Abstract
Today we realize that disease processes can be initiated not only by adverse factors in the purely physical environment but also by adverse factors in the social environment. With the growth of civilisation and urbanisation the technicalities of life have become more and more complicated and difficult to understand. The factors which make for a healthy social environment are becoming more difficult to obtain. A happy family circle, a full and adjusted community life at work and at play, a sense of purpose and responsibility in the world – these are of vital importance to social well-being. 1
These words, written by Hobson in 1949, are still surprisingly relevant for us today. Social factors account for ∼70% of health outcomes
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and more recent work by Wilkinson and Marmot corroborate Hobson’s insights: Societies that enable all citizens to play a full and useful role in the social, economic and cultural life of their society will be healthier than those where people face insecurity, exclusion and deprivation.
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What role can social prescriptions play?
Since the 19th century, there have been various attempts to address social determinants of health at an individual and community level through initiatives such as social medicine, 6 community health 7 and, more recently, social prescriptions. 8 There are subtle differences between these initiatives, but they all largely focus on needs that remain unaddressed in traditional biomedical models.
Social prescriptions have been used for several years across European countries as ‘a way of linking patients in primary care with sources of support within the community to help improve their health and well-being’. 9 Social prescriptions are varied and include sports and leisure/art activities as well activities more focused on health, education or skill development. In the UK context, they are mostly used in primary care to provide under-pressure general practitioners with alternative routes to care. 2
If utilised properly, social prescriptions could help to deliver value-based primary care
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by improving patient and population-level outcomes while optimising resource utilisation by:
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Addressing social determinants of health: Reducing reliance on the biomedical model while also giving a route for health and care systems to address social determinants of health Promoting self-care: Working with individuals with long-term physical and mental health conditions so they can build the knowledge, skills and confidence to manage their condition Creating jobs: Because social prescriptions are largely delivered locally, their active use can help to support job creation by funnelling resources to local voluntary, community and social enterprises Building stronger communities: The delivery of social prescriptions necessitates that the health and care sector must identify and actively work with and support local community assets, which will in turn help to establish and deepen community connections
Where are we with social prescriptions now?
The need for social prescriptions in the current health and care sector is clear; 84% of general practitioners say they have an unmanageable workload 12 and ∼20% of patients go to their general practitioner for primarily social problems. 13 Social prescriptions seem to be largely accepted by English general practitioners as a possible intervention for their patients with 80% saying that social prescriptions should be available from general practitioner surgeries 2 and 59% acknowledging that social prescriptions could reduce workload. 14
The use of social prescriptions is also on the rise. NHS England recently issued national guidance to support the more active roll out of social prescriptions nationally to build on the nearly 69,000 social prescriptions referrals in 2017/2018.
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Although a robust evidence base is lacking,
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data are emerging that demonstrate positive effects on individuals through improvements in quality of life and emotional wellbeing as well as improvements in the use of primary care and other health services including:12,13
– An average 28% reduction (range: 2–70%) reduction in demand for general practitioner services – An average 24% reduction (range 8–26.8%) in Accident and Emergency attendances – An average Social Return on Investment of £2.3 per £1 invested in the first year
The potential for social prescriptions to deliver better value within health and care services is clear, but there is much more that needs to be done to fully realise its potential.
Making social prescriptions mainstream
Social prescriptions have the potential to be a very disruptive force because they could shift the balance of power in health and care systems and markets. They could help to end the expropriation of health and see individuals having their real needs addressed and being supported to manage their physical health, mental health and larger social needs. But making social prescriptions mainstream will not happen overnight; it will take active effort on the part of multiple stakeholders in health and care systems, organisations outside of health and care which impact social determinants, voluntary, community and social enterprises organisations providing social prescriptions, funders (public, private and not-for-profit) and private organisations, particularly technology companies. The goal of our series of articles is to give background on what is being done but, more importantly, to give suggestions and solutions that can help to support the creation of a dynamic and vibrant social prescriptions ecosystem. Our papers will cover five key topics:
Evidence: The evidence around the outcomes and resource optimisation linked with social prescriptions is not robust. We propose the creation of social prescriptions formulary, beginning at practice level and then expanding regionally and nationally – a trajectory that mirrors how pharmaceutical formularies developed – to dynamically and pragmatically build up its evidence base. Technology: Technology, both hardware and software, has the potential to augment social prescriptions. We describe three key domains where technology could augment social prescriptions – demand/capacity planning, uptake/adherence and stratification/personalisation – and three key user groups who could benefit from these technologies – patients, social prescription prescribers (general practitioner and link workers) and social prescription providers (voluntary, community and social enterprises organisations). Precision medicine: The US National Institutes of Health definition of precision medicine states that it needs to take account of genes, environment and lifestyle factors. This paper will explore how social prescriptions can take account of information in these domains to promote health and prevent disease through the inherent adaptability of social prescriptions which means that they can be personalised to address individual lifestyle and environmental factors in a way that is not possible for most biomedical therapeutic options. Resources: A rate-limiting step in the more active use of social prescriptions is the deployment of resources for their development, evaluation and use. This paper will outline the need for resources at various stages in the life cycle of social prescriptions including more research funding to explore the design and delivery of more effective social prescriptions; private investment to facilitate the growth of social prescription providers and the creation of new technology to augment social prescriptions; public funding models to support the delivery of social prescriptions and research funding to support the evaluation and generation of a more robust evidence base around the value of social prescriptions. Active ageing: To fully exploit the value of social prescriptions, they will need to be customised for individuals. This series of three papers will explore the role of social prescriptions to promote active ageing in different age groups including children/youth, adults and older people. The goal of these three papers will be to demonstrate how social prescriptions can be utilised in different settings like schools, workplaces, the home, care homes, etc. and the innovative models that can be used to introduce and pay for their use.
The direction that social prescriptions take is not inevitable or deterministic. We will need to take responsibility to collectively create and shape a dynamic and diversified social prescriptions ecosystem that can improve population health and, ultimately, support more resilient and sustainable societies.