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NOVEMBER 22, 2017 by Admin Team
PREVENTATIVE MEDICINE AND SP

What is Social Prescribing (SP)? Why should humanists concern themselves with a referral scheme in primary care which is designed to shift the focus of GP prescriptions from illness to wellness? SP is a new approach to meet complex needs. If it's a success then  this redirection of ever-decreasing NHS cash from treatment to preventing various illnesses, will be money better spent.

Social Prescribing (SP) can help provide psychosocial support for patients whose needs are not being met within existing primary care services or who may be using these services inappropriately.  Developing SP is a specific aspiration set out in NHS Tayside's Health Equity Strategy: Communities in Control.  For humanists, the degree of empowerment entailed in this initiative must be a community plus point. We also note that equity is not necessarily the same as equality in the common meaning of the two ideas.

The framework mechanism for this delivery of SP is something designated Sources of Support, a Health and Social Care tag for partnership and joint working between GPs and social workers.  The starting point is a prescription written by a GP or a health visitor for a patient that refers the patient to a designated Link Worker, rather than a prescription for medicine or other pharmaceutical, as is the norm. The link worker is one of a number of highly trained specialist social workers with backgrounds in nursing, community development, and  mental health. These link workers engage with the patient referred to them through the Sources of Support scheme (SoS), with the aim of exploring and facilitating the psychosocial needs of the patient. The intent is to link the patient with various services in the local community that can best help each person, a bespoke process fitting the patient to the proper service.

Not every patient is necessarily referred to SoS, nor is a patient guaranteed a referral. By necessity the SP route is an instance of the equity concept of selective targeting of those patients who may benefit. Unlike NHS universalism where prescriptions in Scotland are free, or in other non-health categories such as free bus passes for the elderly, or the winter fuel allowance, for SP the inclusion list is based on the notion of proportionate universalism. With this approach the formula for NHS funding seeks to weight funding towards territorial health boards with greater need.  Actions must be proportionate to the level of disadvantage based on considerations such as deprivation, the age profile of the population, and rurality.

The Sources of Support mechanism works on the basis of inclusion and exclusion. If you are a patient who has poor mental wellbeing affected by social circumstances, or you experience mild to moderate depression and anxiety, then you will be referred, as with those patients with long term physical conditions and co morbidities, such as lung disease. Frequent attenders in primary care are another instance of inclusion into the SoS scheme.  The exclusion (hence targeting or equity list) means that people experiencing acute episodes of psychosis, and those with primary issues of drug or alcohol misuse, methadone misuse, legal highs and so forth, are all dealt with outside of Social Prescribing.

The positive outcomes for Social Prescribing are that participants experience a reduction in symptoms, such as with anxiety and depression.  The social benefits covers inclusion, participation, and access to new networks. There is an uptake of activities such as the arts and creativity within local communities, as well as learning and with volunteering. The practical and material benefits, such as resolving problems with debt, are coupled with experience acquired in negotiating housing and other benefits, reducing  frequent attendance at primary care, unplanned admissions as well as excessive use of other secondary care services.  In terms of quality of life, those patients experiencing the Sources of Support system are reporting reduced feelings of isolation, of loneliness, as well as an increase in self-realisation.

The Social Prescribing Scheme also contributes to other determinants of well-being, such as engagement with over thirty public services and with charities in the Third Sector. There is an awareness of what is on offer in the wider community, as well as partnership capacity with link workers plus primary care plus provider agencies.  Behaviour changes are also reported, with physical activity, social contact, adapting to new skills and to financial self-management.  Tackling the effects of poverty, poor education, as well as bereavement, also feature as positives in the lives of many patients referred to SoS.

The focus of delivery of Sources of Support are to key services in cities like Dundee and Perth which address 1. structural and financial issues, e.g; money and debt, employment and training, housing support, and anti-social behaviour.  2. lifestyle issues e.g; drug and alcohol misuse, physical activity, and condition management. 3. social isolation and other psychosocial and emotional needs, e.g; counselling, volunteering, adult learning and social activities. 4. family and relationship problems, e.g; mediation, children's services.

The barriers to the effective delivery of Sources of Support are:

Patients usually have multiple problems, such as lack of money and resources, poor mobility, ongoing pain, lack of self-confidence, low mood, anxiety, lack of encouragement, lack of basic social skills, as well as literacy and numeracy drawbacks.

Services are sometimes unprepared for Social Prescribing, inflexible, unprepared for the challenges patients present. In addition there can be hidden waiting lists, service fragmentation, referral cancellations, and long waiting times.

GPs are generally supportive, especially as the SoS scheme is preventative, but at times they swamp the service with inappropriate referrals and backlogs.

With link workers, the increasing complexity of cases and the demands of preparing and directly supporting patients at Benefits assessments, means that attrition and turnover of staff, coupled with an increasingly restricted budget due to council cuts, is placing a strain on Sources of Support.

Solutions.

If Sources of Support is to succeed there needs to be a retuning of the delivery mechanism for deeper and more prolonged impact. Any expansion of the facility depends on a selective use of scarce resources targeting greater need of patients most affected by poverty and ill-health. There cannot be a saturation strategy for Social Prescribing. Setting boundaries and limiting the patient intake is a form of rationing that can work in the long run.  The Link Worker role is crucial in an assets based approach to each patient who qualifies for entry into the Social Prescribing system.

This focus is one that encourages the patients to develop their capabilities and skills in order to protect their well-being. The intake population requires access to external services in order to achieve their goals, which in turn depends on a multi-disciplinary SoS team with experience in liaison and advocacy, well-motivated and respected. Given the nature of Sources of Support as a scarce resource it must also be a protected service that is pivotal within the wider context of service fragmentation and uncertainty.

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