Helen Salisbury: Social prescribing and the No 17 busBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l271 (Published 24 January 2019) Cite this as: BMJ 2019;364:l271
All rapid responses
Helen Salisbury’s article raises some important points about the widespread rollout of Social Prescribing (SP) Services. While on the surface, it seems a sensible idea to link people with community and voluntary services that could help to address problems contributing to reduced wellbeing, the approach rests on a number of critical – yet problematic - assumptions:
Assumption 1: SP is effective – there is sufficient high-quality research evidence to judge impacts on patient outcomes, health service costs and GP workload.
Assumption 2: SP services are being implemented in ways that allow for evaluation - there is a clear underlying logic model and robust monitoring of inputs and outcomes (for patients, referrers and onward referral services).
Assumption 3: SP is what patients want – patients have been involved in its development, and users’ experiences have been explored via qualitative research.
Assumption 4: SP is what referrers want – SP services have been developed in collaboration with GPs /other referring health professionals and referrers’ experiences have been explored via qualitative research.
Assumption 5: SP works for onward referral services – small, community groups (often relying on volunteers) are willing and able to accept referrals and respond to people’s needs - and this is sustainable over the longer term.
Assumption 6: We know what skills, competencies and resources SP care navigators (AKA coordinators, link workers, or facilitators) need in order to be person-centred and effective, and to manage risk appropriately.
Assumption 7: There is a close match between services available in the local area and the needs of patients attending primary care – GPs and other health professionals can be confident that an individual’s needs will be met via referral to SP.
At present, there is scant evidence to support these assumptions. A recent systematic review of SP programmes  concluded that current evidence fails to provide sufficient detail to judge either success or value for money. Of the 15 evaluations identified, most were small scale and limited by poor design and reporting. A small number of studies on patient and referrer experience were identified and these mainly reported positive findings, although studies also highlighted lack of understanding/familiarity with SP among both patients and GPs. The review did not identify studies on experience of onward referral services .
Our recent work using evaluability assessment as a method to examine SP  identified several changes that would be necessary to allow for evaluation of the services assessed. Lessons learned included ensuring that: i. SP schemes are developed with involvement (and buy in) of relevant stakeholders; ii. information governance and data sharing agreements are in place from the start; iii. staffing levels are sufficient to cover the range of activities involved in service delivery, data monitoring, reporting, evaluation and communication with stakeholders; iv. SP schemes are co-located with primary care services and v. referral pathways and linkage to health service data systems are established as part of the programme design.
NHS England is undertaking work to build a more robust evidence base on SP. This has included funding 23 projects through the Health and Wellbeing Fund  to test different ways to support people and find out what social prescribing models work best, as well as developing a set of resources to support the implementation and evaluation of SP programmes  . The current gaps in evidence can also be addressed by more systematic planning of SP services, with closer collaboration between those involved in developing, delivering, participating in and evaluating SP programmes, enabling appropriate evaluation frameworks to be built in from the start.
Social Prescribing is part of the NHS Long Term Plan’s commitment to universal personalised care  and has the potential to benefit patients, GPs and the NHS. However, to realise this potential, it is vital that the assumptions underlying SP are made explicit and research efforts are targeted towards these. We propose the list of assumptions above as a starting point for taking this work forward.
1. Bickerdike L, Booth A, Wilson PM, et al Social prescribing: less rhetoric and more reality. A systematic review of the evidence BMJ Open 2017;7:e013384. doi: 10.1136/bmjopen-2016-013384
2. Hamilton-West K, Gadsby E, Zaremba N, Jaswal S. Evaluability Assessments as an Approach to Examining Social Prescribing. Health Soc Care Community 2019, forthcoming.
3. https://www.gov.uk/government/publications/social-prescribing-schemes-to.... fund-2018
Competing interests: No competing interests
The answer to Helen's question "Where's the motivation to go for a walk if you have no one to visit" is obvious. Get a dog.
The average dog owner gets more exercise on a wet day than the average non-dog-owner does on a dry day and there are known mental health benefits. One report of these appears elsewhere in the journal, alongside the possibility that Fido might even detect hypoglycaema, hypergycaemia, cancer or C.difficile.
Competing interests: Joint owner of two dogs.
How very true. The same could be said of the demise of most Post Offices - technology means we don't NEED physical locations. But we're humans. We do.
Competing interests: No competing interests