Intended for healthcare professionals

Rapid Response:

Re: Social prescribing

As highlighted by Drinkwater et.al (1) social prescribing is increasingly popular with the Long Term Plan aiming for over 900,000 people to be referred to social prescribing by 2023/24 (2). However, depending on how ‘wider determinants of health’ are defined it is possibly not true to assert that social prescribing will address them and may therefore distract attention from factors that may have a greater impact upon population health.

The classic Dahlgreen and Whitehead model (3) has four layers of factors affecting health; social and community networks sitting between such as ‘living and working conditions’ and ‘individual life-style factors’. This has been modified by such as Barton and Grant (2006) (4) who placed ‘Community networks, social capital’ between ‘life-style’ and ‘local community’. These are not only academic points but profoundly important as the following example may illustrate.

Drinkwater et. al give the examples the social prescribing of physical activity, associated with reducing all long-term conditions (LTCs) by 20 – 40% depending on the condition (5). From a health perspective therefore the question is what social determinants have meant that physical activity levels are so low (objective rather than self-report measurement indicates that it may be that only 5% of the population meets recommended guidelines (6)) and how to raise them. The causes of physical inactivity may be as complex as those of obesity highlighted by the Foresight Report (7) and include the increasing mechanisation and electronification of life. However, physical activity can also be integrated into everyday life; in Copenhagen 41% of journeys to work or education are by bicycle with ‘being faster’ and ‘easier’ each being cited by over 50% of survey respondents as the reason for cycling (8). In Copenhagen therefore for many physical activity is the default choice; people are physically activity simply because they are going from A to B. London Sport has a target of making London the most physically active city in the world. It may be useful to consider the lessons that might be learnt from example of where people are physically active at the beginning and end of working day.

There are many ways in which the social determinants of health may be defined. From a population perspective though it may be useful to think that ‘the system is perfectly aligned to produce the results that it does’. If lifestyle choices are being prescribing so that people need to make an effort / go out of their way then it is not the ‘social determinants of health’ that are being addressed. And, that in an age of austerity and when the NHS is spending 70% of its budget on LTCs this is profoundly important (9).

References

(1) Drinkwater C, Wildman J, Moffatt S. Clinical Update: Social Prescribing. BMJ 2019;364:1285-doi: https://doi.org/10.1136/bmj.l1285.

(2) NHS. THe NHS Long Term Plan. 2019:www.longtermplan.nhs.uk.

(3) Dahlgren G, Whitehead M. Policies and Strategies to Promote Social Equity in Health. 1991;Institute for Futures Studies. Stockholm. Sweden.

(4) Barton H, Grant M. A health map for the local human habitat. Journal of The Royal Society for the Promotion of Health 2006;126(6):252-261.

(5) Department of Health. Start Active, Stay Active. A report on physical activity for health from the four home countries’ Chief Medical Officers. 2011.

(6) Craig R, Shelton N(. Health Survey for England 2007 Volume 1. Healthy lifestyles: knowledge, attitudes and behaviour. 2008.

(7) Butland B, Jebb S, Kopelman P, MacPherson K, Thomas S, Mardell J, et al. Tackling obesities: future choices – project report (2nd Ed). London: Foresight Programme of the Government Office for Science. 2007.

(8) City of Copenhagen. Copenhagen. City of Cyclists. Facts and Figures 2017. 2017.

(9) NHS. Five year forward view. 2014.

Competing interests: No competing interests

01 April 2019
Glenn Stewart
Consultant in Public Health
Brunel University