Social Prescribing: panacea or medicalization?

Social Prescribing, a panacea or another top-down programme? Part 1

(this is part 1 of 4 in a blog series)

Over the next four blogs I wish to critically explore an approach to patient support called Social Prescribing. While Social Prescribing is happening in Ireland, the Netherlands among other countries, it has really taken off in the UK

Here are two definitions of Social prescribing from two respected sources in the UK:

“Social prescribing is a mechanism for linking patients with non-medical sources of support within the community. These might include opportunities for arts and creativity, physical activity, learning new skills, volunteering, mutual aid, befriending and self-help, as well as support with, for example, employment, benefits, housing, debt, legal advice, or parenting problems. Social prescribing is usually delivered via primary care – for example, through ‘exercise on prescription’ or ‘prescription for learning’, although there is a range of different models and referral options.”

(Social prescribing for mental health – a guide to commissioning and delivery; Lynne Friedli with Catherine Jackson, Hilary Abernethy and Jude Stansfield)

“Social prescribing enables GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services.” 

(King’s Fund, Ideas that change healthcare)

Throughout this series, entitled: ‘Social Prescribing, a panacea or another top-down programme?’ I will argue:

  1. that Social Prescribing at best is a misnomer and at worst is a counter-productive and disabling term. Instead we ought to be speaking about the doctor as a potential ‘participation advocate’ who can work in partnership with key allies. Doctors also engage in medical proscription (preventing inappropriate medicalization).
  2. That Social Prescribing as broadly practiced in the U.K is too focused on referrals to community/voluntary initiatives/sector (CVS), and in so doing falls short of supporting socially isolated individuals to become participating interdependent members of their communities. Far too many of the referrals are to programmes or structured services run by salaried strangers, as distinct from near neighbours interested in fostering reciprocal relationships, where the person is received and celebrated for their gifts. Hence, Community and Voluntary organisations are often being treated as a proxy for resident to resident relationships.
  3. That its (Social Proscribing) current shortcomings are inevitable and that the prime reason for them is that too much emphasis and expectation is being placed on the doctor and CVS organizations and not enough support and animation is being offered to associational life of communities themselves.  While the doctor holds the keys to the medicine cabinet, they do not have the same access to associational/civic life of the neighbourhoods they serve. Which is to say that the doctor can’t be expected to do it all, and even with the support of CVS, unless we move beyond referrals to resident relationships and local associational life, we will fail in our duty of care to those who have been pushed to the margins.
  4. That there is a better way to build on some strong elements of current practice. In the last blog of this series I will scope out what I believe a more viable framework within which the assets of patients, doctors, CVS and local residents and their associations can be discovered, connected and mobilized towards authentic relationships and communities of expanding welcome.

Here’s a 10 minute interview I did recently with Public Health Wales, setting out my thoughts on Social prescribing, and some of the cautions I have around how current custom and practice is unfolding in the UK. The interview is entitled Health Beyond Healthcare:

Next week’s blog entitled: ‘Social Prescribing or Medical Proscription and Participation advocacy?’, will ask the following questions:

  1. Should we be using the term ‘social prescribing’ at all? Does “prescribing” appropriately describe what it is the doctor does when they successfully support isolated people back into interdependent lives in their communities?
  2. Does the term and the practice of “prescribing” place the doctor and allied services in an inappropriate power dynamic with the people they serve?
  3. Does “prescribing” programmatize relationship building and reduce it to manageable and measurable referrals and signposting?
    Should we be speaking about medical proscription, what the doctor will stop happening (like the medicalization of social issues); social prescribing? Hence talking about structural issues, and issues of patriarchy and power.
  4. Should we be speaking about the doctor as a ‘participation advocate’ who collaborates with their patients, other allies and residents to increase the prospects of an interdependent life for those at the margins, in preference to medical or institutional dependency?

 

Cormac Russell

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18 Comments
  • Mick Ward
    Reply

    Thanks Cormac

    Look forward to the next episode

    But a/ – I will feed into the SP discussions (and future commissioning plans of SP) in Leeds
    b/ I think you can apply this thinking to the wider NHS plans re community support, namely ‘New Models of Care’/Population Health Management’ (sic)

    Mick

    August 11, 2017 at 5:42 pm
    • Many thanks Mick,

      I think you’re absolutely spot on re wider application/relevance. BW Cormac

      August 21, 2017 at 6:23 pm
  • Gillian Lewis
    Reply

    I agree that we need to move beyond the medical terminology. Also that Gp to paid project for fixed term does not result in (always) meaningful connections for the individual or the community or addressing in a meaningful way the reasons for the referral in the first place. However the term social prescribing like most terms will be used by professionals only those receiving the service will have their own terms. Also GPs need to develop trust and reassurance in the services they know are needed to address the issues they see affecting their patients and they know they are not best placed/resourced etc to do it. So if the term helps do that then ok. In terms of the CVS it depends who’s getting the referrals – supporting communities to receive referrals will be much more sustainable building links to those in their own community, neighbour to neighbour with programmes included if it helps get people over the door/into the room/ started in any way. I’ve seen this work, I do this regularly but more commitment, confidence and value in what we are doing from primary care could make this better. To achieve this would make me support social prescribing. It’s the how not so much the what’s it’s called I have an issue with.

    August 13, 2017 at 2:04 am
    • Thanks so much for sharing your perspective and experience Gillian. Like you my primary concern is how it’s done. Though the title clearly unnerves me in that it good to know not all patients are subjected to the terms. I know many across the country who are, and who’ve had quite negative experiences. I think the practice is varying significantly across the country. Sometimes Veering quite far from the Peckham experiment of bygone days. Notwithstanding if the practice is good and getting better there’s good grounds for hope. BW Cormac

      August 21, 2017 at 6:30 pm
  • Steve Milton
    Reply

    Wilfully impish as usual Cormac, a good read and I look forward to this critique unfolding over subsequent episodes. As a worn out, knackered, practitioner I think sometimes we need to be wary of pouring cold water on ideas. It is easy to lob bricks from the sidelines. Social prescribing is not a social policy programme, it is a flexible idea. At its heart is the principal of connecting people with community resources that may be beneficial to their wellbeing. So, a GP might suggest that a patient with high blood pressure might like to join a local walking group – a healthy, associational activity. Can’t see that this is a harmful idea. The walking group is there, self organised and fun. Baffling to me how any intervention that has state participants is so damaging. I don’t for one second suggest that community building is a bad thing – we need a whole lot more.

    August 13, 2017 at 10:11 pm
    • Thank Steve, I appreciate your experience on the ground here. I think your correct this discussion can’t be reduced to good or bad. The question is not if it a good idea. But is it good enough? Are we for example really linking in with the assets of the community and the person, or is this still quite instrumental. I feel asking these questions, rather than being impish as you put it, is being civic. It is healthy to challenge. I appreciate your challenges too, hopefully it will help us all get to better. BW Cormac

      August 21, 2017 at 6:35 pm
  • Hello Cormac
    Looking forward to this series. I grew up in an Irish community with strong relationships https://en.m.wikipedia.org/wiki/Atticall i came to work as a GP in Wales 15 years ago. I hoped that the Communities First programme would forge links with primary care but I didn’t see this happen as I expected. I think there is a lot of potential and I have some practical ideas about how to take steps forwards so I’m looking forward to the rest of this series.
    In the meantime I’d like to check about the stats on 40% of attendances being as a result of loneliness. That’s a big figure and it would be great to see references and how it varies across SES and age demographics.

    August 13, 2017 at 11:29 pm
    • Hi Anne Maire, lovely to hear from you and to learn about your contrasting experiences in Ireland and Wales. I agree we are presented with an incredible opportunity to engage in a different conversation that challenges the hegemony of the medicinal model by supporting the creation of community alternatives to over medicalisation.

      Re the 40% reference. You’re right to pick me up on this, I should have been much clearer, the accepted figure is 20%, however in my discussions across the country with GPs I’m consistently hearing estimates of 40%. It’s safest to say 20% but I fear the figure is considerably higher. More research/ expose required. What’s your experience? I’d love also to hear you thoughts and how to better support community alternatives. BW Cormac

      August 22, 2017 at 11:53 am
  • Liam Hughes
    Reply

    Thanks Cormack,

    Social Prescribing is a misnomer – and, of course, it has been useful for some people in some places. Interesting examples of taking the next step include a self-managed public interest company promoted by GPs in mid-Devon, but run independently by local people, in which network members do what they want with other people with similar interests; and a request from GPs in Halesowen for patients to help by making celebratory cards (birthday, festivals) for everyone on the practice list. These are creative initiatives. The step beyond is for communities including GPs to support initiatives that have emerged from local people, like the Poulenc (?) league in North Kirklees, which invites recently bereaved people to join. It isn`t a loneliness project, but a call for new members! We need to look from the other side of the lens, and understand the paradox of supporting mutual help.
    Regards, Liam

    August 14, 2017 at 12:23 pm
    • Thanks Liam,

      Excellent points well made. The practices you describe are aligned to good community development. I’m aware of the work in Devon, and it’s really great, deserves a better description than SP, me thinks. BW Cormac

      August 21, 2017 at 6:59 pm
  • Hi Cormac, you present an interesting debate but I think you need to get out and visit more comm/vol sector projects. You suggest that people will be isolated in the community on some sort of basket weaving programme. Firstly, I have no knowledge of any community project offering basket weaving since the 1950s (although I’m sure you’ll be able to google and find something!). Secondly, no comm/vol sector project provides any activity as an end in itself, they are always about using activities/groups to building relationships and developing confidence within individuals/groups and the community. In any successful social prescribing initiative people are offered alternatives so that they find something that interests them. Interdependent lives and communities are created when isolated people take that first supported step into the comm/vol sector programmes and progress to become more active, more engaged, take up volunteering opportunities or form (or be a part of) a group around issue or interest important to them. The interdependent life is not separate from the comm/vol sector but part of the journey.

    Kind regards

    Paul

    August 14, 2017 at 1:43 pm
    • Hi Paul, thanks for taking time to share your perspective. What I actually state is my concern that people could be referred to places and activities they do not want to be part of. I travel extensively across the UK on a weekly basis and see hundreds if not thousands of community projects a year. Aside from being able to report that basket weaving is making a come back, I’m also told that there is quite a variety of experiences out there with regard to SP. I believe it worth is having a debate not prove whose right or wrong but to promote ctitical reflection and deeper practice. As I’ve argued throughout this series when people become more engaged in reciprocal relationship it is a achievement worth celebrating. My question continues ‘how are doing with regard to the measure of reciprocity?’ I plan on further unpack these issues in part 3’&4 and hope you can join the conversation. BW Cormac

      August 22, 2017 at 11:41 am
  • Patricia Perez Wilson
    Reply

    Totally agree We need to find a better expression than “social prescription”. The objective to make visible and mobilize different resources that the communuty have is a great propose. But “prescription” reproduces the asymmetric power between patients and doctors.

    August 15, 2017 at 3:48 pm
    • Thanks Patricia, and that is my primary concern: asymmetric power. In a word is a word.
      BW Cormac

      August 21, 2017 at 7:01 pm
  • Nick Andrews
    Reply

    Wise words! thanks for sharing.

    August 18, 2017 at 11:52 am

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