Imperial College lunchtime seminar–(18th Oct 2017)

IS THERE A ROLE FOR SOCIAL

PRESCRIBING GLOBALLY?

Dr. Marcello Bertotti (Senior Research Fellow)

Institute for Health and Human Development, University of East London

Steering group member of the Social Prescribing Network

WHY DO WE NEED SOCIAL PRESCRIBING?

Increasing rate of Long Term Conditions. E.g. diabetes. The

WHO (2012) estimated that in 2012 620,000 died of human

violence (war and crime), 1,500,000 died of diabetes.

‘Sugar is more dangerous than gunpowder’ (Harari, 2017).

Around 15m people in England have one or more LTCs

increasing by a third over the next 10 years (DH, 2012).

LTCs account for 50% of all GP appointments and 70% of

all inpatients bed days.

Frequent attenders to primary care: In the UK, 20% of

patients attend GP for social rather than medical reasons. It

costs the NHS £395m per year (Citizen Advice, 2016)

Persistent level of health inequality (Cawston, 2011). This

lead to long-term medical conditions and particularly affects

people in disadvantaged areas

Policy interest in social prescribing

• Model for integration across health

and social care systems

• One of the 10 high impact actions to

release capacity

• One of the emerging models

(Rotherham)

• It was proven to cut A&E, out-

patient and hospital admissions

THE SOCIAL PRESCRIBING PATHWAY

PATIENT

HEALTH AND SOCIAL

CARE PROFESSIONAL

LINK WORKER

COMMUNITY/STATUTORY

SECTOR

“Social prescribing involves

empowering individuals to

improve their health and

wellbeing and social welfare

by connecting them to non-

medical and community support services”

National Social Prescribing Network

Patients/clients

/people

Long term conditions (e.g.

diabetes)

mild/moderate MH problems,

social isolation/loneliness,

social problems (e.g. housing,

employment)

Health and social care

professionals

Mainly GP practices

and doctors but

Social workers

Pharmacies

Others: e.g hospitals,

mental health support

Coaching, motivation

Co-production with user

Knowledge about

community activities

Modes of delivery

Signposting

Referring

….Link workers, community navigators, well-

being coordinators, referral facilitators …..

Community and statutory sector

• Volunteering

• Housing and employment advice

• Psychological counselling

• Walking clubs; sport clubs

• Cook and eat sessions

• Lunch clubs

• Gardening

• Group art and dance

• Museum, books e.g. art on prescription

• Conservation

Direct referral

• GP referring

patient to

comm. Activity

• Very limited

engagement

• Limited range

of services

Signposting SP

• Soc prescriber

signposting (tel

based),

• some

engagement

(often one

consultation)

• limited range

of services

Referral SP

• Soc. Prescriber

• mixed f2f and tel,

co-production,

• in-depth service

(e.g. coaching)

• Wide range of

services

Information

only

•Leaflet in a

surgery

•No

engagement

of patient

DIFFERENT MODELS OF SOCIAL PRESCRIBING

LOW

INTENSITY

HIGH

INTENSITY

WHAT DOES THE EVIDENCE SAY?

Summary of outcome evidence

15 evaluations were analysed (out of 341)

Measured health changes at 6 months

Mental health and wellbeing mainly

All studies measured improvements in

health and well-being

However,

No evidence beyond 6 months

Only one RCT (Grant et al, 2000) but only 4

months follow-up and lack of clarity as to

whether it was SP

Evidence from qualitative studies

Much of qualitative evidence is positive

Changes in self-esteem, hope, motivation particularly when sustained through volunteering

“Best thing has been meeting new people and making friends. My mobile full up with names and numbers of friends before it was just family and doctor’s number. I was really depressed before but now really happy. Before I have nothing to do, now every day I wake I think ‘yes volunteer work!’ or ‘meeting friends!’”

Role of link worker is key to positive changes (from signposting to coaching)

“You feel able to offload if you need to, discuss your fears - it’s about not being so hard on myself and validating myself.”

Summary of economic evidence

94 projects reports

14 projects met criteria: UK

based; referral from primary

care; link worker; third

sector; demand for

healthcare services analysis

One RCT and two matched

controlled studies

8 studies conducted a cost-

benefit analysis. No cost-

effectiveness or cost-utility

analysis was found.

Summary of economic evidence

GP attendance: 28% reduction (2-70%)

A&E attendance:24% fall (8%-27%)

Emergency hospital admissions 6-33% reduction

Overall reduction in referral to secondary care (6%-34%)

Economic data - SROI £2.3 per £1 in first year

Challenges to the development of Social

Prescribing

Lack of feedback to GPs

Most users do not recognise social prescribing

Engagement of GPs: “The terrible thing is that I referred five but I

should have referred about 15 times that. Although I am very enthusiastic about it, it is hard to keep in front of your mind, and that’s the challenge!” (General Practitioner)

Local commissioners have limited funding, although some new funding is now available and 75% STPs involved – increase in discussions between CCG/LA/PH

Third sector needs investment to ensure sustainability of social prescribing. Examples of allocating funding to third sector exist (e.g. Rotherham, Newham community prescribing, Ways to Wellness)

Methodological challenges in evaluating social

prescribing Many outcomes: how do we know which is the right

outcome to measure?

Generalisability of data? What is the right method to

include a control group?

The monitoring of social prescribing is problematic.

Data collection is often patchy. E.g.

What happens to patients after they have been

referred by their link workers?

What and why we have drop outs?

Conclusions (1/2)

Social prescribing represent an important opportunity to:

Prevention (e.g. pre-diabetic), self-care/self-

management of LTCs, social problems (unemployment,

debt, housing etc)

It focuses on the bio-psycho-social model of illness

beyond anatomy and physiology

Makes effective use of the community sector

Takes forward NHS person-centred agenda

Social prescribing as an opportunity

Conclusions (2/2)

The current evidence is not yet robust enough:

Qualitative evidence show much promise, but this is not

yet followed by rigorous quantitative studies

economic analysis also shows promise but

Overall, we need studies with larger samples, over

longer follow up periods and possibly randomised

controlled studies.

Would you see this type of intervention work in other

countries?

Thanks for listening

If you want to join the mailing list of the social prescribing network:

Socialprescribing@outlook.org

For more information:

Dr Marcello Bertotti m.bertotti@uel.ac.uk

References

Dahlgren G, Whitehead M (1992). Policies and

strategies to promote social equity in health.

Copenhagen, WHO Regional Office for Europe

Cawston, P. 2011: Social Prescribing in very

deprived areas. British Journal of General

Practice, 61 (586), 350.

vi Citizen’s Advice (2016) A very general

practice: How much time do GPs spend on

issues other than health?

https://www.citizensadvice.org.uk/Global/Ci

tizensAdvice/Public%20services%20publicatio

ns/CitizensAdvice_AVeryGeneralPractice_May

2015.pdf

Harari, Yuval Noah “Homo Deus. A Brief

History of Tomorrow”, London: Vintage

World Health Organisation (2012) ”Global

Health Observatory Data Repository, 2012”