Social prescriptions have been hailed as a wonderful way of improving health outcomes, at low cost. But Paul Wilson argues that we need less rhetoric and more sound research to evaluate project results.
The Queen’s Speech has seen the new government reconfirm commitments to make an extra £8bn of funding available to the NHS. But with estimates of £22bn in ‘efficiency’ savings needed over the next five years to meet rising demand, a radical rethink of the way health services are currently delivered remains high on the policy agenda.
NHS England’s Five Year Forward View has stressed that developing innovative approaches to delivering health care are integral to the long term future of the NHS. They have announced a £200m investment in 29 new ‘vanguards’, which will act as test bed sites for innovations that integrate new products, processes and ways of working; provide further innovation impetus to the process of integration of health and social care; and provide novel service delivery in primary care. Social prescribing is one such model and is being widely promoted as a way of making general practice more sustainable.
Social prescribing is a way of linking patients in primary care with sources of support within the community. It provides GPs with non-medical referral options that can operate alongside existing treatments to improve health and well-being. There is no widely agreed definition of social prescribing, but referral schemes can include an extensive range of information and advice, community activity, physical activities, befriending and enabling. Schemes such as exercise-on-prescription projects have been established or piloted in a number of areas and have been claimed to be “very successful”.
The Secretary of State for Health Jeremy Hunt is keen. Speaking at the Health Select Committee in December 2014, he said: “The NHS is taking a more holistic view of what it takes to address people’s medical problems than it did before and I do not think that is something we would want to stand in the way of. We are seeing a big growth, for example, in social prescription, where GPs are saying things such as: ‘The root cause of this person’s problem is isolation and loneliness, and so, effectively, I am going to prescribe that you join a lunch club’, or something like that, ‘to make sure that you have company in your life.’ We need to be open-minded to CCGs [Clinical Commissioning Groups] which say, ‘This is the kind of thing that is going to help deal with the root causes.’”
But is the enthusiasm for social prescribing justified?
As part of a study which aims ways to help CCGs make better use of research in commissioning decisions, we have looked at the evidence around social prescribing programmes. We found little supporting evidence of effect to inform the commissioning of social prescribing programmes.
Most of the social prescribing activity taking place appears to be small scale pilot projects. The evaluations we identified were also small scale and limited by poor design and reporting. Missing information made it difficult to assess who received what, for what duration, with what effect and at what cost. Referred patients also appear to have been receiving other interventions and we have no way of assessing the relative contributions of the interventions. Other common design issues included a lack of comparative controls, short follow-up durations, a lack of standardised and validated measuring tools and a failure to consider potential confounding factors. Uncontrolled studies of this type are traditionally associated with a high risk of bias. Despite these shortcomings, most evaluations have presented positive conclusions, generating a momentum for social prescribing that does not appear to be supported by robust research evidence regarding their effect.
So it is not that there is clear evidence that social prescribing does not work: rather, we are not yet able to reliably judge which social prescribing programmes do demonstrate a degree of promise and can be considered for wider roll-out across the country.
Rigorous conduct and transparent reporting are essential in evaluation. Indeed, implementing innovative models of care without adequate evaluation can lead to misattribution of effects and worse, the wider adoption of ways of working without proven benefits over existing alternatives. Even well conducted, small scale exploratory evaluations can only ever give tentative indications of benefit and should only ever represent a starting point. These need to be corroborated by further explanation and more rigorous evaluation.
If social prescribing is to realise its potential as an effective way of delivering health services, future evaluations must be comparative by design. They must address the questions of when, for whom and how well does a scheme work? What effects does it have? At what cost? Only by doing so can the quest to identify and accelerate the uptake of better, more efficient models of care be realised.