• Analysis
  • September 3, 2019
  • 9 minutes
  • 0

Healthy communities: What is ‘social prescribing’?

Unconventional prescriptions are taking off in the UK or elsewhere, but is it just a placebo?

“Spotify ‘should be prescribed to dementia patients instead of dishing out drugs’” The Sun (UK), November 6 2018

“Doctors to prescribe museum visits to help patients ‘escape from their own pain’” CBC (Canada), October 12 2018

At first glance these ideas sound ridiculous: Spotify instead of drugs? Museum trips for pain relief?

But they actually form part of a health policy innovation that is getting serious traction. “Social prescribing” sees medical practitioners directing patients to community workers, who offer tailored support to improve their health and wellbeing.

Before the former UK Prime Minister Theresa May left office, she confirmed that by 2023 all doctors in England will be able to refer lonely patients to community activities and voluntary services. Denmark and Canada are also among the countries trying the approach out.

In practice, rather than a Spotify subscription, it’s more likely that a patient will receive a mainstream service like employment coaching, a physical activity or learning support, often in a group setting.

But it’s not just about what patients get. By encouraging people to take personal responsibility for their own healthcare, social prescribing encourages them to look beyond medicine for answers to their healthcare problems.

Dr Flora Cornish, Associate Professor in Research Methodology at the London School of Economics, said that the social element of the prescription was just as important as the physical task itself. “It’s much more than just getting on a treadmill,” she said. “It’s patients spending time with other people in a social setting.”

Advocates love the approach for the freedom it offers patients and prescribers, but critics question the evidence for its effectiveness.

International interest

The UK is spearheading social prescribing, but the practice is also gathering pace internationally, with pilots in Canada and Denmark.

The Alliance for Healthier Communities, the association of community and Aboriginal health centres in Ontario, Canada, is experimenting with the practice in 11 different centres, including an intergenerational knitting group and a support group for LGBTQ youth.

Canadian cultural institutions are also getting involved. Physicians who are members of Médecins francophones du Canada are able to prescribe visits to the Montreal Museum of Fine Arts alongside more traditional treatment options. It’s the first initiative in the world to link together a museum with a health prescription.

In Denmark, four municipalities were awarded DKK 7 million ($1.04 million) to pilot a cultural activity program, Kultur på Recept, designed to target people who had experienced long-term mild to moderate depression, stress and anxiety.

In Sweden, an experiment is being run encouraging patients on sick leave to meet weekly for different cultural activities.

Traditional roots

The idea of prescribing non-medicinal activities to sick people isn’t entirely new, though.

Sebastian Kneipp, a Bavarian priest, prescribed various unconventional “cures” to his patients, including brisk walks and home gymnastic exercises. Around the same time, Victorian physicians in the UK were recommending visits to the seaside to fight tuberculosis.

And the practice has been commonplace in Japan since the 1980s, when “forest bathing” (or “shinrin-yoku”, in Japanese) was first advocated by the government. Despite the misnomer, forest bathing does not involve water. Instead, shinrin-yoku is the taking in (or “bathing in”) of forest air, without distractions, for a few hours.

Forest bathing has been appropriated with a “wellness” slant in more recent years, and gathered some celebrity fans. The UK’s Duchess of Cambridge was said to be inspired by the practice when designing a garden for this year’s Chelsea Flower Show.

What’s not to like?

The boundary between medical social prescribing and more general “wellbeing” isn’t always clear. Getting doctors on board with the practice can be difficult as a result. “Doctors work on a medical model,” Cornish explained. “They’re used to pharmaceutical tests giving yes or no answers. Social prescribing is much more complex.”

A lack of emphasis on targets or specific health outcomes from a social prescription can mean that doctors can be reluctant to prescribe a service. “If they’re passing a patient along to someone who isn’t clinically qualified, they’re worried that they are professional reputation on the line,” Cornish said. “They need to have confidence in the service for it to work.”

Cornish also expressed her fear that social prescribing could easily be watered down to a one off activity, or a short course, rather than a lifelong health shift — whether due to a lack of confidence or for funding reasons. “Exercising and socialising, for example, have to be continuous for it to work. It can’t just be a six week program,” she said.

And when doctors refer patients to a prescribed program, it needs to be sustainably funded. Cornish stressed that this instability was a pressing concern for social prescribers. “Sometimes, when referring a patient, the question is: ‘how long will this service exist?’” she said.

Measuring success

Disparate funding pots mean that social prescribing projects are often small pilots, each evaluated according to different indicators, meaning often one single picture of social prescribing cannot easily be drawn.

The University of Westminster sought to build a picture of UK-based social prescribing projects, and found contrasting results. On average, they found that there was a 28% reduction in demand for GP services following referral. But this figure hides a split in the results: reductions ranged from a 2% in one paper to 70% in another.

But the evidence they found for social prescribing was broadly supportive of its ability to reduce patient demand on medical care services.

Cornish, an expert in evaluating social projects, acknowledged that evaluating social prescribing projects was “really difficult”.

“It’s a complex intervention, involving not just the practice itself, but a cross sector collaboration,” she said. “Evaluating social prescribing projects requires policymakers to think outside the box, consider case studies instead of traditional approaches, while paying attention to the whole system, and how the program fits within it.”

It’s not an overnight fix either. “I’d suggest a long time to see results — perhaps even a couple of years,” Cornish added.

Replication

So if it’s so difficult to measure, should we continue taking social prescribing seriously?

It seems relatively easy to replicate, as Canada, Denmark and Sweden have found. But it needs to sit alongside a thriving voluntary sector, who are ready to receive applications for social prescriptions.

Researchers also need to think carefully about creative and lengthy evaluations if projects are going to leave the pilot stage.

Only then perhaps the headlines will stop, and a visit to the museum, or joining a knitting class, will become just as accepted as a trip to the pharmacy. — Emma Sisk

(Picture Credit: David Sherry/Deathtothestockphoto)

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