A Social Prescription a Day Keeps the Doctor Away?

“Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.” Paracelsus

With the next general election in less than two months’ time, mental health and wellbeing issues have recently become a political talking point with several parties promising to “bring mental health out of the shadows”. This attention is much needed given the estimated 8%, or £600 million, cuts to mental health over the course of this parliament. As a result, politicians and commissioners alike are looking for ways to do ‘more for less’.

One approach that has been a recent talking point in the news is that of ‘social prescription’, which one news article suggests could save the NHS in excess of half a billion pounds. Social prescription can be defined as “a mechanism for linking patients with non-medical sources of support within the community”. The most common examples prescribed to people with an array of health conditions are: exercise on prescription, prescription for learning and arts on prescription. However, these are only a small number of potential schemes that may fall under the remit of social prescription which can range from fishing clubs to knitting groups and include initiatives such as The Royal Society of Arts’ ‘Social Mirror project which aims to demonstrate how GPs can help spread healthy behaviour amongst isolated populations.

As well as media attention, this approach has also begun to gather political attention. For instance, the independent task force behind ‘the mentally healthy society’ recently recommended that GPs should regularly use social prescribing. Moreover, earlier this month, Vince Cable spoke of his personal experience with social prescription within his family, describing how his mother grappled with postnatal depression for a year in hospital, but purports her recovery began only when she was given the opportunity to attend an adult education course. He explains:

“She’d never had a proper formal education. She started going to these classes and learned about art and history and things she’d never studied before. It gave some focus to her life and perhaps it kind of stabilised her mentally and she started leading a normal life. The mental illness problems went away. She attributed it to the fact that she had had these educational opportunities later in life.”

These claims for social prescribing suggest that it could have a real, positive impact on the lives of people with a mental health problem, so we wondered what the published research literature had to say.

There is some evidence to show that social prescription leads to a wide range of benefits for those with mental health problems, including: increased awareness of skills, activities and behaviours that improve and protect mental wellbeing; increased levels of social contact and social support among marginalised and isolated groups; and reduced levels of inappropriate prescribing of antidepressants. However, there is, as yet, no concrete evidence to support media claims that social prescription will lead to significant cost savings; the most relevant economic evaluation of primary care referral to non-medical, voluntary sector activities showed that the costs actually increased in the short to medium term.

However, the evidence remains limited due to a paucity of research examining social prescription and its impacts. This is partly due to the challenging nature of researching such a complex, person-focussed intervention. Whilst the media showcases an array of positive case studies of social prescription, there are still several questions that remain unanswered. Research must untangle which prescriptions work best for whom and why; and which specific aspects of the prescription result in the greatest benefits.

Janet Brandling and William House explain this challenge in their blog for the British Journal of General Practice:

“The multiplicity of options is one of the key challenges. The idea is simple but the reality is complex. How can busy GPs and others in primary care know what is available? How is it done? You can’t write it on an NHS prescription. What is the evidence that it works? Which patients might benefit? Is it yet another unwanted role to be foisted onto GPs, or a welcome path away from the medicalization of society?”

What is clear is that there is a demand for these questions to be answered. In polls commissioned by Nesta in 2013 for their reportMore than Medicine” they found that out of 1,000 GPs surveyed, four out of five thought that social prescriptions should be available from their surgeries, whilst 59% of the 2,000 members of the public surveyed said that they would like their GP to offer social prescriptions. For this to occur there must be a wider base of evidence which may give GPs, as well as the general public, the confidence to engage in these schemes. As one news article put it “If social prescribing is to be more widely and systematically adopted it needs to be seen to work. It needs to demonstrate it can reduce queues in GP surgeries and A&E and relieve hard-pressed mental health services and social care.”

So what are we doing at the McPin Foundation to explore social prescribing?

Currently, we are evaluating the Kent Six Ways to Wellbeing Project which includes multiple Kent County Council funded initiatives. Several of these are relevant to the notion of social prescription, including library wellbeing hubs to promote self-help books, creative arts programmes to enhance the wellbeing of 11-19 year olds and a primary care link worker program which aims to link primary care professionals with the voluntary sector. We will be monitoring these programs in terms of their impact on people’s wellbeing, using a standard scale – the Warwick-Edinburgh Mental Wellbeing Scale – and mapping mechanisms for change in each project to unpick how these impacts have been achieved. Through this work, we hope to contribute in a small way to the evaluation of projects that could be part of a social prescription.

So what’s next for social prescription? As outlined, there is a clear case for further research into social prescription, to see whether the reality lives up to the promising claims made in recent news reports. This research needs to grapple with the challenge of providing good evidence without reducing social prescription to a ‘one-size-fits-all’ intervention, recognising that social prescription is most effective when it is truly person-centred. This year is the anniversary marking 15 years since a UK government first declared the intention to create a ‘patient centred NHS’ and this commitment must be reflected in any innovations to improve mental health support.

What is your experience of social prescribing? How can we help to build the evidence base around social prescribing? If you have suggestions, please do get in touch.