Top tips: social prescribing in general practice

Dr Vasumathy Sivarajasingam offers eight top tips on maximising the benefits of social prescribing for the provision of personalised, holistic patient care

Social prescribing is a ground-breaking initiative with the potential to reduce costs, particularly within primary care.¹ This growing movement seeks to empower people to choose personalised solutions to their social, emotional, and practical needs.¹

The ‘one-size-fits-all’ nature of the health and care system means that it cannot meet the needs and expectations of every patient.² Personalised care aims to combat this by providing support based on people’s individual preferences, strengths, and needs.^2,3 In personalised care, services are integrated around people using a whole-system, all-age approach that incorporates both mental and physical healthcare.³ Social prescribing—in which healthcare professionals refer patients to support services in the community to improve their health and wellbeing—is an important part of the delivery of personalised care.⁴

Social prescribing link workers

Social prescribing link workers are nonclinical staff, recruited for their listening skills, empathy, and ability to support people, who work to support people to find individualised solutions to issues affecting their wellbeing.⁴ The term ‘social prescribing link worker’ is used generically; other names used to describe the link worker role include:⁴

• community connector
• wellbeing advisor
• community navigator
• health advisor.

These different titles have emerged as local areas have developed their own social prescribing schemes.⁴

As part of a wider shift towards universal personalised care,⁵ the NHS long term plan states that: ‘Link workers within primary care networks will work with people to develop tailored plans and connect them to local groups and support services. Over 1000 trained social prescribing link workers will be in place by the end of 2020–21 rising further by 2023–24, with the aim that over 900,000 people are able to be referred to social prescribing schemes by then’.⁶ In this way, social prescribing link workers will enable people, particularly those with more complex needs, to take greater control of their health and care.⁶

This article provides advice on harnessing the benefits of including a social prescribing link worker in the multidisciplinary primary care team.

1. Appreciate the benefits of social prescribing for GPs

In 2015, the Primary Care Foundation and NHS Alliance reported that around one-fifth of a GP’s time is spent on social rather than medical problems.⁷ In a 2007 study that examined social problems presenting in primary care, GPs stated that they spent significant amounts of time dealing with the consequences of poor housing, debt, unemployment, and loneliness.⁸ Many people attend GP consultations for social problems because it’s a familiar way to seek help; social prescribing provides GPs with a nonmedical referral option so that they can help people who have more than just a medical need (see Box 1).⁴

Social prescribing by a trained link worker is an effective way to improve the health and wellbeing of patients who have long-term health conditions—such as diabetes, chronic obstructive pulmonary disease, asthma, coronary artery disease, heart failure, epilepsy, and osteoporosis—that may also be associated with mental health conditions, low self-confidence, and/or social isolation.⁹ Social prescription has also been shown to enhance engagement with prescribed health-related activities, such as exercise programmes.¹⁰ In 2017, an evidence summary published by the University of Westminster showed that the number of GP consultations was reduced by 28% and accident and emergency department attendances decreased by 24% among people receiving social prescribing support.⁴ In addition, a survey conducted by the Royal College of General Practitioners found that 59% of GPs feel that social prescribing has the potential to reduce their workload.¹¹

Box 1: Common reasons for referral to a social prescribing link worker at the author’s practice

LGBTQ=lesbian, gay, bisexual, transgender, and questioning; SEND=special educational needs and disability.

2. Understand how social prescribing link workers can support patients

Social prescribing link workers help patients to develop skills, friendships, and resilience.⁴ Positive outcomes for individuals include increased self-esteem, self-efficacy, and confidence, improved mood, opportunities for social contact, and development of transferable skills.¹⁰

Link workers are recruited for their ability to listen, their empathy, and their proficiency in supporting people.⁴ They help to reduce health inequalities by assisting people to examine issues impacting their wellbeing.⁴ People’s health and wellbeing are influenced by a range of social, economic, and environmental factors; the link worker seeks to address people’s needs in a holistic way, supporting them to take greater control of their own health.¹² In this way, people are empowered to identify personalised solutions to social, emotional, or practical issues, often using services provided by the voluntary and community sector.¹ The aim is to support long-term behaviour change and better self-care.

This tailor-made, nonclinical approach gives patients more time to focus on what matters to them and prioritise their needs.⁴ The targeted support they receive as a result enables them to feel empowered to move forward.¹¹ Through involvement in community groups, patients gain confidence and control over their lives, develop key skills, and give their time to others.⁴ Examples include volunteering, creative classes, community gardening, cookery, debt management workshops, housing advice, career coaching, help with writing a curriculum vitae, walking groups, and a range of sports.^4,11

3. Identify patients who would, and would not, benefit from a social prescription

Social prescribing doesn’t suit everyone,¹⁰ and is not an emergency service. It aims to support people who lack the confidence, skills, and resources to resolve social issues on their own; it is not about signposting services/activities to people who lack the ability to work independently on issues impacting their health and wellbeing. In addition, link workers do not carry out health coaching or administrative work on behalf of clinicians.

However, social prescribing can be offered to a wide range of people,¹³ including those:¹⁴

• with one or more long-term conditions
• who need support with their mental health
• who are lonely or socially isolated
• who have complex social needs that affect their wellbeing.

4. Be familiar with the referral pathway

For social prescribing to work successfully, the whole team should understand the referral system and ensure that people are referred appropriately (see Figure 1).¹⁵ As for any type of treatment, test, or examination,¹⁶ patients must be asked if they consent to being referred to a link worker.

Patients should not be given a waiting time; however, they should be informed that there is a waiting list. Over a 3-month period, link workers will then have between six and 12 contacts with a person, on average, depending on their needs.⁴

Information technology systems can be set up so that the referral can be made directly to the social prescribing link worker by the primary care team. Coding permits the auditing of appropriate referrals and support offered to patients.¹⁷ Having a system in place that enables assessment of the efficacy and benefits of social interventions—such as the collection of patient feedback or production of case studies—can provide further opportunities for reflective learning.

5. Acknowledge the role of social prescribers during the pandemic

As a result of the threat it poses to our safety, security, and comfort, COVID-19 has acted as a trigger for poor mental health, and contributed to the deterioration of long-standing mental health conditions.¹⁸ Increased social isolation, loneliness, health anxiety, stress, and financial difficulties caused by the pandemic have further harmed people’s mental health and wellbeing. The pandemic has also exacerbated health inequalities and inequalities in access to green space, highlighting the importance of time spent outdoors to people’s mental and physical health.¹⁹

Mental health has taken a back seat during the pandemic as key workers face challenges arising from the physical impacts of COVID-19. Now, the health service is increasingly dealing with people experiencing mental health issues as a result of the pandemic—including front-line healthcare workers, people who have had the disease, families who have lost loved ones, individuals who remained in isolation, those whose work environments have changed drastically, and people who have lost their jobs or businesses.¹⁵

Link workers build trusting relationships with individuals in a compassionate and holistic way. This sense of partnership and connection provides a safe and positive space for someone experiencing poor mental and physical health and wellbeing, allowing them to feel acceptance and validation. Social prescribing initiatives support people to identify their strengths, wishes, and goals, to build resilience, and to tackle wider factors affecting their health—including social and welfare issues, which often influence and contribute to poor mental health and wellbeing; all of this is more relevant than ever during the COVID-19 crisis.⁹

By working with individuals during the pandemic, link workers have facilitated access to community services (for example, local organisations, charities, events, and groups) to address nonmedical challenges (for example, isolation and bereavement) that affect people’s physical and mental health and wellbeing.²⁰

6. Recognise the value of green social prescribing

It is the ambition of the NHS to become the world’s first carbon-neutral national health system by 2040.²¹ Medicines account for 25% of emissions within the NHS, and are the greatest contributor to the carbon footprint of primary care.²²

Medical research has highlighted the physiological and psychological benefits of ‘green prescribing’ (prescription of outdoor physical activity) to patients, as well as the willingness of doctors to participate.²³ Green prescription increases levels of physical activity and improves quality of life over a 12-month-period, without adverse effects, and has the potential to reduce the risk of all-cause mortality—making it a cost-effective strategy for promoting healthier behaviour.²³ Visiting local neighbourhood green spaces has demonstrated great health benefits—not just for adults, but also for children.¹⁹

Green social prescribing assists clinicians to recommend low-carbon, nonpharmaceutical interventions to patients affected by chronic health conditions, mental health problems, and social isolation.²² It links people to nature-based interventions and activities in both green and blue (for example, lakes and rivers) environments. Activities are varied, and include exercise (such as local Walking for Health schemes, Parkruns, and green gyms), travel (such as cycling), community gardening and farming projects, conservation volunteering, and creative and cultural activities that take place outdoors.¹⁹

7. Consider inviting social prescriber link workers to multidisciplinary team meetings

Social prescribing link workers are an integral part of the multidisciplinary team in primary care networks (PCNs). Currently, the majority of general practices share a link worker with a number of practices within the PCN group. Therefore, to get the maximum benefit from a link worker without overstretching them, we need to collectively understand their capacity, including the maximum number of patients a particular surgery can refer to them and/or the maximum number of patients they can review at any one time.⁴

The number of people requiring support from a social prescribing link worker will vary between practice populations. Sharing information with the whole team within a practice is vital to the holistic support of our patients—it helps to understand our expectations of the designated link worker and assess their competency in delivering their services. Through regular communication, engagement, and feedback, we can evaluate the service and ensure that adequate support and reassurance is offered to link workers. This will also contribute to analysing the outcomes of introducing social prescribing, benefiting both practice staff and patients, and potentially helping to secure funding in the long term.

8. Encourage uptake of training and support

Encourage those healthcare professionals who want to learn more about social prescribing and the role of link workers to enrol in online learning and/or regional learning events, resources, and webinars (for example, the Health Education England e-Learning resource Social prescribing—learning for link workers, available at: www.e-lfh.org.uk/programmes/social-prescribing/). This will not only help the team to be more aware of the support available to patients, but will also help team members to understand what they can do to further develop/support designated link workers. Clinical supervision of the link worker by healthcare professionals helps them to provide sustainable solutions to patients.²⁴

Upskilling of existing practice members as social prescribing link workers has many benefits. These individuals are already known to GPs within the practice/PCN, and will be familiar with procedures in the practice²⁵ —therefore, they are more likely to hit the ground running after appropriate training. To fulfil the person specification of a social prescribing link worker, existing members of staff must demonstrate good soft people skills, including a desire to help people, good listening, communication, and organisational skills, empathy, patience, the ability to inspire trust and confidence, and the flexibility, resilience, and initiative to work independently.²⁵ Nurses, healthcare assistants, receptionists, social workers, and voluntary workers already have good soft people skills and, as such, often make good link workers.²⁵ They may wish to take on the link worker role in addition to (as part of staff upskilling) or instead of their current role; once qualified, they must abide by the rules and responsibilities of the social prescriber, including those related to safeguarding.

Summary

Social prescribing enables healthcare professionals to refer people with social, emotional, and practical needs to a link worker who will give them time, focus on what matters to them, and engage in shared decision making and personalised care and support planning. It is a logical extension of the biopsychosocial model of healthcare,²⁶ connecting people to sources of help and support within the community, and providing GPs and other healthcare staff with a nonmedical referral option operating alongside existing medical treatments to help improve the health and wellbeing of individuals.

The goal of social prescribing is to reduce rising healthcare costs and ease pressure on general practice clinics.²⁷ Evidence suggests that social prescribing leads to improved quality of life and enhanced emotional wellbeing, and gives individuals more control over their lives. In addition, it contributes to overcoming social inequalities by addressing mental health, psychosocial, and socioeconomic problems using effective and appropriate methods.

References

1. University of Westminster website. Social prescribing network. www.westminster.ac.uk/research/groups-and-centres/patient-outcomes-in-health-research-group/projects/social-prescribing-network (accessed 19 August 2021).
2. NHS England website. Personalised care. www.england.nhs.uk/personalisedcare/ (accessed 19 August 2021).
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5. NHS England. Universal personalised care: implementing the comprehensive model. London; NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf
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19. Gov.uk website. Green social prescribing: call for expressions of interest. www.gov.uk/government/publications/green-social-prescribing-call-for-expressions-of-interest/green-social-prescribing-call-for-expressions-of-interest (accessed 19 August 2021).
20. Tierney S, Mahtani K, Turk A; Oxford COVID-19 Evidence Service Team, Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford. Can social prescribing support the COVID-19 pandemic? www.cebm.net/covid-19/can-social-prescribing-support-the-covid-19-pandemic/ (accessed 19 August 2021).
21. NHS England website. NHS becomes the world’s first national health system to commit to become ‘carbon net zero’, backed by clear deliverables and milestones. www.england.nhs.uk/2020/10/nhs-becomes-the-worlds-national-health-system-to-commit-to-become-carbon-net-zero-backed-by-clear-deliverables-and-milestones/ (accessed 19 August 2021).
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First published in Guidelines in Practice on 20.8.21