Social prescribing: community chance

Social prescribing is not a new phenomenon. It has been practised in an ad hoc way for a long time, though people tend to point to a 1990s scheme in Bromley-by-Bow as the first example of a formal scheme. But it has been growing in profile over the last few years. Fitting neatly with increasing moves towards personalisation, it is listed as one of the 10 high-impact actions in 2016’s General practice forward view. And now the NHS long-term plan, published in January, looks set to bring social prescribing into the mainstream.

Social prescribing enables GPs or other healthcare professionals to refer patients to a non-clinical link worker. This link worker spends time with the person so they can work out together what their needs and goals are and then refer them on to activities, voluntary groups or local schemes to help address those needs. This may tackle some of the patient’s social needs – such as loneliness or social isolation – which in turn contribute to their well-being.

It is perhaps a bit ‘touchy feely’ compared with emergency and acute treatment of patients – but it is increasingly seen as having the potential to make a big difference to patient outcomes – or avoiding ill health – and to the costs of healthcare delivery. The fact that it is being taken extremely seriously is underlined by its inclusion in January’s long-term plan.

The long-term plan names the approach as a key component in its attempts to rebalance the NHS more towards prevention and supporting people to manage their own health and conditions. Rather than the current piecemeal approach to social prescribing – universal services in some areas, no social prescribing in others – it will become ‘accessible across the country’ in the next five years. ‘Over 1,000 trained social prescribing link workers will be in place by the end of 2020/21 rising further by 2023/24, with the aim that over 900,000 people are able to be referred to social prescribing schemes by then,’ the plan says.

Devon GP Michael Dixon, NHS England’s national champion for social prescribing, told the HFMA annual conference in December that social prescribing had the potential to change the face of general practice and primary care within the next five years.

In many ways, it could pick up a role played by GPs before demand increased, when they could spend more time with patients. And it provides a response that is better suited to addressing socioeconomic or psychosocial issues than many medical interventions.

It has been estimated that about 20% of patients consult their GP for what is primarily a social problem. And while it can be used to meet the needs of people with wide-ranging issues, it has particular relevance for those with mild mental health conditions, such as depression, or long-term conditions.

Dr Dixon believes the NHS often takes an ‘over-medicalised’ approach – a medical response to a young new mother feeling isolated and unhappy might be to offer antidepressants or refer for a psychiatric intervention. But in many cases, social prescribing might offer a solution that addresses the causes not the symptoms.

‘It can create not only a cheaper alternative and a better alternative in terms of sustainability,’ he says, ‘it also creates a virtuous circle whereby the patient instigates their own improvement and isn’t relying on [the medical] profession.’

Link workers – sometimes known as health advisers, community navigators or wellbeing co-ordinators – are key to the social prescribing model. They need to engage with referring professionals, the referred people and the local voluntary, community and social enterprise sector. Once they have received a referral, they will spend time with the patient and co-produce a solution to address identified issues. This could involve matching the person to a local activity or service from a menu of local options – advice, theatre or walking groups, exercise classes or art/gardening sessions, for example – and perhaps even accompanying them to their first session.

Outcomes often claimed for social prescribing schemes include improved self-confidence and employability, better lifestyles, reduced isolation and patient ‘activation’ – alongside improved community resilience and reduced costs across the care pathway. Dr Dixon cites growing economic evidence – a 20% reduction in hospital and GP attendances. ‘Across schemes in Gloucestershire, Rotherham, Frome, West London and Croydon, it is a fairly consistent figure with the sites all producing good statistics in the last year,’ he says.

A formal review of the impact of social prescribing on healthcare demand and cost by the University of Westminster – published in 2017 and on the Social Prescribing Network website – supports this claim. ‘The evidence for social prescribing is broadly supportive of its potential to reduce demand on primary and secondary care,’ it concludes. Looking at published reports on UK schemes, it found an average reduction in demand for GP services of 28% following referral and an average fall in A&E attendance of 24%. However, it warns that the small number of reports involved and the quality of data meant that the results needed to be interpreted with caution.

Rotherham Clinical Commissioning Group adopted social prescribing back in 2012, when the commissioner’s third sector partner Voluntary Action Rotherham (VAR) put a clear business case proposal to the CCG. The business case had benefits that would meet service delivery targets – improving patient/user health and wellbeing – and result in finance benefits, primarily reducing hospital admissions and A&E attendances. Following a successful pilot, it was recommissioned, with funding in recent years coming from the Better Care Fund.

VAR acts as a social prescribing broker. ‘It runs the scheme for us and we do all the contract monitoring via VAR,’ says Ruth Nutbrown, the CCG’s assistant chief officer. ‘We give it grants that allow it to spot purchase from the voluntary and community sector so we are putting money into the sector and supporting its resilience in Rotherham.’ VAR has also developed a system of micro-commissioning services from the voluntary and community sector. It acts as the lead contracting body and subcontracts with over 20 different organisations.

VAR link workers refer patients onto non-clinical services ranging from benefits and housing advice to lunch, dancing and fishing clubs. Ms Nutbrown says the services are a mix of existing voluntary services that can be referred to ‘without cost’ and ones where services need to be spot purchased or where pump priming funds are needed.

But often the funds are small in comparison to NHS commissioning budgets. ‘£500 can make an awful lot of difference, sustaining a group for years in some cases,’ Ms Nutbrown says. ‘Quite a lot of the grants are that sort of money – to small local Rotherham groups.

Risk stratification tool

‘The scheme uses a risk stratification tool to identify those people most likely to attend A&E or be admitted to hospital and GPs will put patients forward for a referral in multi-disciplinary team meetings,’ she adds.

An evaluation of the long-term conditions scheme in 2016 reinforced earlier assessed benefits. It found reductions of 7%, 11% and 17% in non-elective inpatient episodes, non-elective inpatient spells and A&E attendances. And these reductions rose to 19%, 20% and 23% when the over-80s were excluded. Progress was also made against outcome measures looking at areas such as lifestyle and managing symptoms.

Estimates suggested that NHS costs avoided could be as high as £2 for every £1 invested after five years and before benefits from improved service user outcomes were factored in.

Following the success of the scheme, the CCG started a parallel scheme focused on mental health in 2015 – aimed at supporting discharge from secondary mental healthcare services. It is run in partnership with Rotherham, Doncaster and South Humber NHS Foundation Trust and VAR. This scheme focuses on three service user care pathways: cluster 4 (severe depression and anxiety); cluster 7 (long-term anxiety and depression); and cluster 11 (history of psychotic symptoms, in recovery but needing to regain confidence).

A transition pathway has been developed to support users moving from mental health services to social prescribing activities and discharge – broken down into three separate phases. The social prescribing activities commissioned fall into four broad themes: befriending; education and training; community activity; and therapeutic services.

Two-year evaluation

An evaluation of the first two years of the service was extremely positive. More than 90% of service users made progress against at least one outcome measure. Some gained employment or had sustained involvement with voluntary sector activity. And more than half of the users eligible for a discharge review were discharged from secondary mental health services – a very positive result considering some patients had been supported in secondary care for between five and 20 years.

If discharge can be sustained for at least a year, the evaluation suggested ‘potential for the service to provide fiscal and economic return on investment’, with this return increasing if benefits for non-discharged patients are also taken into account. Wellbeing benefits were estimated to equate to a social return on investment of £1.84 per £1 invested.

The mental health scheme involves smaller numbers of patients than the long-term conditions scheme as it focuses on breaking the cycle of appointments and admissions for patients already in the system. Often the users are also much younger. ‘But we have results where we have actually got people back into work,’ says Ms Nutbrown.

The scheme is also a victim of its own success as referrals are dropping as the numbers of people ‘stuck’ in the system fall. ‘So we are looking to transform the scheme and upstream it to have a focus on prevention,’ she adds.

Last year the government awarded a share of £4.5m to 23 social prescribing projects to extend schemes or establish new ones – as part of a voluntary, community and social enterprise health and wellbeing programme. The funding runs for one-year with additional joint funding from local commissioners to be agreed for the subsequent two years.

The new expansion plans unveiled in the NHS plan suggest far more money will need to flow into social prescribing – both to create the link worker infrastructure and to support the development of community groups and programmes.