The pandemic has exposed our need for social connection and GPs are especially well placed to write the community prescription. Cathy O’Leary reports.
Social prescribing is not radical, nor is it new. The concept has been simmering quietly on the backburner of Australia’s health policy hotplate for several years.
In principle, it seems a no-brainer. Where appropriate, GPs and other primary health care workers write ‘scripts’ to refer patients to non-medical services in their local community, such as the social running group parkrun.
And while progress has been slow to get social prescribing (SP) officially on the national agenda, COVID-19 could now be the catalyst that finally gets things cooking.
The pandemic’s all-pervading impacts on physical health, mental health and social wellbeing appear to have galvanised efforts to explore patient care beyond the boundaries of traditional medicine.
Prominent GP and consumer groups argue it is more important than ever to link patients to non-medical activities which address underlying contributors to poor health, such as loneliness.
Twelve months ago, the push to get SP formally recognised in preventive health planning was given a shot in the arm with the release of a landmark report off the back of a roundtable meeting.
Produced by the Royal Australian College of GPs and the Consumers Health Forum just as the coronavirus bullet was starting to ricochet around the world, the report highlights the need for better links between general practices and community services.
Now moves are afoot to see social prescribing included across several health plans this year including the Federal Government’s 10-year Primary Health Care Plan.
In the meantime, WA GPs are being encouraged to register their interest in tracking progress here and overseas.
Current models
The call for more social prescribing comes after successful trials in Canada and Singapore as well as its widespread introduction in the UK.
It has been used in a limited way in Australia with a 2019 survey of almost 3000 healthcare professionals, including 271 GPs, showing almost 70% had ‘prescribed’ parkrun to their patients.
But supporters of SP argue that while it is popular with both doctors and patients, the infrastructure and funding are lacking, and the practice needs to become a routine part of primary care in Australia.
Previous surveys of primary care doctors found that many did not have links to appropriate services, and 57% of consumers reported that their GP had never discussed SP-type approaches as part of
their care.
Dr Mark Morgan, chair of RACGP’s expert committee on quality care, is now optimistic about progress. “Things are moving quite rapidly,” he told Medical Forum.
The RACGP-CHF partnership has been joined by Mental Health Australia and by the end of last year they were finalising a budget submission to Federal Health Minister Greg Hunt, together with a detailed proposal for implementing a staged roll-out of a national social prescribing system.
“What we’ve been doing is taking the strong drive for social prescribing to work out how a policy might roll out in Australia, and some suggested funding around that,” Dr Morgan said.
“There have been discussions with community houses, or local providers of non-health services for people, which are part of the jigsaw to make social prescribing more accessible.”
Connection works
A recent college survey with responses from 140 GPs showed a strong belief that referring people to community groups and services could improve health outcomes.
“We also know 20% of the primary reason for people to visit their GPs could be described as social issues rather than directly health issues,” he said.
“In fact, social issues form a component of most consults with GPs.”
Dr Morgan conceded some people thought social prescribing sounded paternalistic, so it was important to define it because people tended to recognise it when someone described it but not necessarily by the term itself.
“It’s where a GP or nurse might connect someone to a non-health service such as parkrun or a community group that can address loneliness and social connectedness, and provide opportunities for physical activity,” he said.
“It’s more than just sign-posting and that’s where the role of link-workers becomes very important, and that’s why models internationally and nationally have always had a link-worker role fulfilled by someone with local knowledge of the community.
“My vision is that the role in some instances would be done directly by GPs and practice nurses, and at other times there would be an additional role for an appropriately trained, informed and supported link-worker, hopefully embedded in general practice to work closely with GP teams.
“GPs are very aware of community services available for their patients, such as those with chronic disease management, but what’s needed is a system that facilitates in providing information about what’s available and has an appropriate level of government safety.”
Clare Mullen, deputy director of WA’s Health Consumers’ Council, said it was encouraging to see work being done through the Compassionate Communities model focusing on improving the end-of-life experience.
“There are some interesting lessons emerging from the nine sites across Australia, including in the South West of WA, that have been applying that SP approach for a couple of years, but it’s still early days,” Ms Mullen said.
Change of focus
“We are talking about a very different approach to delivering support than the traditional clinical model. It’s about moving from a ‘doing to community’ model, to a model based on ‘doing with community’ or even a ‘doing by community’.
“One element of a social prescribing approach in the UK is the creation of a role that can support a consumer to navigate the fragmented system of care.
“This is something we hear at almost every community discussion about health services – that the system is confusing and difficult to navigate if you don’t have someone who can support you through it.”
Armadale GP and WAGPET medical educator Dr Ramya Raman is a fan of social prescribing.
She is concerned about increased rates of family domestic violence during the COVID-19 pandemic and argues it is crucial to make sure people have access to the right resources.
“I’ve become more familiar with the concept of social prescribing over the past 18 months and the use of it particularly in the UK to enable patients to target issues such as loneliness, chronic medical conditions and mental health wellbeing,” she said.
“I believe that as GPs we’re the primary care, the frontline workers, who are best placed to employ social prescribing to patients because I’d like to think we’re a trusted source of information.
GP strength
“We don’t deal with the one patient, often we deal with entire families, so there’s a lot of traction we can potentially influence.”
Examples of social prescribing in action in WA were community choirs and parkrun, which could target patients who were feeling lonely and give them the opportunity to meet others.
“Parkrun a very non-competitive environment, it’s not about running marathons or being a gym junkie, and women can take their kids along,” Dr Raman said.
Dr Raman has a big culturally and linguistically diverse population of patients, so social prescribing could help them discover what activities were available in their local community.
Activities such as parkrun also allowed new mothers to be in a social environment while getting some physical activity which ultimately benefited their mental wellbeing.
“I think the biggest thing GPs hold is the trust of their patients, and when you put something on a script, even if it’s non-medical, it can help with engagement and commitment,” Dr Raman said.
“It’s not for everyone but as GPs our focus is on preventative health, to try to ensure our patients are well and keep them out of emergency departments, so social prescribing is an excellent tool.
Holistic care
“General practice is not just about prescriptions and examining the patient. We know our patients best, and the beauty is our continuity of care. We get an understanding of the family dynamics which gives us an insight into holistic care.”
Dr Raman said that during COVID-19 people had found new ways to communicate with each other such as online platform or deliveries. But she was stunned how many patients had come to see her once the lockdown eased up.
“It just drives home that we are social beings, and that exactly echoes the concept of social prescribing. We thrive on the social interactions and conversations we hold,” she said.
Dr Morgan agreed that COVID-19 had shown how reliant people were on community and contact with others. “We’ve woken up to how much we need and value community connectedness,” he said.
Ms Mullen said the pandemic had shown that health services and the community could make positive changes quickly when needed.
“I think social prescribing and more holistic care of patients has great potential for helping to meet people’s needs that may not neatly fit into the box of either ‘clinical’ or ‘social’, she said.
“We regularly hear from people who want to be seen and treated as whole people.”
However, even supporters of social prescribing recognise some potential negatives and limitations.
Dr Morgan said it was not a one-size-fits-all, some people could benefit more than others, and some would not want to engage at all.
“It’s not a requirement, it’s just another opportunity to assist with both physical and mental health and take that bio-psychosocial approach that we all try take in,” he said.
“It’s about having more arrows in the quiver for patients.”
Dr Morgan said GPs had an enormous number of things to consider when seeing patients, especially those with multi-morbidities, but they had more than one opportunity to intervene, unlike emergency departments which might have the one chance. GPs were also used to working in teams and sharing tasks.
“It’s a way to provide an extra level of health care, and affordable local services are features of social prescribing which make it stand out,” he said.
Better, not more
Dr Raman said she did not see social prescribing as an extra burden.
“If anything, most GPs are already incorporating this in their day-to-day practice, so it’s more about taking it to the next level, or a central hub to find more information and resources,” she said.
Ms Mullen said the HCC wanted to see more positive case studies about the benefits for the community, and more people lobbying their local providers for a more holistic approach.
“I think one of the potential pitfalls is looking ‘over there’ and thinking – we can do that here,” she said. “From what I know of successful approaches, they’re quite specific to the local context.
“There may be lessons we can learn from others, but any model would need sustained community and clinical engagement in the local area right from the outset and throughout.”
Like any service, social prescribing could have funding implications for the health sector, but many believe it will be cost effective and even save money because it is not re-inventing the wheel.
Dr Morgan said that while social prescribing was already happening in Australia, it was piecemeal and lacked the necessary support. Having a national arrangement designed properly would not create barriers or bureaucracies, it would just help things happen more smoothly.
“It’s not about paying for services in an expensive way, it’s more about tapping into current health services, and perhaps a small ask in terms of supporting an organisation, instead of a massive commitment to create something from scratch.”
Public health physician Bret Hart said COVID-19 had provided a real opportunity to re-evaluate the healthcare system as a whole, which historically did not work well using integrated multidisciplinary teams, particularly outside the hospital system.
Allied health
But he questioned how community connectors or link workers would be accommodated in the funding model if allied health services still struggled to attract rebates, underlining the need to change the GP funding model.
Dr Hart said some critics of social prescribing worried it was a smoke screen for change without addressing some of the more fundamental issues that contributed to health inequities, which had become even more stark with COVID-19.
“The massive investment in SP in the UK is a measure of its success but to obtain a prescription you have to visit a health repair shop,” he said.
“Ideally, it would be better not to have to attend the repair shop in the first place by tackling the upstream determinants of health including, for example, early years education, housing and employment, to reduce inequity which is what kills on a grand scale.”
Dr Hart said a whole of government response, which COVID-19 had shown was possible, needed to be applied to upstream strategies that protected and promoted the health of populations. While social prescribing was a vast improvement on the mainly downstream focus, it was not enough on its own because it was a midstream activity.
He said GP practices in WA were being encouraged to track the social prescribing trend in the UK and elsewhere by registering their interest at bret@hart-solutions.com.au.