The ethos of social prescribing

From the website of The King’s Fund:

This explainer was originally written by David Buck and published in February 2017. It was updated in November 2020 by Leo Ewbank.

Social prescribing, also sometimes known as community referral, is a means of enabling health professionals to refer people to a range of local, non-clinical services. The referrals generally, but not exclusively, come from professionals working in primary care settings, for example, GPs or practice nurses.

Recognising that people’s health and wellbeing are determined mostly by a range of social, economic and environmental factors, social prescribing seeks to address people’s needs in a holistic way. It also aims to support individuals to take greater control of their own health.

Schemes delivering social prescribing can involve a range of activities that are typically provided by voluntary and community sector organisations. Examples include volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports.

Social prescribing is designed to support people with a wide range of social, emotional or practical needs, and many schemes are focused on improving mental health and physical wellbeing. Those who could benefit from social prescribing schemes include people with mild or long-term mental health problems, people with complex needs, people who are socially isolated and those with multiple long-term conditions who frequently attend either primary or secondary health care.

There are different models of social prescribing being employed across England. Most involve a link worker (other terms such as community connector, navigator and health adviser are also used) who works with people to access local sources of support. For example, at the Bromley by Bow Centre, a community and primary care hub in east London with a long history of social prescribing and other community-focused work, staff work with people, often over several sessions, to help them get involved with local services ranging from swimming lessons to financial advice services.

Social prescribing can be understood as one of a family of approaches, sometimes called community-centred approaches, which aim to mobilise the power of communities to generate good health.
Does social prescribing work?

There is a growing body of evidence that social prescribing can lead to a range of positive health and wellbeing outcomes. Studies have pointed to improvements in quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety.

For example, an evaluation of a social prescribing project in Bristol from the early 2010s highlighted improvements in anxiety levels and in feelings about general health and quality of life. And a study of a scheme in Rotherham (a liaison service helping people access support from more than 20 voluntary and community sector organisations), showed that for more than 8 in 10 people referred to the scheme who were followed up 3 to 4 months later, there were reductions in NHS use in terms of accident and emergency (A&E) attendance, outpatient appointments and inpatient admissions. Exploratory analysis of the scheme suggested that it could pay for itself over 18–24 months due to reduced NHS use.

More recent evaluations have pointed to similar opportunities. A community connector scheme in Bradford reported improvements in service users’ health-related quality of life and social connectedness (among other measures). And a programme in Shropshire, evaluated between 2017 and 2019, found that people reported statistically significant improvements in measures of wellbeing, patient activation and loneliness. At three-month follow up, it also found that GP consultations among participants were down 40 per cent compared to a control group.

While experience – much of it positive – continues to accumulate about social prescribing, there remain weaknesses in the evidence base. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative and relies on self-reported outcomes.

Determining the cost, resource implications and cost-effectiveness of social prescribing is particularly difficult. Several studies highlight the importance of measuring the wider social value generated through social prescribing, for example, through reducing welfare benefit claims. Again, this can be difficult to measure, and may require a longer-term approach. A recent study found that more than half of the outcomes social prescribing can deliver are not being routinely measured in evaluation frameworks.

Overall, the evidence available today offers good reason to think social prescribing can deliver benefits for some people. But, as a number of recent meta-analyses and Public Health England have concluded, further work is needed to strengthen the evidence base and clarify expectations of what benefits can be delivered and for whom.
How does social prescribing fit in with wider health and care policy?

Social prescribing and similar approaches have been practised in the NHS for many years, with schemes dating back to the 1990s, and some even earlier (the Bromley by Bow Centre was established in 1984). For a long time, though, social prescribing was practised in pockets and largely unnoticed by national NHS bodies.

The past few years have seen an important change: national NHS bodies have embraced social prescribing and committed resource to rolling it out across England. The NHS five year forward view (2014) opened the door with its focus on prevention, its emphasis on the role of the voluntary and community sector, and by citing examples of social prescribing schemes having a positive impact. Subsequently, the General practice forward view (2016) noted the role voluntary and community sector organisations, and particularly social prescribing, can play alongside GP services in offering people community-based support.

The NHS long-term plan (2019) marked a step change in ambition by incorporating social prescribing into its comprehensive model of personalised care. Composed of six programmes including personalised care planning and personal health budgets, the model aims to enable people, particularly those with more complex needs, to take greater control of their health and care.

Rather than seeking to directly fund the groups that deliver social interventions, the Long-Term Plan commits funding to the link workers who connect people to the range of support and engagement opportunities – largely run by charity and voluntary organisations – in their local area. The Long-Term Plan set a target that by 2023/24 every GP practice in England will have access to a social prescribing link worker and 900,000 people will be referred by then.

Primary care networks (PCNs), groupings of GP surgeries serving populations of around 30–50,000 patients, are the channel for this resource and in many cases will host the link-worker service. In 2019, a new five-year contract framework for general practices came into effect, which allows every PCN with a population of 30,000 or more to be reimbursed the costs of employing a link worker (one full-time equivalent and more for PCNs with populations of more than 100,000). By autumn 2020 national NHS bodies were reporting that more than 1,200 link workers were in post.

Alongside funding link workers, national NHS bodies are seeking to grow the infrastructure that supports social prescribing. In 2019, the Department of Health and Social Care made £5 million available to establish a National Academy of Social Prescribing. The academy was officially formed as an independent charity in 2020, with support from a number of partner organisations, such as NHS England and NHS Improvement and Sport England; it plans to focus on raising the profile of social prescribing, building the evidence base and sharing promising practice. It also seeks to support voluntary organisations involved in social prescribing and explore funding partnerships.

Other government departments have shown a growing interest in the potential of non-clinical interventions in recent years. In 2018, the government’s strategy to tackle loneliness backed the roll-out of social prescribing, and in 2020 the Department for Environment, Food and Rural Affairs announced funding for a two-year trial of ‘green social prescribing’ – initiatives intended to help people engage with the natural world.

National policy-makers backing community-centred approaches to health, including social prescribing, is welcome. Implementing social prescribing at scale will see more people benefit than has been possible in the past. However, its incorporation into the NHS’s national agenda also brings risks. It remains to be seen, for example, if the ethos of social prescribing will be changed by a more proximate relationship with NHS national policy-makers.

Looking ahead, it will be important that national roll-out of social prescribing is done in a way that pays careful attention to learning. For example, further insight is needed into the impact of different models of link working, and how link workers can be effectively supported and embedded within a wider multidisciplinary team. There is an opportunity to improve the quality of evaluation and develop a more granular understanding of which approaches from within the range of models deliver value, for whom, and how. National NHS bodies, and the National Academy of Social Prescribing, will have a key role to play in this.

Partnership between the NHS and the voluntary and community sector is integral to effective health and care; the national roll-out of social prescribing supports that. But its impact over the coming years will also depend on the scale and vitality of the voluntary and community sector, particularly small place-based charities. Covid-19 has seen the voluntary and community sector’s income fall, while the need for the sector has increased. The policy support for social prescribing must be accompanied by adequate funding for those organisations, primarily local charities, receiving social referrals if it is to be sustainable in the long term.”

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