Imperial College lunchtime seminar (18 th Oct 2017) IS THERE A ROLE FOR SOCIAL PRESCRIBING GLOBALLY? Dr. Marcello Bertotti (Senior Research Fellow) Institute for Health and Human Development, University of East London Steering group member of the Social Prescribing Network
WHY DO WE NEED SOCIAL PRESCRIBING? Increasing rate of Long Term Conditions. E.g. diabetes. The WHO (2012) estimated that in 2012 620,000 died of human violence (war and crime), 1,500,000 died of diabetes. Sugar is more dangerous than gunpowder (Harari, 2017). Around 15m people in England have one or more LTCs increasing by a third over the next 10 years (DH, 2012). LTCs account for 50% of all GP appointments and 70% of all inpatients bed days. Frequent attenders to primary care: In the UK, 20% of patients attend GP for social rather than medical reasons. It costs the NHS 395m per year (Citizen Advice, 2016) Persistent level of health inequality (Cawston, 2011). This lead to long-term medical conditions and particularly affects people in disadvantaged areas
Policy interest in social prescribing One of the emerging models (Rotherham) It was proven to cut A&E, outpatient and hospital admissions Model for integration across health and social care systems One of the 10 high impact actions to release capacity
THE SOCIAL PRESCRIBING PATHWAY PATIENT HEALTH AND SOCIAL CARE PROFESSIONAL Social prescribing involves empowering individuals to improve their health and wellbeing and social welfare by connecting them to nonmedical and community support services National Social Prescribing Network LINK WORKER COMMUNITY/STATUTORY SECTOR
Long term conditions (e.g. diabetes) mild/moderate MH problems, social isolation/loneliness, social problems (e.g. housing, employment) Patients/clients /people
Health and social care professionals Mainly GP practices and doctors but Social workers Pharmacies Others: e.g hospitals, mental health support
.Link workers, community navigators, wellbeing coordinators, referral facilitators.. Coaching, motivation Co-production with user Knowledge about community activities Modes of delivery Signposting Referring
Community and statutory sector Volunteering Housing and employment advice Psychological counselling Walking clubs; sport clubs Cook and eat sessions Lunch clubs Gardening Group art and dance Museum, books e.g. art on prescription Conservation
DIFFERENT MODELS OF SOCIAL PRESCRIBING Information only Leaflet in a surgery No engagement of patient Direct referral GP referring patient to comm. Activity Very limited engagement Limited range of services Signposting SP Soc prescriber signposting (tel based), some engagement (often one consultation) limited range of services Referral SP Soc. Prescriber mixed f2f and tel, co-production, in-depth service (e.g. coaching) Wide range of services LOW INTENSITY HIGH INTENSITY
WHAT DOES THE EVIDENCE SAY?
Summary of outcome evidence 15 evaluations were analysed (out of 341) Measured health changes at 6 months Mental health and wellbeing mainly All studies measured improvements in health and well-being However, No evidence beyond 6 months Only one RCT (Grant et al, 2000) but only 4 months follow-up and lack of clarity as to whether it was SP
Evidence from qualitative studies Much of qualitative evidence is positive Changes in self-esteem, hope, motivation particularly when sustained through volunteering Best thing has been meeting new people and making friends. My mobile full up with names and numbers of friends before it was just family and doctor s number. I was really depressed before but now really happy. Before I have nothing to do, now every day I wake I think yes volunteer work! or meeting friends! Role of link worker is key to positive changes (from signposting to coaching) You feel able to offload if you need to, discuss your fears - it s about not being so hard on myself and validating myself.
Summary of economic evidence 94 projects reports 14 projects met criteria: UK based; referral from primary care; link worker; third sector; demand for healthcare services analysis One RCT and two matched controlled studies 8 studies conducted a costbenefit analysis. No costeffectiveness or cost-utility analysis was found.
Summary of economic evidence GP attendance: 28% reduction (2-70%) A&E attendance:24% fall (8%- 27%) Emergency hospital admissions 6-33% reduction Overall reduction in referral to secondary care (6%-34%) Economic data - SROI 2.3 per 1 in first year
Third sector needs investment to ensure sustainability of social prescribing. Examples of allocating funding to third sector exist (e.g. Rotherham, Newham community prescribing, Ways to Wellness) Challenges to the development of Social Prescribing Lack of feedback to GPs Most users do not recognise social prescribing Engagement of GPs: The terrible thing is that I referred five but I should have referred about 15 times that. Although I am very enthusiastic about it, it is hard to keep in front of your mind, and that s the challenge! (General Practitioner) Local commissioners have limited funding, although some new funding is now available and 75% STPs involved increase in discussions between CCG/LA/PH
Methodological challenges in evaluating social prescribing Many outcomes: how do we know which is the right outcome to measure? Generalisability of data? What is the right method to include a control group? The monitoring of social prescribing is problematic. Data collection is often patchy. E.g. What happens to patients after they have been referred by their link workers? What and why we have drop outs?
Conclusions (1/2) Social prescribing represent an important opportunity to: Prevention (e.g. pre-diabetic), self-care/selfmanagement of LTCs, social problems (unemployment, debt, housing etc) It focuses on the bio-psycho-social model of illness beyond anatomy and physiology Makes effective use of the community sector Takes forward NHS person-centred agenda
Social prescribing as an opportunity
Conclusions (2/2) The current evidence is not yet robust enough: Qualitative evidence show much promise, but this is not yet followed by rigorous quantitative studies economic analysis also shows promise but Overall, we need studies with larger samples, over longer follow up periods and possibly randomised controlled studies. Would you see this type of intervention work in other countries?
Thanks for listening If you want to join the mailing list of the social prescribing network: Socialprescribing@outlook.org For more information: Dr Marcello Bertotti m.bertotti@uel.ac.uk
References Dahlgren G, Whitehead M (1992). Policies and strategies to promote social equity in health. Copenhagen, WHO Regional Office for Europe Cawston, P. 2011: Social Prescribing in very deprived areas. British Journal of General Practice, 61 (586), 350. vi Citizen s Advice (2016) A very general practice: How much time do GPs spend on issues other than health? https://www.citizensadvice.org.uk/global/ci tizensadvice/public%20services%20publicatio ns/citizensadvice_averygeneralpractice_may 2015.pdf Harari, Yuval Noah Homo Deus. A Brief History of Tomorrow, London: Vintage World Health Organisation (2012) Global Health Observatory Data Repository, 2012