Social Prescribing is a term which is growing in importance throughout our health and community services and within health and social care policy. It’s a term that few members of the public recognise; some reject it as the medicalisation of what should be a normal process of connecting people and for third sector organisations, it’s core business. Others are concerned that the systematic referral of ‘patients’ through social prescription models places pressure on community and neighbourhood resources, which may have a detrimental effect on volunteers and third sector organisations.
What we do know is that there is little published evidence to tell us what good social prescribing looks like, which interventions work best and for whom, how we best sustain the community resources or assets which we need as part of the social prescribing journey. Earlier this year the Wales Social Prescribing Research Network was launched to develop the critical evidence needed to support the three communities of practice in north, west and east Wales. This is co-chaired by Wales Council for Voluntary Action (WCVA), the national membership body for the third sector in Wales, and PRIME Centre Wales, the Wales Centre for Primary and Emergency (including Unscheduled) Care Research, at the University of South Wales.
Social Prescribing is a structured approach for linking individuals with appropriate community resources. Its purpose is to improve individual wellbeing, help to promote individual problem solving skills and create new opportunities to form useful and often long lasting community and neighbourhood relationships. It recognises that a person’s health and wellbeing is multidimensional, not only secured by certain physical attributes but also that there are social, emotional and environmental factors which are equally as important.
In Wales, this means that the start of the social prescribing journey usually involves a person with a problem presenting themselves at a GP surgery, via a call to a social services duty team or a community service often led by the third sector. The type of problem could include a mild to moderate mental health issue which has an underlying cause, for example due to a housing or debt issue, loneliness, social isolation, low self-esteem or confidence; these issues might then affect performance in the workplace, or attendance at work. Often the person may be referred by the GP or other health or social care professional to someone called a social prescriber, community connector or link worker. Initially, there is a face to face or over the phone ‘what matters’ conversation so the social prescriber can recommend the best way forward. This may lead to further face to face conversations about the problem, which might in turn lead to the individual being referred to a community or neighbourhood asset: for example a debt counsellor, theatre group or gardening club.
Social prescribing isn’t something new. It’s been working in some areas of Wales for quite a few years. However, most recently, there have been a number of champions from across Welsh Government, statutory and non-statutory health and care organisations which have energised the social prescribing agenda. Public Health Wales have provided a map of the evidence, description of projects by area; it has steered the advancement of an effective electronic directory and led national events to share the learning. Key to this has been the political drive through the Social Services and Well-being (Wales) Act 2014, the Well-being of Future Generations (Wales) Act 2015 and their regulations and policies which have all recognised the social determinants of health and well-being and that working together is essential to sustaining our public services. A recent review of evidence assessing the impact of social prescribing suggests that there is an average reduction of 28% in GP services following referral to social prescribing schemes and a reduction in 24% of A&E attendances (Polley et al, 2017).
Often social prescribers (community connectors or community link workers) are based in other settings including community hospitals and local authority one stop shops. Characteristically they are needs driven, they take time to gain individual, professional and organisational trust and strive to ‘get it right the first time’. In Arfon a traditional model of social prescribing demonstrates how a community link worker supported a lady who had recently moved house and presented at the GP surgery with severe depression. Whilst the GP prescribed medication in the first instance, the community link officer gave practical and emotional support with unpacking the boxes and getting her settled into the community. This was followed by an information pack on the support that was available locally from Gofal a Thrwsio (Care and Repair) and Nest to support with energy efficiency. Over time the lady gained confidence and was able to find part-time employment in a local supermarket. The outcomes were a reduction in medication, increased household income and hospital admission avoidance.
In rural Powys a partnership approach has created a ‘non-specific’ social prescribing service working across multiple settings. With ten community connectors working across the county (managed by a coordinator), they source a myriad of opportunities, support and activities to avert crisis, resolve problems and often provide interim support whilst awaiting longer term services. For example, an older lady waiting to go home after surgery was on a waiting list for the Reablement service. The community connector had already developed a trusting relationship with her and the community hospital staff and responded by liaising with the British Red Cross Home from Hospital Scheme, arranged a financial assessment with Age Cymru local service and persuaded the local pub to provide and deliver a hot meal until other arrangements could be made. The lady went home the following day, thus avoiding a four-week stay in hospital.
These third sector community and neighbourhood groups are what Welsh Government are calling community assets and the key to maximising the value of care and sustaining our NHS services, as part of the vision outlined in A Healthier Wales. The types of challenges these social prescribing services face include inequality in the workplace (where occasionally they are not recognised as part of the multi-agency team), developing an information sharing policy across organisations to capture standardised valuable data and short term funding focused on referrals as opposed to the whole of the social prescribing journey. Local community and neighbourhood organisations struggle to survive. They provide these services often free of charge through volunteers or reduced charges subsidised through charitable moneys they have to actively raise. They battle daily with finances, wondering if contracts are going to be renewed due to cuts in public funding, facing clients when services are suddenly discontinued, juggling funds or closing the charity or group when larger organisations don’t pay invoices on time, increase costs in hiring venues and costs of training and paying expenses for volunteers. If social prescribing is indeed part of the answer to sustaining our health and social care services for the future, the question we must ask is how can we shift funds to build and sustain the community and neighbourhood assets which receive and resolve the referrals which are at first presented in primary and secondary care or in social services?
The authors wish to thank Powys and Mantell Gwynedd for their case studies
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