Jonathan T. W. Au EongIntroduction
In the practice of medicine, it is not uncommon to observe drastically different treatment outcomes in patients with nearly identical diseases and medical treatment. This phenomenon can be attributed to a variety of factors apart from medical care that can influence health outcomes, collectively known as the social determinants of health (SDOH). These include income, education, employment status, availability of healthy food and social support (1).
The impact of SDOH on well-being and health was illustrated by McKeown et al, who studied death records in England and Wales from the mid-19th century to the early 1960s (2, 3). They observed that mortality from different causes had fallen significantly and steadily decades before the emergence of modern medical care modalities such as antibiotics and the intensive care unit. They posited that the increase in life expectancy could be attributed to improved living conditions, such as access to clean water, nutrition and sanitation (4).
It is becoming increasingly clear that the practice of medicine goes beyond just the biomedical aspect. This is encapsulated in the “biopsychosocial” approach to medicine proposed by Engel in 1977 (5). It emphasizes the social, psychological and behavioral dimensions of illness beyond the biomedical aspect and has grown in popularity since its introduction (5).
The practice of social prescribing
Social prescribing, also known as community referral, is the practice of connecting patients and their carers with a range of local non-medical sources of support to optimize SDOH (6). The referrals are generally, but not exclusively, from professionals in primary care settings. First practiced in the United Kingdom (UK) in the 1990s, social prescribing aims to expand the options in primary care consultation by providing locally available resources which are often within the voluntary, community and social enterprise sector (7). This allows individuals to be more connected and resilient, enabling them to take ownership of their own care.
Social prescribing is in line with the World Health Organization's (WHO) Regional Action Plan on Healthy Aging in the Western Pacific, which advocates for support of the older population through collaboration between community service providers and the community health team (8). As supporting patients whose medical issues are exacerbated by non-medical problems becomes progressively more complex, social prescribing has become increasingly relevant and important, especially in the practice of family medicine. This is because family physicians typically follow-up with patients over a long period of time and often understand their patients' social background thoroughly.
The practice of social prescribing is gradually becoming more popular because the demand for non-medical care is increasing in most societies, and social prescribing is theoretically an effective way of addressing these needs (9). This article discusses some of the potential rewards and challenges in offering non-medical care in the primary care setting.
Rewards of social prescribing
Social prescribing has a myriad of potential benefits, among which is an improvement in well-being and health. It achieves this by incorporating a variety of social, economic and environmental considerations to address an individual's needs in a holistic way and encourages individuals to take greater ownership of their health.
Improvement in health and well-being
According to the WHO, global life expectancy has increased significantly, from 66.8 years in 2000 to 73.4 years in 2019 (10). Loneliness and depression amplify with age, stemming from a loss of familial ties, independent living and diminishing ties to cultural roots (11). There is mounting evidence that loneliness is detrimental to health and is associated with an increased risk of coronary heart disease, stroke, depression, cognitive decline and Alzheimer's disease (12). Recent evidence suggests that loneliness is not exclusive to the elderly but affects people of all ages (13, 14). It is clear that there is a great societal need for emotional and well-being services outside of medical therapy.
A wide variety of services are available through social prescribing, including community-based activities, information and advice, befriending and community transport. These were the most frequently assessed services in the Rotherham Social Prescribing Pilot Project in the UK (15). In this regard, social prescribing emerges as a feasible solution to match community resources and activities with those facing loneliness and social isolation. A mixed methods evaluation of social prescribing in the UK found that 72% of service-users felt less lonely after receiving support, with additional benefits of improved well-being, increased confidence, and greater life purpose (16).
Beyond emotional well-being, social prescribing has positive effects on physical health as well. This is especially helpful as many of those living longer have chronic medical conditions and poor health which compromise quality of life (17). For example, green social prescribing, which aims to connect people with nature-based activities to improve physical health, has become increasingly popular. An evaluation of the Opening the Doors to the Outdoors program in north Wales, a 12-week intervention focusing on either outdoor walking or climbing activities, found that participants experienced benefits to physical health in terms of fitness and strength (18). Likewise, an appraisal of the Luton Social Prescribing Program by Pescheny et al. also found an increase in energy expenditure from all levels of physical activities after enrollment in the program (19). A social prescribing pilot in Australia for individuals living with mental illness also found that participation in social prescribing programs led to significant improvements in quality of life and health status (20).
Current literature shows a strong link between emotional well-being and physical health. A meta-analysis by Lamers et al. found that improvements to emotional well-being may improve the prognosis of physical illness (21). Social prescribing can help to alleviate social isolation and anxiety, boost social interaction and improve confidence in daily activities and health (9).
Appropriate usage of scarce medical resources and improving patient satisfaction
In a world where medical resources are finite, there is a mismatch in the supply of medical resources and growing demand of patients (22). Appropriate resource allocation remains a central tenet of the decision-making process in any healthcare system (23). Social prescribing is a potential solution to relieve the strain on the medical system, ensuring the judicious use of limited medical resources.
The medical and non-medical issues of patients are often intricately intertwined, as complex socioeconomic factors such as income, wealth and education have a profound effect on health outcomes (4, 24). It is estimated that approximately 20% of patients in the UK consult their general practitioner for primarily social issues (25), with an expectation to find solutions to their non-medical problems.
However, primary care workers may lack the appropriate expertise or capacity to address these non-medical issues by themselves (7). This mismatch of expertise and patient expectations may result in unmet social needs, leading to repeat clinic visits, perceptions of inadequate medical care and subsequently patient dissatisfaction (9). In addition, patients referred from primary care settings to tertiary care centers with persistent unresolved social issues may require prolonged hospitalization stay. This was shown by Toh et al. in a Singapore study which found that social factors such as patients living alone, the need for financial aid and caregiver stress had significant associations with prolonged length of stay in acute hospitals (26).
Social prescribing serves as an adjunctive measure in medical care to address the non-medical needs of patients. By referring patients to social prescribing link workers, primary physicians can ensure that the non-medical concerns of patients can be addressed by professionals with the appropriate expertise, while channeling limited clinical resources towards patients' medical complaints. Furthermore, supporting patients with the appropriate resources for their non-medical issues helps to enhance patient satisfaction and also fosters trust in the healthcare sector.
Challenges of social prescribing
Despite its potential benefits, a number of challenges pose barriers to the wider adoption of social prescribing within the healthcare system.
Lack of understanding and awareness
One challenge is the lack of understanding and awareness of available resources, both amongst healthcare professionals and patients. As social prescribing is a relatively new concept, healthcare providers may be unaware of the available services and may find it difficult to explain these to their patients (9). A survey on general practitioners' perceptions of social prescribing within the UK's National Health System (NHS) found that 63% of doctors felt that they would like a deeper understanding of the practice, with some responding that they were unaware of some aspects of social prescribing (27). In countries where general practitioners operate individually, they may feel overwhelmed by the lack of capacity to take on social prescribing amidst their already heavy workload and responsibilities (28).
Patient expectation and acceptance
Many patients are unaware of the existence of social prescribing programs and their potential benefits (29, 30). In addition, patients who favor medical treatments may be less open to considering social prescribing programs (31). Many patients present to their doctors with preconceived expectations and personal agendas. For example, patients conventionally expect physicians to thoroughly assess their medical complaint, come to a diagnosis with appropriate investigations and formulate a treatment and long-term care plan (32). In fact, Williams et al. found that patients primarily wanted an explanation to their health problems and showed lesser desire for “support” (33). With this in mind, social prescribing should be advocated as an adjunctive measure for holistic care in the healthcare setting, and not as a replacement for medical therapy.
Lack of evidence for social prescribing
Evidence-based medicine is the meticulous, explicit, judicious, and reasonable use of modern, best evidence in decision-making about the care of individual patients (34). It has grown in popularity due to its transparent nature and the extensive accessibility of electronic databases from which clinical data and research can be acquired (35). In this era where evidence-based medicine has helped to routinely define the standard of care in medical practice, the evidence base relating to social prescribing has been problematic and is a barrier to its widespread adoption (25).
Given that the practice of social prescribing is heterogenous and highly dependent on local context, it is difficult to evaluate its components and outcomes (25). It is also difficult to arrive at generalizable conclusions that can be applied to societies with vastly different cultures. A systematic review conducted in 2017 on the effectiveness of social prescribing programs found little evidence of either effectiveness or value for money (36). The relative lack of robust evidence on social prescribing may hinder its acceptance within the medical profession.
Sustainability and funding
The administration of a robust social prescribing system requires many moving parts, including human resources and community programs. The goodwill of the voluntary sector is crucial to social prescribing as community services are often provided free-of-charge with volunteer help. In an evaluation of a social prescribing pilot in Brighton and Hove by Farenden et al., it was found that a total of 5824 volunteer hours were given to community navigation during the first 12 months of the pilot program (37). In addition, funding for social prescribing programs come from a combination of public and private funding, which are often non-recurrent and variable depending on governmental goals (38). As social prescribing becomes more popular, the operating costs to run and expand services to cope with more referrals can be expected to rise. In fact, the total expenditure on adult social care services by the NHS in England has risen over the past decade, with the total expenditure in 2022/23 more than £2 billion higher than in 2010/11 (39). Thus, its long-term sustainability remains uncertain and must be thoroughly evaluated.
A paradigm shift in medical care
Social prescribing facilitates a shift in medical care towards a person-centric and preventive care approach. It acknowledges that a balanced lifestyle is as crucial as medical care and emphasizes the importance of proactively addressing SDOH in disease prevention. In the context of an aging and increasingly chronically unwell population, preventive interventions are key to ensuring a sustainable healthcare system (40).
Conclusion
In conclusion, despite growing recognition of the potential benefits of social prescribing in family medicine, various challenges pose barriers to its widespread adoption. Thus, it is important to continue raising awareness of social prescribing and pursuing evaluation of its efficacy. By addressing the current barriers and promoting greater integration of social prescribing in family medicine, we can move towards embracing a more holistic approach to healthcare which embodies the “biopsychosocial” concept of medicine.
Author contributions
JTWAE: Writing – original draft, Writing – review & editing, Conceptualization.
Funding
The author declares that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
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References
1. Islam MM. Social determinants of health and related inequalities: confusion and implications. Front Public Health. (2019) 7:11. doi: 10.3389/fpubh.2019.00011
2. McKeown T, Record RG. Reasons for the decline of mortality in England and Wales during the nineteenth century. Popul Stud (Camb). (1962) 16(2):94–122. doi: 10.1080/00324728.1962.10414870
3. Mckeown T, Record RG, Turner RD. An interpretation of the decline of mortality in England and Wales during the twentieth century. Popul Stud (Camb). (1975) 29(3):391–422. doi: 10.1080/00324728.1975.10412707
4. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. (2014) 129 Suppl 2(Suppl 2):19–31. doi: 10.1177/00333549141291S206
5. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. (1977) 196(4286):129–36. doi: 10.1126/science.847460
6. Lee KH, Low LL, Lu SY, Lee CE. Implementation of social prescribing: lessons learnt from contextualising an intervention in a community hospital in Singapore. Lancet Reg Health West Pac. (2023) 35:100561. doi: 10.1016/j.lanwpc.2022.100561
7. Brandling J, House W. Social prescribing in general practice: adding meaning to medicine. Br J Gen Pract. (2009) 59(563):454–6. doi: 10.3399/bjgp09X421085
8. Marmot M, Bell R. Fair society, healthy lives. Public Health. (2012) 126:S4–10. doi: 10.1016/j.puhe.2012.05.014
9. Islam MM. Social prescribing—an effort to apply a common knowledge: impelling forces and challenges. Front Public Health. (2020) 8:515469. doi: 10.3389/fpubh.2020.515469
10. Global Health Estimates: Life expectancy and leading causes of death and disability [Internet]. World Health Organisation; [cited 2024 Mar 29]. Available online at: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy#:∼:text=Globally%2C%20life%20expectancy%20has%20increased,reduced%20years%20lived%20with%20disability (accessed March 29, 2024).
11. Singh A, Misra N. Loneliness, depression and sociability in old age. Ind Psychiatry J. (2009) 18(1):51. doi: 10.4103/0972-6748.57861
12. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. (2016) 102(13):1009–16. doi: 10.1136/heartjnl-2015-308790
13. Eccles AM, Qualter P. Review: alleviating loneliness in young people—a meta-analysis of interventions. Child Adoles Ment Health. (2021) 26(1):17–33. doi: 10.1111/camh.12389
14. Hawkley LC, Buecker S, Kaiser T, Luhmann M. Loneliness from young adulthood to old age: explaining age differences in loneliness. Int J Behav Dev. (2022) 46(1):39–49. doi: 10.1177/0165025420971048
15. Dayson C, Bashir N. The social and economic impact of the Rotherham Social Prescribing Pilot: Main evaluation report [Internet]. 2014 September Available online at: https://shura.shu.ac.uk/18961/ (accessed March 29, 2024).
16. Foster A, Thompson J, Holding E, Ariss S, Mukuria C, Jacques R, et al. Impact of social prescribing to address loneliness: a mixed methods evaluation of a national social prescribing programme. Health Soc Care Community. (2021) 29(5):1439–49. doi: 10.1111/hsc.13200
17. While A. The benefits of social prescribing. Br J Community Nurs. (2016) 21(5):266. doi: 10.12968/bjcn.2016.21.5.266
18. Makanjuola A, Lynch M, Hartfiel N, Cuthbert A, Edwards R. Prevention of poor physical and mental health through the green social prescribing opening doors to the outdoors programme: a social return on investment analysis. Int J Environ Res Public Health. (2023) 20(12):6111. doi: 10.3390/ijerph20126111
19. Pescheny JV, Gunn LH, Randhawa G, Pappas Y. The impact of the Luton social prescribing programme on energy expenditure: a quantitative before-and-after study. BMJ Open. (2019) 9(6):e026862. doi: 10.1136/bmjopen-2018-026862
20. Aggar C, Thomas T, Gordon C, Bloomfield J, Baker J. Social prescribing for individuals living with mental illness in an Australian community setting: a pilot study. Community Ment Health J. (2021) 57(1):189–95. doi: 10.1007/s10597-020-00631-6
21. Lamers SMA, Bolier L, Westerhof GJ, Smit F, Bohlmeijer ET. The impact of emotional well-being on long-term recovery and survival in physical illness: a meta-analysis. J Behav Med. (2012) 35(5):538–47. doi: 10.1007/s10865-011-9379-8
22. Ye Q, Deng Z, Chen Y, Liao J, Li G, Lu Y. How resource scarcity and accessibility affect Patients’ usage of mobile health in China: resource competition perspective. JMIR Mhealth Uhealth. (2019) 7(8):e13491. doi: 10.2196/13491
23. Calman KC. The ethics of allocation of scarce health care resources: a view from the centre. J Med Ethics. (1994) 20(2):71–4. doi: 10.1136/jme.20.2.71
24. Cawston P. Social prescribing in very deprived areas. Br J Gen Pract. (2011) 61(586):350. doi: 10.3399/bjgp11X572517
25. Husk K, Elston J, Gradinger F, Callaghan L, Asthana S. Social prescribing: where is the evidence? Br J Gen Pract. (2019) 69(678):6–7. doi: 10.3399/bjgp19X700325
26. Toh H, Lim Z, Yap P, Tang T. Factors associated with prolonged length of stay in older patients. Singapore Med J. (2017) 58(3):134–8. doi: 10.11622/smedj.2016158
27. Moore C, Unwin P, Evans N, Howie F. Social prescribing: exploring general practitioners’ and healthcare professionals’ perceptions of, and engagement with, the NHS model. Health Social Care Comm. (2022) 30(6):e5176–85. doi: 10.1111/hsc.13935
28. Foo CD, Chia HX, Teo KW, Farwin A, Hashim J, Choon-Huat Koh G, et al. Healthier SG: Singapore’s multi-year strategy to transform primary healthcare. Lancet Reg Health West Pac. (2023) 37:100861. doi: 10.1016/j.lanwpc.2023.100861
29. Carnes D, Sohanpal R, Frostick C, Hull S, Mathur R, Netuveli G, et al. The impact of a social prescribing service on patients in primary care: a mixed methods evaluation. BMC Health Serv Res. (2017) 17(1):835. doi: 10.1186/s12913-017-2778-y
30. Morris SL, Gibson K, Wildman JM, Griffith B, Moffatt S, Pollard TM. Social prescribing during the COVID-19 pandemic: a qualitative study of service providers’ and clients’ experiences. BMC Health Serv Res. (2022) 22(1):258. doi: 10.1186/s12913-022-07616-z
31. Pescheny JV, Pappas Y, Randhawa G. Facilitators and barriers of implementing and delivering social prescribing services: a systematic review. BMC Health Serv Res. (2018) 18(1):86. doi: 10.1186/s12913-018-2893-4
32. Oster A, Wiking E, Nilsson GH, Olsson CB. Patients’ expectations of primary health care from both patients’ and physicians’ perspectives: a questionnaire study with a qualitative approach. BMC Prim Care. (2024) 25(1):128. doi: 10.1186/s12875-024-02389-2
33. Williams S, Weinman J, Dale J, Newman S. Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? Fam Pract. (1995) 12(2):193–201. doi: 10.1093/fampra/12.2.193
34. Masic I, Miokovic M, Muhamedagic B. Evidence based medicine—new approaches and challenges. Acta Inform Med. (2008) 16(4):219. doi: 10.5455/aim.2008.16.219-225
35. Mellis C. Evidence-based medicine: what has happened in the past 50 years? J Paediatr Child Health. (2015) 51(1):65–8. doi: 10.1111/jpc.12800
36. Bickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open. (2017) 7(4):e013384. doi: 10.1136/bmjopen-2016-013384
37. Farenden C, Mitchell C, Feast S, Verdenicci S. Community Navigation in Brighton & Hove. Evaluation of a Social Prescribing Pilot. Hove: Brighton and Hove Impetus (2015).
38. Sandhu S, Alderwick H, Gottlieb LM. Financing approaches to social prescribing programs in England and the United States. Milbank Quarterly. (2022) 100(2):393–423. doi: 10.1111/1468-0009.12562
39. Adult Social Care Activity and Finance Report, England, 2022-23 [Internet]. NHS England; Available online at: https://digital.nhs.uk/data-and-information/publications/statistical/adult-social-care-activity-and-finance-report/2022-23/activity-and-finance-overview (accessed March 29, 2024).
Keywords: social prescribing, family medicine, holistic care, biopsychosocial (BPS) model, social determinants of health (SDOH)
Citation: Au Eong JTW (2024) The challenges and rewards of social prescribing in family medicine. Front. Health Serv. 4:1446397. doi: 10.3389/frhs.2024.1446397
Received: 9 June 2024; Accepted: 26 September 2024;
Published: 14 October 2024.
Edited by:
Leire Ambrosio, University of Southampton, United KingdomReviewed by:
Skaiste Linceviciute, University of Southampton, United KingdomCopyright: © 2024 Au Eong. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jonathan T. W. Au Eong, am9uYXRoYW5hdWVvbmdAZ21haWwuY29t
This article was awarded the College of Family Physicians Singapore Prize in Family Medicine in Lee Kong Chian School of Medicine academic year 2023-24.