Fiaz A Hussain is an experienced teacher who has worked across education from primary to further education, including English for speakers of other languages, and has advised and developed guidelines on gender and race equality, and teaching materials on a local and national level.
Feryad A Hussain is a consultant clinical psychologist with North East London NHS Foundation Trust, and has worked in a wide range of health psychology services for over 20 years.
‘When the world comes crashing at your feet
it’s okay to let others
help pick up the pieces
if we’re present to take part in your happiness
when your circumstances are great,
we are more than capable
of sharing your pain.’
(Unnamed poem by Rupi Kaur from The Sun and Her Flowers)
The idea of social prescription to support and maintain overall good health is not new. Historically, it was not unusual for physicians to prescribe 2 weeks in the mountains or a long sea voyage, and aspects of such ideas were incorporated in the old sanatorium (sanatorium from the Latin sānāre, ‘to heal, make healthy’) model of care.
Currently we see a return of these ideas in the more accessible form of social prescribing (SP). However, with the aftermath of both physical and mental health problems resulting from the COVID-19 pandemic and lockdown, these ideas are being given greater support to reduce common problems facing increasing numbers of the population.1,2
With an increasing number of GP surgeries having dedicated social prescribers signposting patients to an extensive range of community support services, SP is being acknowledged as a possible means to improving health and psychological wellbeing while encouraging the individual to take responsibility for their own health.3–5
The community groups involved in the referral pathway for social prescriptions are not simply an excuse for social gatherings but require clear and relevant content and organisational structure in order to manage patient social needs and clinical presentations without offering any clinical guidance.
This brief article presents the experiences of a group facilitator with extensive experience of running community groups. It offers patient feedback and highlights the challenges of implementation at the coalface, offering a number of considerations for GPs and SPs. It builds on existing research that, at present, is limited to experiences of providers and link workers but offers little information regarding the end point, that is, the experience of professionals at the end of the SP chain. This perspective is invaluable if we are to fully understand the patient experience and review the process in its entirety.
SP: definitions and process
Healthcare professionals appreciate that physical and mental health is influenced by a range of socioeconomic and environmental factors. As such, a ‘social prescription’ aims to support population health in a holistic way, as well as encourage individuals to take greater responsibility for their own health and indirectly support carers and families.1
Also known as a community referral, SP is a practical means for healthcare professionals to refer identified patients to non-clinical services provided by voluntary and community sector organisations.
“This [group facilitator’s] perspective is invaluable if we are to fully understand the patient experience [of social prescribing]”
These referrals allow access to a range of social groups and activities such as supported volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice, and a range of sports, with some schemes joining local councils to contribute to ‘green schemes’ with a multilingual and multicultural approach.1–3,6,7
SP is offered to a wide range of people, including those with one or more long-term conditions, who need support with their mental health, who are lonely or isolated, and who have complex social needs that affect their wellbeing. Self-referral is also encouraged.2
Link workers are involved in facilitating the initial referral from GP prescribers and enable patients access to wider community networks based within general practice, pharmacies, multidisciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations, and voluntary, community, and social enterprise organisations.2
Government bodies offer a generic framework indicating six core elements that need to be in place for effective SP, which include workforce development, common outcomes framework, creating a personalised plan, support for community groups, collaborative commissioning and partnership working, and easy referral from all local agencies.
However, the details of implementation are not prescribed, allowing for the emergence of numerous models across the country. This is largely because the support needs to be specific to the local need as of the population and related resources.2,8,9
It is important to note that SP is not intended to replace any medical/psychological treatments, but aims to supplement physical and emotional health by considering those environmental factors that may maintain ill health.
The evidence base for effectiveness of SP is complex, raising problems at numerous levels of process as well as methodological problems with researching SP itself. The picture appears to be inconsistent and so unclear as to the overall benefits.
Systematic reviews suggest that there is some evidence of effectiveness of SP on both physical and mental health, with reduced workload for health professionals and decreased attendance at healthcare services. However, these effects have been found to be somewhat time-limited, with some studies suggesting that SP does not necessarily add to patient health at all.10–13
“It is important to note that social prescribing is not intended to replace any medical/ psychological treatments”
Problems regarding the evidence base are conceptual as well as systemic, with issues such as an absence of a more specific definition of SP regarding interpretation/implementation and so varying outcomes, inconsistencies in individual referral and discharge pathways, poor and inconsistent levels of training for link workers, as well as problematic structures for feedback to GPs resulting in an absence of constructive follow-up.14–19
Husk et al20 make the point that research studies themselves have often faced difficulties relating to methodology, generalisability of results, and practicalities. The lack of clarity around what constitutes SP means that evaluation is equally varied, making it difficult to compare and assess for quality as these may vary according to different communities (be these ethnic/socioeconomic, gender, or age). This in turn makes generalisability a challenge and its applicability across groups limited.
Husk et al20 add that there are also practicalities around generating evidence regarding control groups and measuring extent of impact, resources, and data collection, as well as information governance/consent and outcome measures that do not influence practice.
The above factors have all been found to affect the accuracy and effectiveness of SP studies, and since the existing research studies often point to gaps in the evidence base the onus is on providers to build a stronger evidence base.
A facilitator’s perspective
Islam3 makes the point that SP is a natural addition to the current biopsychosocial model of health care, and as such the role remains not only significant but, in spite of debate around effectiveness, likely to be sustained. Additional focus then requires attention to quality, and addressing the challenges and reality of implementation.
“Group facilitators play a key role in the social prescribing process and, as such, greater support and attention to their experience is necessary.”
While Wildman et al21 present one of the few articles relating the experiences of link workers, to the authors’ knowledge, there is no research on the group facilitator experience in this chain of support. Given that the group facilitators sit at the end point of the SP process, they can offer a unique insight and overview on issues relevant to the process as a whole.
The following is the experience of one group facilitator in developing and implementing SP community groups.
Facilitator’s background and role profile
The facilitator is an experienced teacher who has worked across education from primary to further education including English for speakers of other languages. She has advised and developed guidelines on gender and race equality, as well as teaching materials for teachers and facilitators on a local and national level. She has a special interest in women and those (ethnically diverse) groups who have had little access to education, to encourage a sense of life-long learning.
The facilitator was involved in a number of community initiatives leading to her involvement in the SP process at the request of local city charities and community initiatives across Birmingham. She was trained as a community group facilitator through the Time Bank Initiative. In addition to running a wide range of groups she also acted as an intermediary between community groups and charitable organisations, and was also involved in writing up teaching packs for other group facilitators around functional English teaching materials.
Each group was split into two parts, with one educational and the other social. The focus of each group was teaching English to various levels across a range of contexts accompanied by a social activity. Examples included, functional English in preparation for English as Second Language qualifications, English conversation, reading, writing, speaking and listening English. Accompanying activities included gardening, physical exercise, socialising, and day trips, as well as visiting libraries and national historical landmarks.
Aims and values
The facilitator ensured that each group was embedded in the following aims and values:
· educate; and
The facilitator developed groups in accordance with the following principles to ensure longevity and expansion of individual benefit across the community:
· embedded within the community;
· stakeholders all taking responsibility;
· providing a model with microfinancing; and
· developing partnerships and expanding networks.
Group objectives varied according to the group needs. Age, gender, language, mobility, visual/hearing impairments, and cultural considerations were made when deciding on related group activities within the wider context of general psychological and physical wellbeing. Secondary objectives included increased social interaction, increased and improved community interaction, exercise activities, UK cultural awareness, and IT and social media skills.
Group member profiles
Group members were from varying social and ethnic backgrounds and covered an age range of 24–84 years. Specific requests for groups focused largely on women from ethnic minority groups, women aged over 55 years, refugees, asylum seekers, and new arrivals into the UK, as well as UK citizens who were prescribed attendance under mental health services as individuals with no prior access to education or community services.
Group members represented multiple nationalities, from countries including Afghanistan, Algeria, Bangladesh, Croatia, Denmark, Ethiopia, Egypt, France, Ireland, Iraq, Iran, India, Lithuania, Morocco, Pakistan, Poland, Somalia, Spain, Tanzania, Venezuela, and Yemen.
Feedback from members across groups
The following are comments left as feedback by attendees and demonstrate the extent to which the groups have impacted on the lives of members and their families:
‘I want to learn English so I can help the grandkids read too.’ (Participant, aged 61 years)
‘I have cancer and feel very sad all the time, no-one seems to have any time to talk. My neighbour told me about this group, and I am so happy. I feel like a girl again swimming and laughing with my friends.’ (Participant, aged 53 years)
‘I have learned how to use the mobile and now I want to use a computer … after our trip to the library I put my name on a list for an IT course!’ (Participant, aged 47 years)
‘I am so happy we have this class because I didn’t go to school. I didn’t know about anything! Now I am going to college to study more, thank you.’ (Participant, aged 32 years)
‘When my nephew heard I had joined this group, he said I must go every week even if it is wet or cold outside as he saw it made me feel less alone.’ (Participant, aged 45 years)
‘At first I was shy but now I want to talk to other ladies in English because this group is very friendly and kind, and I can ask any questions I like without feeling shy.’ (Participant, aged 39 years)
‘I am really glad this project has been set up, many older ladies feel they have little reason to leave the house, especially like my mum who has arthritis in her hands. It has been difficult to persuade her to come but she does see the benefits and has made new friends here. Thank you!’ (Daughter of a participant)
From the above we can clearly see the extent to which these community groups have impacted positively on the physical and emotional wellbeing not only of members but also their families/carers, enabling attendees to develop life skills and personal goals.
Challenges to successful implementation
Implementation of groups was hindered by a number of notable practicalities across the SP system. Challenges observed during groups include:
· poor awareness of community initiatives within the community itself. The advertising of initiatives is largely limited to social media, which in itself is most used by groups who may not need to attend;
· an absence of allocated funding by community stakeholders means future groups cannot be planned;
· there is a lack of awareness of SPs regarding the range of community activities available;
· an absence of accountability across group facilitators and types of groups offered means quality is inconsistent; and
· poor communication channels between layers of the SP process (that is, SPs, link-workers, facilitators, community organisations, and group members) creating unnecessary delays.
The above challenges all create avoidable delays and disruption, resulting in an unnecessary waste of limited resources, time, and funding.
Considerations for GPs and social prescribers
The following are reflections and recommendations by the facilitator sourced from her experiences of implementing SP groups within the community:
· greater networking with other group facilitators would be a helpful way to exchange ideas and consider how to address local challenges;
· basic counselling training would be helpful to all facilitators when they are required to support attendees who are in distress;
· signposting links for relevant mental health and social service options would be helpful for those attendees who show increased signs of distress or deterioration in mental and physical health in general, to avoid informal advice being offered by unqualified staff;
· improved guidance and training on appropriate outcome measures and data collection would be helpful at a local level and assist group facilitators when reviewing their interventions and feedback to providers;
· a forum to meet with GPs/social prescribers and link workers would be important to ensure a more comprehensive structure and address ongoing practical issues regarding the SP process and its impact at a local level;
· greater overseeing and monitoring of the process;
· greater creative application of access for members; and
· greater investment in community projects.
The above recommendations would support improved communication across the SP process as a whole and in turn create a more robust system.
SP is a growing aid for health services. While the evidence base is evolving, existing services require ongoing review. Group facilitators play a key role in the SP process and, as such, greater support and attention to their experience is necessary. This can help ensure an improved structure with increased connectivity and ultimately effective outcomes for both patients and healthcare professionals.
- Office for Health Improvement and Disparities. Social prescribing: applying All Our Health. 2022. https://www.gov.uk/government/publications/social-prescribing-applying-all-our-health/social-prescribing-applying-all-our-health (accessed 4 Nov 2022).
- NHS England. Social prescribing. https://www.england.nhs.uk/personalisedcare/social-prescribing (accessed 4 Nov 2022).
- Islam MM. Social prescribing — an effort to apply a common knowledge: impelling forces and challenges. Front Public Health 2020; 8: 515469.
- Royal College of Nursing. Social prescribing models. 2022. https://www.rcn.org.uk/clinical-topics/Public-health/Self-care/Social-prescribing/Social-prescribing-models (accessed 4 Nov 2022).
- NHS England. Green social prescribing. https://www.england.nhs.uk/personalisedcare/social-prescribing/green-social-prescribing (accessed 4 Nov 2022).
- Roland M, Everington S, Marshall M. Social prescribing — transforming the relationship between physicians and their patients. N Engl J Med 2020; 383(2): 97–99.
- Thomson LJ, Camic PM, Chatterjee HJ. Social prescribing: a review of community referral schemes. 2015. https://repository.canterbury.ac.uk/download/b4200c5d0d0b31dfd441b8efedffae2865b13569e44cb4a662898a3ed20c1092/3729872/Social_Prescribing_Review_2015.pdf (accessed 4 Nov 2022).
- Hassan SM, Giebel C, Morasae EK, et al. Social prescribing for people with mental health needs living in disadvantaged communities: the Life Rooms model. BMC Health Serv Res 2020; 20(1): 19.
- Cawston P. Social prescribing in very deprived areas. Br J Gen Pract 2011; DOI: https://doi.org/10.3399/bjgp11X572517.
- Fixsen A, Polley M. Social prescribing for stress related disorders and brain health. Int Rev Neurobiol 2020; 152: 237–257.
- Dayson C, Painter J, Bennett E. Social prescribing for patients of secondary mental health services: emotional, psychological and social well-being outcomes. J Pub Ment Heal 2020;
- Chatterjee HJ, Camic PM, Lockyer B, Thomson LJM. Non-clinical community interventions: a systematised review of social prescribing schemes. Arts and Health 2018; 10(2): 97–123.
- Brandling J, House W. Investigation into the feasibility of a social prescribing service in primary care: a pilot project. 2007. https://purehost.bath.ac.uk/ws/portalfiles/portal/426828/Brandling_SocialPrescribingFeasabilityReport.pdf (accessed 4 Nov 2022).
- Aughterson H, Baxter L, Fancourt D. Social prescribing for individuals with mental health problems: a qualitative study of barriers and enablers experienced by general practitioners. BMC Fam Pract 2020; 21(1): 194.
- Wakefield JRH, Kellezi B, Stevenson C, et al. Social prescribing as ‘social cure’: a longitudinal study of the health benefits of social connectedness within a social prescribing pathway. J Health Psychol 2022; 27(2): 386–396.
- Husk K, Blockley K, Lovell R, et al. What approaches to social prescribing work, for whom, and in what circumstances? A realist review. Health Soc Care Community 2020; 28(2): 309–324.
- Drinkwater C, Wildman J, Moffatt S. Social prescribing. BMJ 2019; 364: l1285.
- Kilgariff-Foster A, O’Cathain A. Exploring the components and impact of social prescribing. J Pub Ment Health 2015; 14(3): 127–134.
- Maughan DL, Patel A, Parveen T, et al. Primary-care-based social prescribing for mental health: an analysis of financial and environmental sustainability. Prim Health Care Res Dev 2016; 17(2): 114–121.
- Husk K, Elston J, Gradinger F, et al. Social prescribing: where is the evidence? Br J Gen Pract 2019; DOI: https://doi.org/10.3399/bjgp19X700325.
- Wildman JM, Moffatt S, Penn L, et al. Link workers’ perspectives on factors enabling and preventing client engagement with social prescribing. Health Soc Care Community 2019; 27(4): 991–998.