,” targets people with a range of long term physical and mental health conditions living in an area of high socioeconomic deprivation.25 Other schemes target people with mental health conditions,26 or frail older people.26
Different people will require different levels of support to engage with activities (fig 1). At one end of the scale, someone with a high level of health literacy and motivation will find out and do all that needs to be done without any support. At the other end of scale, someone who is feeling overwhelmed or depressed may need intensive personal motivational support. In between, others may need signposting and information about the range of support and activities available.
What sort of activities do people get involved in?
Our initiative in Newcastle upon Tyne, north east England, offers more than 180 different activities, many of which are no cost or low cost. Activities and services can be roughly grouped into: physical activities (such as “green gyms” and exercise classes); weight management and nutrition; arts based activities; employment based and volunteering activities; and support to access welfare rights, debt, and housing advice and advocacy services. Some social prescribing interventions provide free, time limited activities (for example, providing six weeks’ free exercise classes).27
Who provides social prescribing services?
Social prescribing services can be provided by the voluntary sector,2528 primary care practices acting as hubs for local community wellbeing,29 or by partnerships between health service commissioners and the voluntary sector.28
Who can make a social prescribing referral?
Patients can self refer to social prescribing schemes, or be referred by a clinician or other member of the healthcare team. The referral may be directly to an activity, such as physical exercise, or to a link worker. Self referral to digital social prescribing is also being developed; for instance, patients can use an app that matches them with non-medical activities that may benefit their health condition.30 In the UK, referrals from generalist clinicians working in the community are most common, but referral can also be from specialist services, for instance for people recovering from cancer31 or those with early dementia.32
What is a link worker?
People who accept referrals and provide support for social prescribing in the UK are known by a variety of titles, including community navigator, health trainer, social prescribing coordinator, and community connector. However, “link worker” is an increasingly popular title because it references the need for a link between referring clinicians, patient, and local voluntary and community sectors. Figure 1 shows the stages in referral to a link worker. In the UK, this approach is gaining traction, particularly in disadvantaged communities where problems are more complex and challenging and more intensive support is likely to be required.33
Key aspects of the link worker role include: working with patients to identify meaningful goals; co-producing an action plan with the patient; enabling access to activities and sources of support in the community, and providing ongoing motivational support to help patients achieve their goals. In some schemes, link workers also work with clinicians to generate social prescribing referrals and provide feedback to referring clinicians on patients’ progress. Ideally a link worker is someone with community connections and an in-depth knowledge of sources of community activities and support. An understanding of the local community is particularly crucial in areas of socioeconomic disadvantage, as the link worker role may also involve generating and building capacity in the local voluntary and community sectors to provide a wide range of local activities. The recent NHS Long Term Plan for England includes the aim to recruit more than 1000 trained social prescribing link workers by the end of 2020-21, with a further increase by 2023-24.3
Embedding social prescribing into your way of working
These tips are drawn from our experience in developing Ways to Wellness, a link worker social prescribing scheme in Newcastle upon Tyne, England.
Build links with your local voluntary and community sector. A good starting point is the National Association for Voluntary and Community Action, which offers useful information and seeks links with general practices35
Discuss social prescribing with your patient participation group. They may have ideas about how to take it forward and champion it in the practice
Decide which patient group(s) to target. Focusing on a particular area may be helpful; for example, patients with long term conditions such as type 2 diabetes, socially isolated patients, or those with anxiety and depression
Consider adding a social prescribing option to annual care plans, health checks, or frailty reviews as part of care and support planning36
Talk to other local practices and identify a local lead who can support people into activities. From April 2019 the GP contract includes funding for a social prescriber within each primary care network13437
The whole practice team needs to plan how to encourage patients to take up the offer of a social prescription
Provide patients with a full explanation of the social prescribing programme offered. This has been found to help manage patient expectations of the service and increase their satisfaction15
In partnership with link workers or the organisation dealing with referrals, clarify and agree referral criteria and feedback mechanisms. Develop a referral form that collects basic patient data and patient consent to share information. Consider how the practice will collect feedback from referred patients20
Plan how you are going to evaluate your social prescribing service from the outset.
Education into practice
Think about which of your patients might benefit from seeing a link worker who could link them into local community and voluntary sector services.
What social issues do you often feel unable to help patients with that might be addressed with the help of a link worker?
How would you evaluate whether your social prescribing scheme is accessible, helping patients, and cost effective?
Information in this article came from a personal archive of references assembled over a period of years. Academic peerreviewed references were assembled from the bibliographic databases Medline, Scopus, Web of Science, and Embase, and from citation searches. References from the “grey” literature, including reports and websites, were assembled using internet search engines.
How patients were involved in the creation of this article:
A group of patients from Ways to Wellness have read this article. Although patients have been heavily involved in the development of and continuing review of Ways to Wellness,38 none of those who read the article felt able to comment on the wider aspects of social prescribing discussed in this article.
Useful information resources
The Social Prescribing Network. https://www.socialprescribingnetwork.com
The King’s Fund. What is Social prescribing. https://www.kingsfund.org.uk/publications/social-prescribing
Local Government Association. https://www.local.gov.uk/just-what-doctor-ordered-social-prescribing-guide-local-authorities-case-studies
National Association for Voluntary and Community Action. https://navca.org.uk/
Ways to Wellness. https://waystowellness.org.uk.
Provenance and peer review: commissioned; externally peer reviewed.
Competing interests The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: Chris Drinkwater is chair of Ways to Wellness.
Further details of The BMJ policy on financial interests is here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests