Kathy Oxtoby looks at the value of social prescribing for older people, the benefits and challenges of this approach, and how it can help isolated individuals connect with their communities
Enid is 84. She has hypertension and type 2 diabetes, which is controlled. Physically she was coping well, until last year when her husband of 62 years died. Recently, Enid has been a bit snappy with staff at her doctor’s surgery, and more demanding than usual.
Society is a bit uncomfortable with the what to do about the needs of this ageing widow whose family live 100 miles away. But her problems cannot be managed with medicine. Enid is lonely. Recognising this, her GP put her in contact with a primary school group that links mature women with young mums that are a long way from their own families. Enid meets the group two times a week sharing the benefits of her experiences as a mother. Enid feels needed again.
Professor Helen Stokes-Lampard, a GP, and chair of the National Academy for Social Prescribing uses the example of her ‘patient’ Enid to illustrate the many cases of lonely, isolated older people that community geriatricians and GPs come across in the course of their practice, who could benefit from what she describes as ‘Enid shaped care’.
“”Everyone of us recognises an ‘Enid’ in their consulting room whose problems are so much wider than medical problems. Enid didn’t need more drugs to mask her pain, she needed a cure for her loneliness,” says Professor Stokes-Lampard.
What is social prescribing?
Enid’s case shows the power of ‘social prescribing’ – an approach which “recognises the importance of people’s social needs, and helps them to have the best life they can”, says Professor Stokes-Lampard. She defines social prescribing as “the process of supporting people, via social prescribing link workers, to make community connections and discover new opportunities, building on individual strengths and preferences to improve health and wellbeing”.
According to NHS England, social prescribing is said to work for “a wide range of people”, including people with one or more long-term conditions, who need support with their mental health, who are lonely or isolated, or who have complex social needs which affect their wellbeing.
As for how social prescribing fits in with wider health and care policy, The NHS Long Term Plan emphasises its importance and states that by 2023/24, over 900,000 in England people will have been referred to social prescribing schemes.
In addition to funding link workers, national NHS bodies want 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.
Professor Stokes-Lampard says the academy aims to “make some noise to raise the profile of social prescribing, find resources, develop innovative funding partnerships, build relationships across sectors, improve evidence, and spread good practice”.
Need for social prescribing
Helen O’Connell, an advanced nurse practitioner (ANP) and Queen’s Nurse, Haworth Medical Practice, West Yorkshire, says there is a need for social prescribing because “more patients are presenting at primary care with a vast array of complex problems that are not medical, but social issues which are affecting their health”.
This approach is particularly relevant for older people whose health and care needs are changing. Increasing numbers are living with the combined effects of age-related chronic illness or disability, social isolation and/or poor mental health. According to one study on social prescribing, it has “the potential to benefit older people by helping those with social, emotional or practical needs to access relevant services and resources within the local community”. (Hamilton-West et al, 2020.)
Social prescribing is often referred to as a remedy for loneliness and social isolation. However, as the British Geriatric Society states in its report Healthier for longer. How healthcare professionals can support older people (2019), it can also be used to “help people to find practical support for things that may be worrying them”, such as help with the garden or financial advice. “There is potential for social prescribing to be utilised to great effect in helping older people to cope with daily living and to live independently,” the report says.
Social prescribing in practice
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, befriending, cookery, healthy eating advice, and a range of sports.
There are numerous examples of social prescribing in action across the country. For example, in Frome, Somerset, a project was created by a GP surgery in 2013. Known as the Compassionate Frome Project, it has ‘health connectors’ who act as a bridge between the patient’s medical and social needs and community connectors to link patients with support including help with house and debt problems as well as choirs, exercise classes and lunch clubs.
And this July, Ms O’Connell launched a new social prescribing platform www.treacle.me - also known as the Social Prescribing (Self-Care) Directory - in Howarth, which has details of community resources for residents all in one place, making it easier to access support and advice. “It’s connecting people, making them feel supported, and allowing them to tap into community expertise that otherwise they wouldn’t know about,” says Ms O’Connell.
During the pandemic the value of social prescribing has come into its own, as case studies highlighted by NHS England show. The need for social isolation and shielding to help prevent transmission of the virus has made the task of social prescribing for older people harder because activities typically involve face to face contact. But “link workers have been doing a fantastic job, using their skills via the phone or online, for example through Zoom meetings, to continue to engage with populations,” says Kerryn Husk, senior research fellow, University of Plymouth, who runs a research group looking at non NHS delivered interventions and social prescribing.
Dr David Attwood is a GP Partner and GPwSI Older People at Pathfields Medical Group, Plymouth, honorary secretary of the British Geriatrics Society, and clinical lead for the Integrated Care of Older People in Devon. He says that prior to the pandemic, the practice was running a one-year pilot to “systematically and opportunistically” identify all the older people who live with a medical diagnosis of frailty. That population was then sub-segmented by whether or not people were housebound, or living in a care home.
This meant that when the first lockdown hit, “we were able to send a list of people who were housebound to our social prescribing organisation, the Wolseley Trust, and every single one of those individuals were given a welfare check, which included checking they had adequate care and necessary food and medical supplies,” says Dr Attwood.
Benefits and challenges
There are many benefits associated with social prescribing, practitioners say. “From the patient’s point of view it helps them to be healthier, happier people, and from the clinician’s point of view it’s a more rewarding way to practice. And from a system point of view, if people are happier and fulfilled they will do better on their health journey, leaving doctors to spend less time on ‘social’ and more time on ‘medical’”, says Professor Stokes-Lampard.
For Dr Attwood, one of the advantages of this approach is that rather than prescribing pills “social prescribers are asking the patient what really matters to them, what they would like their life to be like, what’s stopping them getting there and what series of steps they need to take to get there. It’s about working with and supporting patients to be their own agents of change”.
According to The King’s Fund 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 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.
However, the King’s Fund also points out 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”.
While social prescribing is “another positive tool” for practitioners, it should not be viewed as “a panacea that will address all the shortcomings of the NHS”, stresses Mr Husk. And funding for social prescribing, says Ms O’Connell, is another challenge, because many schemes are run by charities and social enterprises who are already stretched for money.
In their recent report New horizons in supporting older people's health and wellbeing: is social prescribing a way forward?, Hamilton-West and colleagues emphasise the need for “researchers and planners to work together to develop a more robust evidence-base, advancing understanding of the impacts of social prescribing (on individuals, services and communities), factors associated with variation in outcomes and strategies needed to implement effective and sustainable programmes”.
They also call on policymakers to “recognise the need for investment in allied initiatives to address barriers to engagement in social prescribing programmes, provide targeted support for carers and improve access to older adult mental health services”.
More ‘Enid shaped care’
Looking ahead, the King’s Fund says 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,” the King’s Fund says.
Ms O’Connell envisages an “exciting future for partnerships between the primary and voluntary sector, which is already starting to happen locally”. And Prof Stokes-Lampard hopes to see the expansion of social prescribing throughout the NHS, including in psychiatry “where many colleagues are desperate to have access to this wonderful resource”.
Such expansion will help make more ‘Enid shaped care’ possible. And as the case of Enid shows, and as the British Geriatrics Society and Royal College of Psychiatrists say in their position statement on loneliness and social isolation: “Feelings of loneliness do not have to be an inevitable part of growing old, and there is much that all of society – from government right through to community groups and individuals – can do to better support older people”.