HERE are some recent headlines from the popular press: “Why your doctor may be prescribing art classes in the future”, “How creativity on prescription can improve mental and physical health”, “Combat loneliness with social prescribing”, “Why social prescribing is the latest drug-free trend”, “The arts are a shadow health service”.
These headlines indicate that our current health and wellbeing is reliant on far more than what medicine and psychology can provide.
Research indicates that we tend to underestimate the relevance of social factors such as loneliness and social isolation, and other social, economic and environmental determinants of health. For example, a recent meta-analysis showed that social isolation is associated with an overwhelming 29% increase in mortality, and there is evidence to suggest that 20% of all GP visits are for social issues primarily.
Social prescribing (sometimes referred to as non-medical prescribing or community referral) is a relatively new concept, developed as an innovative way to move beyond the medical model and to address the wider social determinants of health. Social prescribing enables GPs and allied health care professionals to refer patients, whose health or mental health is affected by non-medical factors such as housing, financial stress, health literacy, loneliness or social exclusion, to a range of community services that can deal with these issues.
Social determinants of health — the conditions into which we are born alongside the broader set of forces and systems shaping the conditions of our daily life — are the cause of many health inequalities. Non-medical factors have a widespread effect on our overall physical and mental health. For example, individuals who are less affluent and less educated have more health problems and die earlier than those who are more affluent and more educated.
Social prescribing acknowledges that individual health is largely determined by a wide range of social, economic and environmental features, thus offering holistic support that is person-centred and tailored to individual needs. It involves the creation of referral pathways to the “third sector” (local non-clinical voluntary services and community groups) that enable health care professionals to refer patients or clients to a link worker in order to codesign a non-clinical social prescription to improve their health and wellbeing. This link worker (community development worker, wellbeing coordinator, social prescribing coordinator) holds detailed knowledge of local organisations, services and supports to ensure appropriate signposting for individuals and facilitate access.
Some examples of the groups and services used by social prescribing schemes include luncheon clubs; walking and reading groups; literacy classes; support with housing, employment, debt and legal advice; gardening groups; cooking classes; exercise programs; and arts and creative activities.
The social prescription should be an activity that is in keeping with the individual’s interests in order to enhance its benefits and individual adherence to it. These activities can then be combined with appropriate medical treatment (if required) to optimise chances of recovery wellbeing and quality of life.
A number of models of social prescribing have been described. While there is no commonly agreed upon best model, these models range from low to high intensity and from limited to full patient or client engagement. The low intensity model offers information only, such as a brochure in a GP office and no patient engagement. The next level of intensity involves direct referral with a GP or allied health professional referring a patient to a community activity or program. This typically involves a limited range of services and limited engagement. More intense models involve explaining the logic of social prescribing, which encompasses a social presciber — whether that’s a GP or a link worker — signposting over the phone with some consultation, often in the form of a single consultation, and a limited range of services.
The most intense model is known as “referral social prescribing”, in which there is a link between the social prescriber role with mixed face-to-face and telephone interactions, an in-depth coaching service and a wide range of services offered.
What does the evidence tell us about the effectiveness of social prescribing?
There is emerging evidence that social prescribing has the potential to result in an array of positive health and wellbeing outcomes including increases in self-esteem and confidence, a sense of control and empowerment, improvements in psychological or mental wellbeing, and positive mood linked to decreases in symptoms of anxiety and depression. A recent systematic review of social prescribing schemes in the UK reported increased self-esteem and confidence, improved mental wellbeing and positive mood, improvement in physical health and lifestyle, increased social connectedness, reduced social isolation and loneliness, and reduced anxiety, depression and negative mood. Bickerdike and colleagues analysed 15 evaluations and reported that, although all studies showed improvements in health and wellbeing, there was a lack of evidence beyond 6 months.
There was only one randomised controlled trial reviewed, but it focused on 4-month follow-up only and there was some lack of clarity regarding whether it represented social prescribing. Using a mixed methods analysis, Woodall and colleagues found improvements in wellbeing and perceived levels of health and social connectedness as well as reductions in anxiety. In many cases, the social prescribing service enabled individuals to have a more positive and optimistic view of their life, often through offering opportunities to engage in a range of activities in the local community.
In general, social prescribing schemes appear to result in high levels of satisfaction on the part of participants, primary care professionals and commissioners. In spite of this, systematic and rigorous evidence of effectiveness is fairly limited and more sophisticated designs are needed to provide further rigour. Many studies are small in scale and focus on process rather than outcome. Much evidence is based on self-reported outcomes and often lack comparative data. However, as Woodall and colleagues have noted, relying on the randomised controlled trial to assess social prescribing effectiveness is not only challenging, but has moral and ethical implications — primarily precluding clients from accessing voluntary and community services to improve their health.
There is now an imperative to develop research programs aligned with implementation of social prescribing that are longitudinal and that combine process and outcomes-focused mixed methods evaluations with embedded randomised controlled trials. This will produce empirical evidence regarding our understanding of who can benefit from which interventions in which contexts and enhance our understanding of patients’ unique interactions with referring service providers, link workers and community supports in the broad array of social interventions available.
Social prescribing represents an approach to public health that has the potential to address the health and social needs of individuals and communities. It offers a significant opportunity to focus on biopsychosocial and environmental models of illness that move beyond traditional biomedical models, to make efficient and effective use of the voluntary and community sectors, and to highlight a patient- and client-centred focus. Given the influx of funds to support social prescribing, particularly in the UK, we must ensure a concomitant evidence base. Such an evidence base can elucidate the potential of this scheme to move us beyond clinical options, enriching the capacity of the community to respond to the biopsychosocial and environmental aspects of our daily lives.
Professor Katherine Boydell is Co-Director of the Qualitative Research Lab, a Black Dog–UNSW initiative, and is Director of Knowledge Translation in the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE). She is an internationally recognised leader in qualitative inquiry and arts-based knowledge translation in the early psychosis field.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.