THE ESSENCE PROJECT

ESSENCE CASE STUDY Social prescribing

Author(s): Annette Bauera;  
Institution(s): a Care Policy and Evaluation Centre, London School of Economics and Political Science;  
Production date: March 2023
Last reviewed: March 2023
Acknowledgements: We are grateful to the ESSENCE project advisory group for their helpful comments on earlier versions of this case summary.
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Background

Social prescribing has been introduced as a measure to address social problems in a healthcare setting context. It seeks to reduce pressure on GPs who face an increasing demand of people who have social needs.

Key Points

  • In England, social prescribing schemes have been (re-)introduced as a policy tool for reducing pressure on GPs and promoted as a solution for health service-budgeting constrains; they consist of link workers integrated into primary care structures, which support people in managing their health conditions and accessing resources in the community thus addressing the social determinants of health.
  • A large number of studies have investigated the impact on health and wellbeing outcomes as well as on healthcare resources; findings suggest that schemes have the potential to change health behaviour and outcomes; they can also enhance people’s self-confidence. However, not everyone accesses or benefits from social prescribing schemes; and those most vulnerable are less likely to benefit.
  • There is some evidence to suggest that social prescribing schemes can reduce demand on primary and secondary care service and offset the costs of the intervention.
  • Main gaps in evidence include: their relative cost-effectiveness compared to other interventions that seek to address the social determinants of health; how social prescribing schemes need to be designed and implemented in order to achieve good value for money, and which population they should target; the wider community impacts of schemes.

Context

Social prescribing is a way of linking patients in primary care with sources of support within the community. It is being widely promoted and adopted as means of dealing with some of the pressures on general practice and the National Health Service (NHS).1 For example, it is estimated that around 20% of patients consult their general practitioner (GP) for what is primarily a social problem.2 By facilitating access to community resources and encouraging volunteering, social prescribing seeks to address non-medical problems at the individual level, whilst also promoting healthy communities and social capital more widely.

Social prescribing is not a new idea: In England, it has existed, under different names such as community navigators or health champions, for a long time. For example, in 2006, the Department of Health (now Department for Health and Social Care) advocated for the introduction of social prescriptions for those with long-term conditions. Over recent years there has been strong policy support for social prescribing from the Department of Health and Social Care and National Health Service (NHS) England, in particular for social prescribing schemes that target people with long-term conditions, with mental health needs, who are lonely and who have complex social needs. The NHS Five Year Forward View[1]gives innovative personalised care approaches like social prescribing a role in addressing funding gaps in the NHS and social care.

[1] https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

What is social prescribing?

Social prescribing is a way of linking patients in primary care with sources of support within the community.3 There are several definitions of social prescribing. The Social Prescribing Network in England defines social prescribing as ‘enabling healthcare professionals to refer patients to a link worker, to co-design a nonclinical social prescription to improve their health and wellbeing’.4 The Social Prescribing Network also offers the following definitions for terms commonly used to describe different aspects of social prescribing[2]:

  • A social prescriber refers to any healthcare professional or otherwise who refer people to a social prescribing service.
  • A social prescribing service refers to the link worker(s) and the subsequent groups and services that a person accesses to support and empower them to manage their needs.
  • A link worker (also called health advisor, health trainer and community navigator) refers to a non-clinically trained person who works in a social prescribing service and receives the person who has been referred to them. Briefly, the link worker is responsible for assessing a person’s needs and suggesting the appropriate resources for them to access.

[2] https://www.artshealthresources.org.uk/wp-content/uploads/2017/01/2016-Social-Prescribing-Network-First-Conference-Report.pdf

Is social prescribing effective?

Over the past ten to fifteen years, various evaluations of social prescribing schemes have sought to examine individual-level health and wellbeing outcomes linked to schemes.5-11 A review3 of effectiveness of schemes found little quantifiable evidence of even short-term improvements in health and wellbeing. However, a recent review,12 which included qualitative evidence and mixed-methods studies found that qualitative studies consistently reported improvements in health and wellbeing whilst only half of the quantitative studies, which apply standard scales of health and wellbeing, found meaningful or significant improvements. The review identified consistent evidence from both qualitative and quantitative studies that social prescribing schemes improved health-related behaviours such as physical activity but inconsistent evidence for outcomes like social interaction or cultural engagement. In addition, the review also identified evidence from qualitative studies that patients using the schemes benefitted from improved self-esteem, confidence or value, improved feelings of worthiness and in day-to-day functioning.

What do people say about social prescribing?

Overall, social prescribing is liked by people using primary care services as well as by staff (such as GPs) who provide the intervention.13  Uptake measured in attendance at initial appointment with link worker has been found to range from 50% to 79%5,6,8-10,14,15 whilst subsequent attendance at activities referred to by the link worker ranges from 58% to 100%.6,8 A realist review16 found that patients are more likely to enrol if they believe the social prescription will be of benefit, the referral is presented in an acceptable way that matches their needs and expectations, and concerns elicited and addressed appropriately by the referrer. Furthermore, patients are more likely to engage if the activity is both accessible and transit to the first session supported, and adherence to activity programmes can be impacted through having an activity leader who is skilled and knowledgeable or through changes in the patient’s conditions or symptoms. GPs in general find that being able to make a social prescription was a useful additional tool.17,18 However, there is some evidence to suggest that social prescribing is taken up by certain populations more than others, and that additional training or support would be required for schemes to also support vulnerable people with complex needs.19 During the Covid-19 pandemic digital provision of social prescribing excluded populations without necessary technologies.19

Is social prescribing cost-effective?

Most economic evidence in this area stems from studies that measure some but not all economic consequences, focusing primarily on costs linked to certain types of healthcare use. There are also a small number of return-on-investment or cost-benefit studies, including some which seek to explore the wider economic value from a societal perspective, including for example changes in employment.

The evidence broadly supports the potential for social prescribing to reduce demand on primary and secondary care, and potentially reduce total costs to the healthcare sector.

With regards to studies reporting changes in the use of health services (without examing total healthcare cost), services most often reported to reduce because of the introduction of social prescribing include: GP visits (average reduction of 28%10,11) Accident and Emergency attendances (average reduction of 24%7,11,20,21), and secondary care referrals (55% at 12 months and 64% at 18 months10). However, evidence is inconsistent. For example, evidence from one randomised controlled trial5 suggests that whilst the number of primary care contacts were similar between intervention and control groups, there were fewer referrals to secondary care and more prescription drugs for those in the intervention group compared with the control group. A large mixed-method evaluation[3] of a social prescribing for people with Type-2 diabetes in Northeast England found small reductions in non-elective care for people with no additional co-morbidity (in the region of £60 per person) and a shift from A&E and non-elective care to elective care. There is some evidence to suggest that social prescribing leads to potential reductions in health care use among people who engage well, whilst people who fail to fully engage have higher rates of health service use.7

Findings from the few studies which report on total healthcare costs suggest that those are similar between intervention and control groups which means the costs of providing social prescribing are likely to be offset by some reductions in costs for healthcare use. For example, one cost-benefit analysis finds a cost reduction of £552 to the NHS over the 2-year course of a pilot programme.7 An assessment of the social and economic impact of a social prescribing scheme in Rotherham[4] demonstrated cost reductions to the NHS of £647,000 over a four-year period leading to a reported  initial return-on-investment of 35 pence for each pound invested. With regards to the costs of running the programme, one study estimated total yearly running costs of £83,144.11

With regards to studies that report costs from a wider government or societal perspective, a return-on-investment analysis, which assigned monetary values to health, social and financial wellbeing outcomes,22 estimated that for every £1 of the £180,000 funding spent, the service produced more than £10 of benefits in terms of better health. The scheme was provided to people with a long-term (mental) health condition.

[3] http://www.fuse.ac.uk/media/sites/researchwebsites/fuse/2_Wildman_outcomes%20costs%20and%20value_FINAL.pdf

[4] https://www.varotherham.org.uk/wp-content/uploads/2016/01/rotherham-social-prescribing-evaluation-update-May-2017.pdf

What is the quality of evidence on social prescribing?

Overall, the quality of evidence is weak.

Whilst evaluations of social prescribing schemes consistently find improvements in physical health outcomes and reductions in health service use, it is unclear whether those are meaningful or significant. Considering the overall poor design and reporting of the studies,3 with most studies comparing changes before-after referral to social prescribing, it is possible that changes are due to chance.5,20,23 Studies report short-term outcomes meaning there is no evidence about the effects of social prescribing on health and well-being outcomes beyond 6 months. In addition, there is currently a lack of evidence on whether social prescribing also influences wider community-level outcomes. Although some attempts have been made more recently to identify mechanisms and contextual factors that drive or hinder the success of social prescribing,24 there is overall a dearth of evidence how schemes need to be delivered and implemented to achieve improved outcomes for different populations. This includes an understanding of the role of community capacity-building approaches that might need to be provided alongside or embed social prescribing schemes in order to achieve the promised individual and community-level outcomes.25

How is social prescribing implemented?

NHS England introduced a National Social Prescribing Student Champion Scheme, which mobilises NHS staff to help setting up and running scheme and the 2018 and the NHS Long-term Plan set out that until 2024 2.5 million people would benefit from social prescribing.26 As part of the Universal Personalised Care scheme, mentioned in the Long-Term Plan, NHS England has committed itself to building the infrastructure in primary care promising that

  • there will be 1,000 new social prescribing link workers by 2020/21 and significantly more after that
  • at least 900,000 to be referred to social prescribing by 2023/24.
  • social prescribing workers would become an integral part of the multi-disciplinary teams in primary care networks and included in the five-year framework for GP contract reform and the Network Direct Enhanced Service Contract for 2020/21.

Social prescribing is a complex intervention that is implemented differently in different contexts. For example, how the link worker role is fulfilled varies substantially between projects. Whilst some schemes are likely to have additional community capacity-building or development support as part of their scope, the way this has been developed varies widely between localities. In some areas the Better Care Fund has been used to create social action, community and volunteering structures. Key issues identified for the successful implementation of social prescribing programmes include  central coordination of referrals, resources and training to support coordinators and enabling networking with the voluntary and community sector9,27 and good communication between GPs, participants and link workers.8,9,14 For example, it has been found that when GPs give feedback on participants’ progress this increases their commitment for social prescribing.

A range of government initiated or funded organisations or programmes, such as the National Academy for Social Prescribing, Thriving Communities, support the implementation of social prescribing schemes by providing or mobilising resources, knowledge exchange and networking opportunities. They seek to encourage more systematic and coordinated ways towards planning, implementing and evaluating schemes.3

Resources

Social Prescribing Network, https://www.socialprescribingnetwork.com/

National Academy for Social Prescribing, https://socialprescribingacademy.org.uk/

Key Contact

Annette Bauer (a.bauer@lse.ac.uk), London School of Economics and Political Science.

References

  1. Social Prescribing Network Conference (2016) Report of the annual social prescribing network conference. London: University of Westminster, Wellcome Trust, & College of Medicine.
  2. Low Commission. (2015) The role of advice services in health outcomes: evidence review and mapping study.
  3. Bickerdike L, Booth A, Wilson PM, et al (2017), Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open 2017;7:e013384. doi: 10.1136/bmjopen-2016-01338.
  4. University of Westminster. Report of the annual Social Prescribing Network conference. London: University of Westminster, 2016.
  5. Grant, C., Goodenough, T., Harvey, I. and Hine, C.(2000) A randomized controlled trial and economic evaluation of a referrals facilitator between primary care and the voluntary sector. BMJ , 320, 419–23.
  6. Grayer, J., Cape J., Orpwood, L., Leibowitz, J, and Buszewics, M. (2008) Facilitating access to voluntary and community services for patients with psychosocial problems: a before-after evaluation, BMC Family Practice, 9(27).
  7. Dayson, C. and Bashir, N. (2014). The social and economic impact of the Rotherham Social Prescribing Pilot: Main Evaluation Report, Centre for Regional Economic and Social Research (CRESR), Sheffield Hallam University.
  8. Friedli L, Themessl-Huber M, Butchart M. Evaluation of Dundee equally well sources of support: social prescribing in Maryfield. Evaluation Report Four, 2012.
  9. ERS Research and Consultancy. Newcastle Social Prescribing Project: final report, 2013.
  10. Longwill, A, (2014) Independent Evaluation of Hackney Well Family Service, Family Action.
  11. Kimberlee, R., Ward, R., Jones M. and Powell J. (2014) Proving Our Value: Measuring the economic impact of Wellspring Healthy Living Centre’s Social Prescribing Wellbeing Programme for low level mental health issues encountered by GP services. University of West England.
  12. Pescheny, J. V. et al. (2019). The impact of social prescribing services on service users: a systematic review of the evidence. European Journal of Public Health.
  13. Smith, M. and Skivington, K. (2016) Community Links Perspectives of community organizations on the Community Links Workers Programme pilot and on collaborative working with primary health care, Institute for Health and Wellbeing, University of Glasgow.
  14. Faulkner M. Supporting the psychosocial needs of patients in general practice: the role of a voluntary referral service. Patient Educ Couns 2004;52:41–6.
  15. Baines A. Rugby Social Prescribing Project ConnectWELL. Harnessing community capacity to improve health and wellbeing Roundberry Projects: Mid-term evaluation report, 2015.
  16. Husk, K., Blockley, K., Lovell, R., Bethel, A., Lang, I., Byng, R., & Garside, R. (2020). What approaches to social prescribing work, for whom, and in what circumstances? A realist review. Health & social care in the community, 28(2), 309-324.
  17. South J, Higgins TJ, Woodall J, et al. Can social prescribing provide the missing link? Prim Health Care Res Dev 2008;9: 310–18.
  18. Woodhall J, South J. The Evaluation of the CHAT Social Prescribing Scheme in Bradford South and West PCT. Centre for Health Promotion Research, 2005.
  19. Morris, S.L., Gibson, K., Wildman, J.M. et al. Social prescribing during the COVID-19 pandemic: a qualitative study of service providers’ and clients’ experiences. BMC Health Serv Res 22, 258 (2022).
  20. Bertotti, M., Frostick, C., Findlay, G. Harden, A., Netuveli, G., Renton, A., Carnes, D., Sohanpal, R. Hull, S and Hutt, P (2015) Shine 2014 final report Social Prescribing: integrating GP and Community Assets for Health, Health Foundation.
  21. Farenden, C., Mitchell, C., Feast, S. and Verdenicci, S. (2015) Community Navigation in Brighton & Hove. Evaluation of a social prescribing pilot, carried out by Impetus.
  22. Dayson C and Bennett E (2016) Evaluation of the Doncaster Social Prescribing Service. Sheffield Hallam University. Centre for Regional Economic and Social Research Report.
  23. Maughan, D. L. Patel, A. and Cooke, M. (2015) Primary-care-based social prescribing for mental health: an analysis of financial and environmental sustainability, Primary Health Care Research & Development, doi:10.1017/S1463423615000328.
  24. Calderón-Larrañaga S, Milner Y, Clinch M, Greenhalgh T, Finer S. Tensions and opportunities in social prescribing. Developing a framework to facilitate its implementation and evaluation in primary care: a realist review. BJGP Open. 2021 Jun 30;5(3):BJGPO.2021.0017. doi: 10.3399/BJGPO.2021.0017. PMID: 33849895; PMCID: PMC8278514.
  25. Morris, D., Thomas, P., Ridley, J., & Webber, M. P. (2020). Community-Enhanced Social Prescribing: Integrating Community in Policy and Practice. International Journal of Community Well-Being, 5(1), 179-195. https://doi.org/10.1007/s42413-020-00080-9.
  26. NHS England, (2018). The NHS long term plan. London: NHS England. https://www.england.nhs.uk/long-term-plan/.
  27. White J, Kinsella K, South J. An evaluation of social prescribing health trainers in south and west Bradford, Yorkshire and Humber Regional Health Trainers Hub / Leeds Metropolitan University, 2010

Other useful references

Polley, M., Bertotti, M., Kimberlee, R, Pilkington, K. Refsum, C. (2017), A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications, University of Westminster.

Dayson C and Damm C (2017) The Rotherham Social Prescribing Service for People with long-term conditions: evaluation update. Sheffield Hallam University. Centre for Regional Economic and Social Research.

Kimberlee, R. (2016) Gloucestershire Clinical Commissioning Group Social Prescribing Service: Evaluation Report, University of the West of England, Bristol.

Palmer, D. Wheeler J, Hendrix, E., Sango, P N, Hatzidimitriadou E. (2017) Social Prescribing in Bexley: pilot evaluation report, Mind in Bexley.

Rempel, E.S., Wilson E.N., Durrant, H. et al. (2017), Preparing the prescription: a review of the aim and measurement of social referral programmes. BMJ Open 2017;7:e017734. doi:10.1136/ bmjopen-2017-017734.

Woodall J, Trigwell J, Bunyan A-M, et al. Understanding the effectiveness and mechanisms of a social prescribing service: a mixed method analysis. BMC Health Serv Res. 2018;18(1):604. doi: 10.1186/s12913-018-3437-7.

 

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