Social prescribing in the NHS—is it too soon to judge its value?
BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p699 (Published 24 March 2023) Cite this as: BMJ 2023;380:p699
- Debra Westlake, research fellow,
- Stephanie Tierney, senior researcher,
- Geoff Wong, associate professor,
- Kamal R Mahtani, professor
Social prescribing aims to promote people’s health by linking them to activities and groups in their community that can meet their non-medical needs. Over the past four years, the idea has been taken up in the NHS as a way to improve population health and reduce workload for other healthcare staff—particularly GPs. NHS England rolled out social prescribing in 2019 as one of the six core pillars of its comprehensive model of personalised care.1 General practices have been encouraged to employ social prescribing link workers (SPLWs) through the Additional Roles Reimbursement Scheme. The scheme is due to be reviewed by NHS England in early 2024 when a decision will be made on future funding.2
The concept of linking individuals to community support is not novel. However, for primary care and recently formed integrated care systems, the pace and scale of introducing SPLWs into the NHS is relatively new. It is reasonable, therefore, to ask whether enough time has been allowed for such a large and complex programme to become established, understood, and evaluated before its funding is reviewed.
Academics and researchers who have evaluated social prescribing programmes (including our team) have highlighted their potential, but warned that the innovation is unlikely to represent a “quick fix,” even when well resourced.3 Furthermore, we might be expecting “too much too soon.”4 Consequently, caution is needed when reviewing the role of SPLWs in primary care. We argue that 2024 will be too early to judge if SPLWs have produced sufficient benefits and warrant further NHS investment.5
Why more time is needed
Social prescribing is a complex intervention set within complex social systems, and implementation models vary across organisations and locations.3 According to normalisation process theory,67 a complex intervention requires four components to become part of routine practice: the initiative must be clearly understood and distinct from other approaches (coherence); practitioners must believe in and buy into the innovation (cognitive participation); they must know what workload changes it requires and how it fits with current practice (collective action); and they must assess whether it is working as intended and if changes need to be made (reflexive monitoring). Many GP practices are still at the coherence stage.
Healthcare staff often need a clearer understanding of what a SPLW is and what their role might be in supporting work in primary care.5 Buy-in to the role from healthcare professionals is still being negotiated.8 The use of SPLWs represents a radical change for the culture of health systems and the mindsets of professionals and patients alike. Embracing a more biopsychosocial model of care, which considers the wider determinants of health, will not be a linear path. If SPLWs are to help tackle entrenched health inequalities, especially during the current economic challenges facing the UK, they will need more time and resources.
NHS England should factor in that the programme has been in constant flux. SPLWs have responded to rapidly changing situations in primary care, including undertaking work related to covid-19, such as supporting the vaccination programme.91011 This has taken its toll on the wellbeing of SPLWs and challenged the coherence and distinct nature of their work. As the rollout of SPLWs in primary care coincided with the pandemic, it disrupted their integration into existing teams.910
Teams have also experienced organisational change that has shifted the timeframe for the rollout of SPLWs in primary care and the maturity of social prescribing in the NHS. Many primary care networks in England are still evolving and have not yet established a clear plan for the SPLW role.12 Integrated care systems, which have been tasked with planning healthcare programmes like social prescribing that bridge statutory and community sectors, are also still in the process of forming. They face many strategic challenges, including recovering from the covid-19 pandemic and dealing with a workforce crisis.
Learning by doing
The SPLW role and approach takes time to develop, embed, and evolve. No one-size-fits-all blueprint exists, nor is it warranted as local teams will decide what works best for their area. Local programmes often learn by doing, but by 2024 they may not have had enough time for this individualised process to have fully emerged. As teams grow under the Additional Roles Reimbursement Scheme, and as policies and local circumstances change, the delivery of social prescribing in primary care will need to be reviewed. We know, for example, that the current cost of living crisis presents huge challenges for the most vulnerable people in society. SPLWs are experiencing a rise in referrals for assistance with housing crises, debt, and food and fuel poverty, requiring more resources and different ways of working.
The evidence for SPLWs is heterogeneous—including across systematic reviews.13 Consequently, we cannot yet say if introducing SPLWs into primary care has had its desired impact or not. Data collection is often skewed towards health outcomes, rather than those that reflect the wider determinants of health, including social outcomes. A mismatch may exist between what SPLWs are supporting people with and how any impact is measured and documented.14 Empirical studies of SPLWs are under way, including a national evaluation15 and our own research.16 These will provide important evidence, but final findings will not be reported before 2024.
The planned 2024 review of social prescribing risks prematurely judging the SPLW role when it has not yet had the opportunity to realise its potential. The evaluation timeframe should be extended—at least for two more years—before key commissioning decisions are made.
Footnotes
Competing interests: Debra Westlake is a co-applicant of the NIHR HS&DR funded study: NIHR134589 and trustee of a charity contracted by PCN to provide social prescribing. Stephanie Tierney and Kamal Mahtani are members of the National Academy for Social Prescribing’s Academic Partners Collaborative and co-leading a study funded by the NIHR on the implementation of link workers in primary care (NIHR130247). Geoff Wong receives grant funding from a range of funders, for the complete list see: https://orcid.org/0000-0002-5384-4157. He is deputy director of graduate studies at the Nuffield Department of Primary Care Health Sciences, University of Oxford, a board member of the NIHR School of Primary Care Research, UK, and member of the Marie Curie Research Funding Committee.
Provenance and peer review: not commissioned; not externally peer reviewed.
Thanks to Steven Markham (researcher) who discussed this work with us and gave thoughts on earlier drafts.