Kerryn Husk: Social prescribing offers huge potential but requires a nuanced evidence base

The evidence base for social prescribing lags behind practice and needs to catch up

Social prescribing is generating considerable interest among GPs, policy makers, service providers, patients, and researchers. Many general practices are beginning to follow the early adopters and link patients with a diverse range of non-NHS delivered interventions and activities. This is likely to be a good thing, as social prescribing has the potential to address many of the factors that perpetuate illness (for example, social isolation or a lack of meaningful activity), and which those with a range of physical and mental health needs are faced with. Social prescribing has expanded the options available to GPs whose patients are seeking financial, housing, and other social advice alongside medical guidance.

However, the evidence base for social prescribing currently lags considerably behind practice. As a community, we should proceed with an open mind but we need to ensure that we’re integrating implementation with research in order to maximise the potential benefit, ensure its appropriate use, and to avoid wasting resources.

The ability for primary care to focus on the whole person and to be creative in responding to their multi-faceted needs in an increasingly pressurised environment has clear advantages. Those working at the frontline often want to be able to provide more comprehensive support for their patients with long term conditions and complex needs, yet lack the dedicated time and resources to do so effectively. The potential for social prescribing to offer this kind of person centred approach is a central point in its favour.

However, importantly, we have been here before. Exercise referral schemes (ERS) were considered all but a panacea a decade ago, and the political will that amassed in support of them meant these programmes proliferated across the UK before robust assessments of their effectiveness had caught up. We now know that for a substantial number of patients ERS offer little benefit, with uptake and adherence levels relatively low, and with those we most want to target more likely to drop out or not attend in the first place (a good summary can be found in the NICE guideline or Pavey’s paper in The BMJ).

We’ve recently seen a slew of high quality papers examining social prescribing from a number of angles. Reported results are still mostly equivocal, have highlighted evidence gaps rather than demonstrating effect, and typically focused on the effectiveness of the myriad interventions when aimed at particular conditions or groups (see, Bickerdike; Chatterjee; Pilkington). However, regardless of the effectiveness of the intervention, if the patient doesn’t even initiate or make use of their particular social prescription, it’s impossible for it to be useful.

Almost all studies of social prescribing conclude by making persuasive arguments for the need to examine and better understand the process of social prescribing, yet so far we haven’t acquired this knowledge.

Greater attention should be paid to the elements of the process that allow individualisation and responsiveness to the needs of different groups of patients and providers. We also need to understand how we can maximise uptake and adherence and engage those who may benefit most.

To start this process of considering process alongside effectiveness, I (along with several colleagues) am conducting a realist review (which you can see the protocol for here). Previous work demonstrates that many interlinking factors such as geography, cost of, or anxiety about both the intervention and the social nature of it determine whether or not an individual will engage. Given the policy push to see social prescribing as part of the “new models of care,” which will contribute to both health creation and reduced healthcare utilisation, it is important to ensure that we understand how to ensure social prescribing is part of a single person centred care plan for each individual. We must seize the opportunity we have now to develop a programme of research alongside implementation of social prescribing, combining mixed methods evaluations with embedded RCTs, so as to understand which patients can accrue benefits (improved social functioning, disease prevention, fewer admissions) and from which interventions, as well as to deepen our understanding of patients’ nuanced interactions with their referring practitioner, signposting expert, care navigator, and the workers in the range of social interventions available.

The evidence for how exactly these important pathways work, interlink, and might be optimised is lacking. By bringing research and evaluation expertise to this activity and disseminating lessons collaboratively we will be able to support continual quality improvement, which encourages individualised care, and ensure that policy makers and health systems direct resources to social prescribing programmes that are effective. If we want to harness the great work now being undertaken in community and primary care settings up and down the UK,  we need to understand what works in social prescribing, for whom, and in what circumstances.

Kerryn Husk is a research fellow with the NIHR CLAHRC South West Peninsula (PenCLAHRC), based at Plymouth University Peninsula Schools of Medicine and Dentistry. Twitter @kerrynhusk

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None

Disclaimer: KH is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula. The views expressed are those of the author and not necessarily those of the NHS, the NIHR, or the Department of Health.

Acknowledgements: The author would like to acknowledge the contribution of the review team: Rebecca Lovell, Kelly Blockley, Richard Byng, and Ruth Garside.