This blog shares the key insights from NPC’s recent policy roundtable on social prescribing. At the event, discussions focussed on how to support the further rollout of social prescribing in light of the inequalities laid bare by the Covid-19 pandemic; the need for better funding for voluntary charities and social enterprise (VCSE) organisations; and the challenges around measurement.
NHS leaders and the government have signalled that they are committed to the expansion of social prescribing. Social prescribing is an approach that seeks to connect people with community resources, such as local social groups, which they can participate in to improve their health.
The government recently pledged £5m for social prescribing, to support people following the Covid-19 pandemic, and they have repeatedly announced pledges to support the recruitment of more link workers. This is critical, because link workers form the backbone of a strong social prescribing system by listening to patients, understanding what matters to them and connecting them with relevant support or services.
At our recent roundtable, James Sanderson, Director of Personalised Care at NHS England and NHS Improvement, and CEO of the National Academy for Social Prescribing, emphasised how far the sector has come by saying, ‘the fantastic thing is, we are now talking about the implementation issues and the things we need to get right to scale social prescribing up across the country. It wasn’t long ago that we were scratching our heads about what social prescribing is and why we need it.’ He argued however, that progress is still needed on building a better approach to the social determinants of health (social, economic, and environmental factors that influence a person’s health), such as by creating personal health budgets and by fundamentally changing conversations about what matters to patients. ‘For far too long we have assumed people have cancer on Tuesday and mental health problems on Wednesday,’ he said.
The expansion of social prescribing also needs to be carefully managed, or inequalities could worsen. Firstly, communities with high levels of depravation need to be able to have access to social prescribing. Secondly, social prescribing risks putting more strain on an already struggling social sector. What’s more, there is a concern that without a focus on the right metrics, social prescribing may not deliver the right outcomes to those who need them. With these concerns in mind, how can the social sector support the further rollout of social prescribing?
Social prescribing and inequality
Dr Rachna Chowla, Joint Director of Clinical Strategy at King’s Health Partners (KHP), painted an all too familiar story of the trajectory of healthy life expectancy in the UK. She talked about how it had been improving since the Second World War, it started to stall in 2011, and it has now been going backwards for certain groups since 2015.
[Health inequalities arise from a complex set of interactions between socio-economic, geographic and cultural factors, which have a clear impact on life expectancy among Southwark residents. Reference: With thanks to Professor K. Fenton.]
Following the recent Marmot review, Rachna and Dr John McGuinness, a GP and KHP Darzi Fellow, both emphasised how place has an important part to play in this issue. People can be as equally deprived in parts of London as in parts of the North East of England, for example, but life expectancy is still five years shorter in the North. It is important to ensure that existing inequalities are not made worse by a lack of access to social prescribing in some areas.
The good news is that four of the top five risks of early death are modifiable, including smoking, high alcohol intake, having high blood pressure, and having a high BMI. KHP focuses on these risks, mental health, and well-being in its vital five factors that could, at the population level, extend the time before people get long-term conditions or improve the lives of those already with them. While this approach to reducing inequalities may sound straightforward, we know that healthcare is only the tip of the iceberg in terms of what affects health. It’s imperative to understand the complexities underneath these risk factors. Social prescribing is part of the solution.
John has been trying to understand the health and care needs of primary care patients, and trying to link them up with activities that will keep them well. He described a patient with medical and non-medical problems: Paul was 60, had issues with alcohol, and didn’t have a working boiler or cooker. With support from his link worker, he now has a warm flat and can cook his own food. This was the first time a professional had really thought about what matters to him. Paul is now doing much better and is less reliant on primary care.
In Lewisham, Covid-19 has resulted in the number of free school meals doubling, 36,000 jobs being furloughed, and 12,000 requests for food support being made. It is clear that social prescribing will be critical in helping to fight inequalities that have been exacerbated by Covid-19. Positive steps have been made though, with social prescribing being further developed, more emphasis has been put on community-centred care and new partnerships have been established with the VCSE.
What to consider when scaling up social prescribing?
The rollout of social prescribing should specifically target the most vulnerable so as not to exacerbate existing inequalities.
Barriers to inclusion: Some groups don’t think social prescribing services are for them.
Meeting people where they are: Different communities have their own needs and best means of engaging them. Because some people are not comfortable going to GPs, it may be more productive to establish connections in other locations, for example food banks.
Mapping community assets: Social prescribing systems that work best understand and build on what is already in place.
Using data: More data from link workers on local needs will help identify what needs to be built in communities.
Using digital to create more bespoke offers. Digital methods can help bring together groups for activities.
Research inequalities within hard to reach groups: Co-produce surveys with them, do community mapping of the organisations that can help, and conduct needs assessments.
Social prescribing and VCSE funding
Charlotte Augst, CEO of National Voices (NV), described her organisation’s recent NHS England funded research into VCSE experiences of the rollout of social prescribing. The research engaged VCSE organisations throughout the country, across five interrelated areas. These areas included link workers, collaboration, measurement, inequalities, and funding.
NV found that funding is not always necessary for every social prescription, many organisations are actively looking to engage more people with their existing resources. On the other hand, organisations that work one to one with people, such as to deliver debt, benefit or parenting advice, or that work with people with particularly complex needs, do need more funding to help more people. For those organisations, more attendees means more service delivery hours.
Charlotte also argued that the NHS cannot be the sole funder of these types of services. Austerity has hollowed out state provision in a number of critical ways but social prescribing uncovers unmet need that people have rights to have met. In John’s example, Paul had the right to have his housing adapted. While this is a right, the NHS shouldn’t be responsible for paying to modify people’s housing. The NHS can only be one pillar of a state that empowers its people to live well.
The solution to this is multifaceted, and funding may need to come organically from a range of sources—even if that makes life complex for many VCSE organisations. As Charlotte pointed out, rather than depending on one giant funder, lots of charities successfully rely on the state for bare bones provision, and then on grant-makers for more additional funding. Better funding for local authorities, the part of the state closest to communities, will be critical in ensuring that charities aren’t overstretched.
The NHS on funding social prescribing
James Sanderson emphasised how the NHS was already extensively supporting the infrastructure of social prescribing, by funding the recruitment of link workers for example. He also emphasised the need for a mixed model of funding, involving national and local funders, as well as private investors. Better local coordination, through mechanisms such as local shared investment funds, will be key to ensuring that local areas can innovate. One of the responsibilities of the National Academy for Social Prescribing is to help put in place infrastructure and partnerships outside of the NHS. Just as the circumstances that affect peoples’ health are far broader than just medical, it would be very narrow to ‘over-medicalise’ social prescribing and to make the whole system dependent on the NHS.
Social prescribing and measurement
Measurement is often about nitty gritty detail and technical capacity. But Dr Marie Polley, Co-Chair of the Social Prescribing Network, started by taking a step back and considering why outcomes are collected at all. She highlighted two key reasons: to find out whether the intervention works or to determine the return on investment.
The next question is which outcomes to choose. Social prescribing is an architecture that links sectors together, and no single outcome will be able to fit all purposes without conflating the issues. So, which outcomes are best? Ones that are being used already? Ones that are validated (tested rigorously with certain groups) or ones that fully reflect a service?
Because many outcome measures are set questions that have been researched and validated for certain groups and time, they are quickly invalidated when used for other groups and in other contexts. Marie argued that we need more sophisticated means to choose the right outcome for the right intervention and people. Critically, outcomes must be appropriate to the specific intervention and should also reflect the relevant wider determinants of health.
Through extensive research, Marie and her co-authors identified 99 outcomes that were being used to measure social prescribing, less than half of which captured the social determinants of health. Moreover, more than half of these were not routinely collected. This means that important outcomes to patients were simply not being captured. She argued that the biggest risk to social prescribing perpetuating inequality was this gaping hole in outcomes reporting.
One solution to this problem, and another way to ensure the successful further rollout of social prescribing, is to flexibly co-produce outcomes with patients. As social prescribing revolves around listening to people about what matters to them, outcomes measurement should also follow their needs.
What to consider when scaling up social prescribing?
There is a strong consensus that social prescribing should be focused on well-being measures—although there is no agreement on which.
Be aware that the local NHS, commissioners, funders, and eventually the government will need to be convinced of the return on investment. Social prescribing outcomes are so broad, that more research may be needed in order to show value in other areas.
Responsibility for data: With many stakeholders involved in social prescribing, it’s important to think through who’s in charge of what. Charities should only be responsible for collecting proportionate data, such as on well-being, while bigger actors can collect health data or aggregate individual data. The burden should not be on the patient.
Proportionality: Across the country, some areas have a weaker VCSE sector with less capacity, which affects their ability to measure.
The focus should not be on repeatedly measuring what has already been evidenced, for example the benefits of physical activity.
This roundtable built upon NPC’s extensive work on the social determinants of health.We are excited about the further rollout of social prescribing and are keen to help VCSE organisations and funders make the most of this opportunity. We hope you found this write up of our event useful. To discuss NPC’s work on the social determinants of health or social prescribing, get in touch here.
Thomas is a Senior Consultant working with charities, funders and social enterprises to improve their effectiveness and efficiency. He works across a variety of projects, refining strategy, facilitating impact management and helping clients to communicate their impact.
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