Nurses working in primary care and the community know that medicine is not the whole story when it comes to providing effective patient care. They see the evidence daily – when visiting the elderly woman who is painfully lonely, or talking to the young man who is out of work and struggling with debt. A medical prescription may not be what’s needed to treat their problems.
Helen O’Connell, an advanced nurse practitioner at Haworth Medical Practice in West Yorkshire believes that the medical model alone isn’t enough for these patients. ‘Today’s society is lacking in so much. People feel isolated and in need of support.
‘More people are suffering, and the primary care workload is ever increasing. Social prescribing helps ease that workload,’ she says.
What is social prescribing?
According to NHS England, social prescribing is a way for local agencies to refer people to a link worker. 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.
Social prescribing also aims to help people to take greater control of their own health. It can be particularly helpful for patients with one or more long-term conditions, who are lonely, who need support with their mental health, or who have complex social needs which affect their wellbeing.
Schemes providing social prescribing offer activities that are usually provided by voluntary and community sector organisations. Examples include gardening, cookery, befriending, arts activities, healthy eating advice, and sports.
When social prescribing works well, people can be easily referred to link workers from a wide range of local agencies, including general practice, pharmacies, multi-disciplinary teams, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations. People can also refer themselves.
This approach fits in with wider health and care policy, and its importance is highlighted in the NHS Long Term Plan, which states that by 2023/24, over 900,000 people in England will have been referred to social prescribing schemes.
As well as funding link workers, national NHS bodies aim to develop the infrastructure that supports social prescribing. In 2019, the Department of Health and Social Care made £5 million available to set up a National Academy of Social Prescribing (NASP). In 2020, the academy was established as an independent charity, with support from several partner organisations, includingNHS England and NHS Improvement and Sport England.
A drive for this approach
Social prescribing is nothing new. Dr Crystal Oldman, CBE, QNI chief executive says referrals to social interactions and activities have been around for a long time. However, now thatthis approach has been formalised, ‘there is the recognition that this is part of your tool box as a clinician’,
Dr Michelle Howarth is a Senior Lecturer in Nursing at the University of Salford and has a specialist interest in social prescribing, and leads the National Social Prescribing Network Special Interest Group for Nursing. The group shares knowledge and best practice, to support social prescribing at a local and national levels and to inform good quality research and evaluation.
Dr Howarth says there is a drive for social prescribing because, ‘we’re tackling issues around health and wellbeing too late’ when people have already been admitted to hospital. Instead, she says, ‘we should be using assets in communities to enable people to help themselves.’
Social prescribing can also meet the need to treat people as individuals rather than as simply patients. Ms Haworth says that since the 1980s, nursing has become ‘very target driven’, so that that ‘sometimes we forget that someone is not just a patient with signs and symptoms but a person with likes and dislikes.
‘Social prescribing provides a brilliant opportunity to create the time to listen and understand that individual that often nurses and GPs don’t get.’
Putting social prescribing into practice
There are many examples of social prescribing in practice across the country.
Last year, Ms O’Connell launched a new social prescribing platform www.treacle.me – also known as the Social Prescribing (Self-Care) Directory – in Haworth, which provides details of community resources for residents all in one place, making it easier to access support and advice. ‘Doctors and nurses can quickly and easily point people towards the site to find what they need, whether it’s a foodbank, help with employment, or support with their mental health,’ says Ms O’Connell.
In Greater Manchester, 42nd Street offers support and advice for young people’s emotional health and wellbeing. The organisation offers ‘creative programmes specifically to support young people and their families’, says Ms Howarth. And in Salford, she says a simple community gardening group ‘is engaging people through nature to help reduce anxiety and depression’.
This May, the QNI and the National Garden Scheme (NGS) announced the creation of a new scholarship programme for community nurses.The NGS Elsie Wagg Scholarship will support five community nurses each year to undertake a project to improve health and well-being outcomes for people, connected with gardening and social prescribing. The QNI says it is anticipated that the scholarships will, over time, ‘contribute significantly to the evidence base around the value of gardens and gardening to the physical, mental and emotional health of individuals and communities’.
Social prescribing during the pandemic
The value of social prescribing has come into its own during the pandemic as case studies reported by NHS England show.
Ms Howarth says the pandemic has highlighted the ‘power ofcommunity in supporting people particularly those most vulnerable’. In Greater Manchester alone she says the community response has been ‘amazing’, from food banks to helping people to engage with nature.
However, Ms O’Connell points out that carrying out social prescribing has been ‘challenging’ during the pandemic because social distancing requirements led to some community services being stopped, ‘other services started, or moved to be over the phone online, so social prescribing has become accessible to far more people’.
There are numerous benefits to social prescribing, nurses say. According to the RCN, this approach can reduce isolation and enhance social networks, improve physical health, quality of life and emotional wellbeing, and increase patient empowerment. It can also improve self-management increase support to manage long-term conditions, offer person-centred personalised care andreduce pressure on the NHS.
The King’s Fund says 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,’ the King’s Fund states. For example, a programme in Shropshireevaluated between 2017 and 2019, found that people reported statistically significant improvements in measures of wellbeing, patient activation (https://www.kingsfund.org.uk/publications/supporting-people-manage-their-health) and loneliness. At three-month follow up, it also found that GP consultations among participants were down 40% compared to a control group.
However, the King’s Fund also states that 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,’ the King’s Fund says. It adds that, ‘determining the cost, resource implications and cost-effectiveness of social prescribing is ‘particularly difficult’.
Funding is a real challenge for ‘groups providing vital services that don’t know where they are from one month to the next’, says Ms O’Connell.
Patients expecting medications to treat their issues, may not want a ‘social’ prescription. ‘Every nurse is under pressure to ‘fix’ people and some patients want pills and powders,’ says Ms Howarth. She says it is important to have conversations with individuals to understand ‘what matters to them’, while also explaining that not everything can be ‘fixed’ with medication.
Looking ahead, many models of social prescribing are emerging across the country and more are likely to evolve over the next few years. The RCN says that ‘additional work’ is required to develop the evidence base on the impact of social prescribing, and ‘further integration of primary care with wider health and care systems ‘ is needed to reduce demand on stretched primary care services’.
Continued recognition is ‘also needed amongst commissioners, health professionals, social prescribing services, link workers and clients that social prescribing can produce a variety of beneficial outcomes’, the RCN says.
‘Tide is turning’
It is also important for those at the start of their nursing career to learn about the value of social prescribing. Dr Oldman says: ‘We need to ensure this approach is understood by student nurses so that when they qualify they understand that the profession is not all about a prescribing formulary but also about personalised care’.
Recognising this need to raise awareness, Ms Howarth is ‘working with a number of education providers to get social prescribing on the curriculum’.
She believes ‘the tide is turning’ when it comes to health professionals understanding the value of social prescribing. However, for its influence to spread she would like to see social prescribing being more embedded into PCNS and the voluntary sector, and as part of Integrated Care Systems.
Dr Oldman envisages that now social prescribing has funding it will become ‘business as usual’,and ‘a part of the tool box of every nurse working in the community’.
‘Community nurses are well placed to do social prescribing. They’ve been doing it for years. So isn’t it great that what they’ve been doing for years has been funded by government, formally recognised, and seen as great work’.
RCN social prescribing clinical pages: www.rcn.org.uk/clinical-topics/public-health/self-...