I recently learned about an approach to addressing negative social determinants of health (SDOH) called “social prescribing,” and it has the potential to be a complete game-changer. The movement, if I can call it that, seems to have caught fire in places like the United Kingdom, Canada, Australia, Singapore, and, to a lesser extent, the U.S. The concept, which combines the best parts of co-located care (which I discussed in a former blog post) and community-based healthcare, will very likely prove to be an important tool in the transition to value-based healthcare.
Social Prescribing and Community Health
Social prescribing, sometimes referred to as “community referral,” is a relatively new concept that, while in limited use in the United States, has taken on a key role in some countries’ approaches to population health. In the UK, where the concept has perhaps seen its greatest uptake, the National Health System (NHS) is aiming “to have nearly one million patients referred for social-prescription interventions by 2024.”
Social prescribing is seen as one part of a larger concept called “community health.” Community health is a fairly malleable term, but as defined by NHS England, “Community health services cover a wide range of services and provide care for people from birth to the end of their life. Community health teams play a vital role in supporting people with complex health and care needs to live independently in their own home for as long as possible.”
OK, so what does the “community” in “community health” mean exactly? The UK’s National Institute for Health and Care Excellence provides a useful definition of the term that I think works well for our purposes: “A community is a group of people who have common characteristics or interests. Communities can be defined by: geographical location, race, ethnicity, age, occupation, a shared interest or affinity (such as religion and faith) or other common bonds, such as health need or disadvantage. People who are socially isolated are also considered to be a community group.”
That last part about socially isolated or underserved people representing a community is key to social prescribing, which facilitates the improvement of people’s circumstances by employing non-medical interventions. For example, some of these interventions include things like “art classes for wellbeing, knitting, singing, or walking groups.” In other words, social prescribing allows general practitioners (GPs) in the UK to refer patients to designated community health professionals who can, in turn, involve these patients in non-clinical activities that can help improve their overall wellbeing.
Social Prescribing in the UK
Now that we’ve got a few definitions out of the way, let’s examine how social prescribing has come to occupy such an important place in the UK’s National Health System. Central to the success of this approach is something called a “link worker.” NHS England describes link workers like this:
“Link workers give people time, focusing on ‘what matters to me’ and taking a holistic approach to people’s health and wellbeing. They connect people to community groups and statutory services for practical and emotional support.”
In the service of improving the day-to-day lives of patients, link workers leverage an in-depth familiarity with local, community-based non-medical support resources. Social prescribing is ideally suited to people fitting one or more of the following descriptions:
- Those with one or more long-term conditions
- Those in need of support with their mental health
- Those who are lonely or isolated
- Those who have complex social needs which affect their wellbeing.
So how is any of this different from a typical social worker, one might ask? Well, for one thing, the sheer number of stakeholder agencies who can refer a patient to a link worker is quite broad: “general practice, pharmacies, multi-disciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations” represent this potential pool of referrers.
Secondly, the requirements for becoming a social worker (sometimes called a “social care worker”) in the UK differ significantly from those involved in becoming a link worker. Life experience, good communication skills, and a willingness to be trained — and, in some instances, other skills as described here — are all that are required to join the ranks of link workers. This sounds great, because given the pressing need for this kind of work, I can only assume that removing high barriers to entry would help to more quickly address the issue.
By contrast, there are relatively more rigorous requirements involved with becoming a social care worker. A list of these requirements, including having either a BA or a master’s degree, can be found on the British Association of Social Workers website. While there are fast-track options for going into this line of work, the profession seems more highly regulated.
Why Social Prescribing?
When looked at through the lens of population health or population health management, it becomes clear why social prescribing can be so effective. If you skip to the 3:47 mark of this video produced by the Healthy London Partnership, you’ll see a physician attest to the fact that, although initially skeptical that social prescribing interventions could help his patients, he was bowled over by how much the link workers were able to lighten his workload by mitigating negative SDOH. And at the 4:12 mark, another physician explains how in his practice, they’ve seen a reduction in the number of GP appointments for patients where link workers have been involved.
Although its advocates focus on its many merits, real-world evidence for the effectiveness of social prescribing is mixed at best. For instance, a social prescribing pilot project was conducted with much success between April 2012 to March 2014 (and was subsequently re-contracted for another three years starting in 2015) in Rotherham, a metropolitan borough of South Yorkshire in the UK which has a population of over 100,000 people. Here is a summary of the project that appears on the Social Care Institute for Excellence website:
“The service is especially aimed at users with complex long-term conditions (LTCs) who are the most intensive users of primary care resources. The service receives referrals from GPs of eligible patients and carers, and assesses their support needs before referring on to appropriate voluntary and community sector services. The service also administers a grant funding pot, through which a ‘menu’ of voluntary and community sector activities is commissioned to meet the needs of people who use services.”
Top-line results include the following:
- An estimated social return on investment (which the WHO defines as “value produced for multiple stakeholders in all three dimensions of development: economic, social and environmental”) of £570,000–£620,000
- A 7% reduction in non-elective inpatient episodes
- A 17% reduction in accident and emergency department (A&E) attendances
- An initial return on investment of 43 pence for each pound invested in terms of avoided costs to the NHS
All of these points speak to the potential positive impact of social prescribing, but I find this last point most compelling: the upfront investment in preventative care paid dividends. Devoting time and resources to improving people’s lives outside of the clinical space could save health systems money while at the same time leading to better patient outcomes — and this study proves it.
Data provided in the Open Data Institute’s (ODI) November 2021 report on social prescribing seem to back this up the practice’s effectiveness. “If GP appointments fall by 2-5% as a result of social prescribing operating at scale,” say the report’s authors, “it could lead to a diversion of between 3.2-8 million GP appointments per year.” This extra capacity could be used to see more patients, which is key in a system like the NHS which has seen major backups due to the pandemic.
As much success as the Rotherham social prescribing project enjoyed, however, the advent of the COVID pandemic has proved a major headwind for link workers. Given that so much of this kind of work is done face-to-face, strict social distancing orders and lockdowns over the past couple of years have taken their toll.
Although a recent article in The Lancet highlights how primary care doctors have adapted social prescribing during the pandemic to leverage phone and internet engagement when connecting nurses and health-care assistants with patients, resources haven’t been fully aligned to maximize the practice. The ODI’s report exposed several barriers that have conspired to limit social prescribing’s potential in recent years. A few of these issues highlighted in the report include the following:
- Local Authorities, health, and voluntary sector organizations maintain separate directories of locally available services which can lead to duplication of effort and issues with interoperability
- Data sharing is limited when multiple community service directories exist in a local area due to a lack of trust between organizations
- A lack of information on attendance/user satisfaction and challenges means that link workers may have to invest time exploring the suitability of a new service with which they may be unfamiliar
Despite these shortcomings, I think social prescribing holds a lot of promise. It hasn’t made many inroads in the U.S. yet, but it seems to be catching on across the globe. I may highlight examples of social prescribing in other countries in future blog posts.