Developing a Social Prescribing approach for Bristol

Dr Richard H. Kimberlee
October 20131

For more information please contact:
Dr. Richard. H. Kimberlee
Senior Research Fellow
Faculty of Health and Life Sciences
University of the West of England
Glenside Campus
Blackberry Hill
Stapleton
Bristol BS16 1DD
E-mail: Richard.kimberlee@uwe.ac.uk
Mobile: 07946189086
Skype: Kimberlee.richard2

We have seen how hard it is to engage somepeople, and how much patience and time somepeople need. In health we are often quick tojudge, slow to listen, and feel too busy to care in
the way we would want to. Having ****** (alocal social prescribing project) as a partner inour striving to deliver good care for our
registered population is like having an extra pairof arms. The team are amazing in theirresourcefulness and we are very much richer for
the work they are doing.
(A local Bristol based GP)

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Contents
Contents

4

Executive Summary

5

Aims

8

Acknowledgments

10

Introduction

11

What is Social Prescribing?

14

Different models of Social Prescribing

16

The effectiveness of Social Prescribing

25

Costs

31

Some challenges to consider when implementing Social Prescribing

34

What is to be done?

36

Conclusion

38

References

39

Appendix 1

Abbreviations

Appendix 2

Maps of Social Prescribing Provision in Bristol

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Executive Summary
It is very clear from this literature review and the interviews/focus groups undertaken for this reportthat there is no single, agreed understanding of what constitutes social prescribing (SP) in the city or
what interventions/approaches can be called SP. Despite this local projects consulted for this reportfrequently define and promote themselves as social prescribers.
For this report I have run three focus groups with: GPs, Practitioners/ Service Users and officials from
Bristol City Council and Public Health. I have spoken to 14 different SP projects and interviewed 7
more GPs and several Bristol City Council officials.
Current interest in SP has arisen because of three distinct issues:The increasing burden of mental health and other long-term conditions and the cost
implications this poses for service provision;
The crisis in general practice as recognised by Clare Gerada the Chair of the College ofGeneral Practitioners;
The Modernising Mental Health agenda in Bristol.

This report will outline three different models of SP to help to describe the types of SP practiceprovided across the city: Social Prescribing Light, Social Prescribing Medium and Social Prescribing
Holistic. It will briefly outline local examples of each.
There are 57 GP surgeries in BristoI, of which 12% (n=7) practice some form of SP. There maybe
more. However there are very few opportunities of sharing best practice and experience of SP in thecity to ensure its development as an option for supporting patients in primary care.
For a project to be defined as Social Prescribing Holistic it must have:
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a clear GP/Primary Care referral process;a local remit and have developed local knowledge of supportive organizations andevents;be a jointly developed intervention which has been sustained over time;a method to address beneficiary needs in a holistic way;
no limits to the amount of time a health facilitator/worker/officer spends with areferred beneficiary;address beneficiary well-being but anticipate that mental health needs may also be
discovered.

SP Holistic projects are adopting a holistic and preventive approach and aim to work with
beneficiaries with long-term conditions. They encourage beneficiaries to play a central role inmanaging their own care.
All of the local SP Holistic projects identified here have emerged from organic partnerships that have
independently developed between GPs in practice and their local third sector partners to address5

perceived well-being needs that they both identify. They have evolved over time and sometimes
from SP projects that could be previously described as light and medium SP models.
Links between primary health care services and third sector organizations are often underdeveloped
and require considerable time and patience to develop and evolve (South, 2008:310), thus the
projects that have evolved locally represent a considerable pioneering achievement and are atestament to the level of partnership work that has been developed.
SP projects present a lot of qualitative evidence to demonstrate the transformative effect their SPintervention has on beneficiary’ lives. Their impact should not be underestimated. In adopting aholistic approach the complexity of the challenges addressed and the achievements they attain canbe effectively demonstrated.
The GPs interviewed here believe that their SP Holistic projects are making a real impact on thepatients they refer.
I have found only one Randomised Control Trial to assess the cost effectiveness of SP. But it only
looked at an intervention I would describe as a SP medium project. Its conclusion was that SP
beneficiaries of the project were seen to be less depressed and less anxious, but their care was morecostly compared with routine care and their contact with primary care was not reduced (Grant et al,
2000:419).
Data monitoring methodologies are under developed across the third sector. This includes many
projects that deliver SP in the city. Limited resources, cultural pressures and some resistances tomonitoring have stymied their progress.
Two of the SP holistic projects highlighted here have understood the importance of the on-goingneed for data collection for monitoring and evaluation purposes and have invested in methodologies
to prove their value.
Data from one SP holistic project suggests that three months after a beneficiary’s induction on the
project beneficiaries show statistically significant improvement in: PHQ9 (p=0.001), GAD7(p=0.001) ,Friendship Scale (p=0.001), ONS Wellbeing measures (item range p=0.05 through to p= 0.001) and
IPAQ items for moderate exercise.
Analysis of GP contact times also suggest that for 6 in 10 SP Holistic beneficiaries there is a reductionin their GP attendance rates in the 12 months post intervention compared to the 12 months periodprior to the referral. For 26% of beneficiaries it stayed the same and for 14% it actually increased.
Prescription data and impact on referrals to secondary care are still awaited.
It is hard to make cost comparisons across SP projects. Particularly inter-SP models. Even intramodel comparisons are fraught with difficulty. The organic development of all SP Holistic projects
make them very unique. Each has a different focus and they have evolved in time to meet varying
local need.
Amongst the holistic SP projects there are differences in the number and type of staff recruited. One
model relies on a full time Health Worker with supporting volunteers. Another works with a maleand a female Health Worker to deliver gender assigned one-to-one support. These cost variances6also apply to fixed costs; some projects receive benefit in kind support in terms of having
accommodation and telephone access. One GP practice supports their SP project by covering thesecosts which are a great benefit to the project. Other projects rely on external funding to cover theircosts and sustain their work.
By simply looking at the staffing costs/ beneficiary supported there is a range of cost effective ratios
from: £223.74 to £833 for each beneficiary supported across SP holistic projects. A potential core
cost of around £500/beneficiary for mature holistic projects would not be unreasonable to consider
for future commissioning of holistic approaches.
A key outcome to some SP practitioners is that they perceive their intervention is not simply about
achieving positive outcomes like: improved well-being, a return to work or training. Instead it isabout addressing embedded and unaddressed/undiagnosed issues like: agoraphobia brought on byabusive neighbours. It can also be preventative in the sense that it helps to prevent beneficiaries
spiralling down to worse scenarios.
In a recent review of the economic costs involved in mental health prevention the importance ofintervening to prevent worse outcomes cannot be underestimated (Platt et. al.2006). Simply looking
at non-fatal suicide events it is estimated that costs are averted to £66,797 per year per person ofworking age where suicide is delayed. Figures vary depending on the means of the suicide attempt.
14% of costs are associated with A&E attendance and medical or surgical care; but…. more than 70%
of costs are incurred through follow-up with psychiatric inpatient and outpatient care (Knapp et al,
2011:26).
Commissioners should be aware of the additional economic value provided through SP projects
which include: harnessing volunteers, beneficiaries returning to employment and training and childcare responsibilities and community capacity enhanced.
This report highlights the challenges involved in developing SP projects including: non take up of GP
referral, the importance of the GP/SP provider relationships, the initial increase in GP workload, thethird sector’s capacity to develop data monitoring.
This report also makes some suggestions around future commissioning and advises sustaining thelegacy of those that currently deliver and can demonstrate a holistic approach to ensure theresources hitherto invested in very effective SP holistic interventions do not disappear.
It also recommends offering new GP/Third sector partnerships an opportunity and an incentive tostart their own journey to support GP referred patients that local GP practices have no immediate
medical solution and/or sufficient time available to address their often multi-faceted problems. In asituation of tight fiscal control giving new GP/third sector partnerships an opportunity to deliver SPholistic interventions, particularly in areas of deprivation, would be an effective way of broadening
the development of SP services across the city.

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Aims of this report
This piece of work was commissioned by the Bristol Clinical Commissioning Group. It has been led byan Associate Director in Public Health. It was initiated to run in parallel with the decision to recommission mental health services in Bristol. Originally social prescribing (SP) was seen as part ofthe procurement process for mental health services for the city. However, advice was sought on
how best to commission SP in the future. To this end this report seeks to offer guidance by
providing:

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•
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•
•

A summary of inter/national evidence on SP
An outline of alternative SP models
An assessment of their impact and effectivenessA review of the different models of SP used in Bristol
An assessment of the cost/effectiveness of different models
An assessment of whether SP for mental health and wellbeing is the same, ordifferent to SP for preventative measures like falls prevention or physical health.

Primary Research Undertaken
In addition to undertaking a literary review of current evidence I have visited and interviewed
service users, practitioners and some commissioners involved well-being interventions. Those
included here are self-defined as SP projects. In doing this I have always guaranteed anonymity forparticipants and assured participants that their identity would remain unknown in order to facilitate
open reflection and comment on the scale and impact of SP in the city. This was important. Many
providers of well-being services sometimes find themselves in competition with each other to win
funding to deliver and sustain their services. It was important to ensure that they felt that thisresearch was not an evaluation of assessment of their service per se but more an examination of thebest approach to develop for people in the future. Organizations across the city (particularly in thethird sector), who run tight budgets are acutely aware that there will be diminishing resources in the
future and have developed a heightened sense of a need to showcase their work. In guaranteeing
anonymity it means participants in this consultation have been able to provide open reflection on
local SP.

This work has taken more time and resources than unanticipated at the start of the consultation.
This is partly because it was commissioned in August when many people were away on vacation andtherefore unavailable for consultation. Secondly, to get a GP perspective on SP it proved necessary
to fit around GP’s tight timescales which meant interviewing outside lengthy working days. And,
thirdly, because additional organizations that were not identified in the initial remit began to contact
me to ensure that their views were included in this process. Given the development and changes inBristol’s mental health services anticipated by service providers I felt I had to broaden and include
these organizations who felt they had something to contribute and insisted that they should be
consulted.
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To this end the following organizations and individuals were approached:

Focus Groups• Social prescribing practitioners and service users (8 participants)• Bristol City Council/Public Health employees (6 participants)• GPs (4 participants)

Interviews
Practitioners/projects:
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•
•
•
•
•
•
•
•
•
•
•
•
•
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Knowle West Healthy Living Centre
Positive Minds
Health and social care pilot focussed on people with autism
New Directions Project
Care Forum
Second Step
Wellspring Healthy Living Centre
Orchard Medical Centre
Windmill Hill City Farm
Art on Prescription
Mind
Lightbox project
Walking Groups based at Whitchurch surgery
Bristol Homeopathy
Falls Prevention project
A Community Self Build Project
LinkAge
Willow Tree Surgery
Social Mirror ProjectThree GPs in three other practices

Bristol City Council/Public Health• Wendy Sharman
Bristol Clinical Commissioning Group• Glen Townsend• Jo Kapp• Grace Elias

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Projects contacted but not connected with:• Exercise on prescription• Exercise for older people

Acknowledgments
This report is informed by some of the interviews and work I have undertaken with practitioners andbeneficiaries working with different projects over the last five years including: The Wellspring
Healthy Living Centre, the Knowle West Healthy Living Centre, the Care Forum and LinkAge. It is also
informed by the regional evaluation I undertook with colleagues to evaluate the Big Lottery fundedSouth West Well-Being project which included three Bristol based SP projects (Jones and Kimberlee
et al, 2009). I am extremely grateful to all the organizations listed above who spent time with me
discussing the role and influence of social prescribing in primary care in Bristol.

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Introduction
SP is increasingly talked about in primary care across the city. Different wellbeing services
and projects are describing themselves as SP. This increasing interest in SP seems to comefrom three distinct pressures. Namely, the perceived growth in the burden of mental illness
and the economic costs this entails. The growing strain exacted on primary care services andGP services in particular. And, locally, the modernising mental health agenda which isseeking to review the delivery of mental health services for the city.

Increasing burden of mental health
One in four people in the UK are known to suffer a mental health problem in the course of ayear. It is also acknowledged that within primary care around 30% of all consultations and
50% of consecutive attendances concern some form of psychiatric problem, predominantly
depression or anxiety (Kessler et al, 2001; Scottish Executive, 2005). The cost of mental
health problems to the economy in England have been estimated at £105 billion, andtreatment costs are expected to double in the next 20 years. In 2011/12, NHS Bristol spent
just over £50 million on mental health services for the city – the largest spend by the former
Primary Care Trust on non-acute hospital services (NHS Bristol, 2012:4). This is a personal
cost that we all share. It is estimated that the economic costs of mental health are €2000
per annum for each European household (ESN, 2011:8). Mental health is high on thegovernment's agenda. The No Health without Mental Health, document published by the
Department of Health (2011) urged the development of a cross government approach toaddress the issue with a focus on outcomes for people with a mental illness as a way ofdeveloping and promoting solutions to reduce the burden. Although the picture varies
across Europe, the emphasis in mental health services has moved towards the developmentof a more person-centred approach, based on principles of SP (ESN, 2011:8)

Crisis in General PracticeThere is mounting evidence to suggest that primary care services are under increasingstrain. GP surgeries are facing an increase in numbers of presentees. In reality GPs are notnecessarily equipped to handle all the social and psychological burdens that patients
present with. The traditional GP model of service delivery is changing. It has come a longway from a model where patients were examined in their living room. GPs now usuallypractice in stand – alone surgeries and healthy living centres which offer an ever broadening
range of services. Which services they develop and offer can vary across GP practices. But
these changes and pressures coupled with complex reforms have led Clare Gerada the Chairof the College of General Practitioners (CGP) to conclude that general practice is in crisis!

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(Gerada, 2013, Accessed 8th October 2013). Survey work commissioned by the College andundertaken by the Kings Fund reveals that:• 85% of GPs believe their service is in crisis;• nearly 50% think they can no longer guarantee safe patient care;• most GPs are conducting 40-60 patient consultations each day and working
11 hour days in the consulting room
• and, most GPs predict that patients will have to wait longer for an
appointment.
(Gerada, 2013, Accessed 8th October 2013)

With an aging population this burden is going to increase and it is anticipated that
consultation rates will increase by 5% over the next 20 years. GPs also perceive that theirpatients are demanding better services and expect more. In particular younger patients areseen as less likely to grin and bear their ailments compared to older generations(Everington, 2013). Unlike other health services primary care has no waiting list or referral
criteria—they are forced to deal with the here and now in all its ramifications on a daily
basis (Hardy, 2013:347).
With pressures on GPs growing some GPs are advocating and developing new approaches totheir service delivery. This fresh approach includes SP. Dr Sam Everington Chairman ofTower Hamlets CCG has argued that GPs need assistance to manage their workload(Beavers, 2013:5) and believes that GPs should be offered more incentives to develop
partnerships to make their services work more effectively. The Chair of the CGP recently
argued that GPs need all providers of health and social care, within a geographically aligned
area to come together and pool resources (Gerada, 2013, Accessed 8th October 2013).
According to a retired GP from Bethnal Green Health Centre writing in the BMJ it requires
commissioners and GPs to undertake a:a radical rethink on service provision, with perhaps less emphasis onclassification and more on collaborative working practices (Hardy, 2013:347)

Part of this push to encourage primary care services to develop collaborative working is therealization that the burden of managing long-term conditions calls for a holistic approach.
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There are 15 million people in the UK living with a long-term condition. Typically this can
include people who are repeat attendees in surgeries for which SP is increasingly seen as apotential solution. Recent Kings Fund Caring Research has led to a call for GPs to be moreproactive and preventive in their approach.
Improving care for people with long-term conditions must involve a shift awayfrom a reactive, disease-focused, fragmented model of care towards one that ismore proactive, holistic and preventive, in which people with long-term
conditions are encouraged to play a central role in managing their own care,(Coulter, 2013:2)

Modernising mental health services in Bristol
With the responsibility for the commissioning of healthcare services transferred to theBristol Clinical Commissioning Group (CCG) on 1 April 2013, issues raised by the city’smodernising mental health agenda in the city posed fresh challenges and uncertainties. A
decision to re-commission mental health services followed serious concern expressed by
GPs and service users about existing mental health services over a number of years. Part ofthe process has subsequently seen the development of an overarching model of care. The
model seeks to relocate services closer to individuals and the communities where they live.
The suggested model is proposing multiple access points in accessible and non-stigmatisingsettings. This model was widely supported amongst the stakeholder groups that wereconsulted (2012b:15).
As part of the modernisation of mental health services a Recovery Pathway has beenoutlined (as opposed to a chaotic or crisis pathway) which will see the needs of individuals
with on-going mental health needs supported. The plan aspires to meet the needs of these
individuals via a recovery plan informed with input from the service user, their carer, the GP
and supporting mental health specialists, social care and 3rd sector agencies. Socialprescribing is seen as part of this pathway (Bristol NHS, 2013:13). And identified as anintervention that can be an:

early intervention with an emphasis on promotion, prevention, earlyintervention, recovery/resilience and grassroots community provision (NHS
Bristol, 2012:6).

13What is Social Prescribing?
It is very clear from the literature review and the interviews/focus groups which I undertookthat there is no single, agreed understanding of what constitutes SP. Or what
interventions/approaches can be called SP. In a lot of the literature including local policy
documentation around the modernising mental health agenda SP is often usedinterchangeably with social intervention. In fact around the city the term SP is applied to avariety of different interventions aimed at promoting well-being and/or health.
Over the last couple of years Bristol practitioners involved with delivering SP projects havespent considerable time reflecting on their practice and developing a definition of theirwork:

Social prescribing provides a pathway to refer clients to non-clinical services,
linking clients to support from within the community to promote their wellbeing,
to encourage social inclusion, to promote self-care where appropriate and tobuild resilience within the community and for the individual (Social Prescribing in
Bristol Working Group, 2012).

At a general level SP has emerged as a mechanism for linking people using primary care withsupport in the community (Brown et al., 2004, Scottish Development Centre for Mental
Health, 2007:12). It is sometimes called community referral. SP projects usually have areferral system in place and the SP element is often, but not exclusively delivered by thethird sector. SP involves the creation of referral pathways that allow primary health carepatients with non-clinical needs to be directed to local third sector groups. Such schemes
typically use community development workers or health workers with local knowledge orwith skills to navigate locally. And they are formally linked to primary health care settings.
SP assist individual beneficiaries who present with social or psychological needs to accesshealth resources and social support outside of the National Health Service. But they may
also assist with patients who may present with a somatoform disorder i.e. where a patient
has a mental disorder characterized by symptoms that suggest physical illness or injury –symptoms that cannot be explained fully by the individual. Or, where the GP believes that a
non-medical approach could achieve better outcomes. These patients usually have not had
a formal mental health diagnosis before. In fact they may not be suffering from a mental
health disorder. But they are patients who present for which there are no obvious medical
solutions.
Social prescribing can therefore strengthen the links between health care providers andcommunity, voluntary and local authority services. In these services there are potential
solutions to the wider determinants of mental health, for example, leisure, welfare,14

education, culture, employment and the environment (Scottish Development Centre for
Mental Health, 2003:5). But these links between primary health care services and thevoluntary and community sector organizations are often underdeveloped and requireconsiderable time and patience to develop and evolve (South, 2008:310).
In many SP projects the focus can often be on vulnerable and at risk groups and people withenduring and long term mental health problems (Frasure –Smith 2000, Greene 2000, Harris1999). But what characterises the SP more than anything else is that they are services thatare seen as offering a holistic approach (Brandling and House, 2007) to a beneficiary. And inmany ways SP is also a route to reducing social exclusion, both for disadvantaged, isolated
and vulnerable populations in general, and for people with enduring mental healthproblems (Evans, et al., 2011).
But they are very much a local solution galvanising local resources to help theirbeneficiaries:

Social prescribing creates a formal means of enabling primary care services torefer patients with social, emotional or practical needs to a variety of holistic,
local non-Clinical services (Brandling and House, 2007).
SP therefore aims to provide a referred patient with a holistic package of support tailored totheir individual need. Practitioners in Bristol often highlight that beneficiaries would
primarily be around clusters 1–6 (See Mental Health Cluster booklet 2011-12), although all
SP projects work with clients beyond these clusters. In most cases patients referred will notnecessarily present with a mental health diagnosis. So their location on the cluster
framework frequently comes after the referral has been made and the beneficiary has
engaged with the individual SP project. They also acknowledge that SP may also be aneffective part of a recovery and crisis support plan (Social Prescribing in Bristol: Working
Group, 2012).
SP packages can often be delivered through or alongside other opportunities e.g.: arts andcreativity, physical activity, learning new skills, volunteering, mutual aid, befriending andself-help etc. This could involve the SP worker offering an array of support around issues asdiverse as: quitting smoking, addiction, relationship problems through to practical things likeadvice around housing, debt, legal advice, benefits or parenting problems. The HealthWorker may also have additional skills around complementary therapies e.g. Reiki in thecase of one SP project in Bristol.

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Different models of social prescribing
It is clear from my discussions with providers, practitioners and local authority employeesthat there is no clear agreement as to what they mean by SP. Focus group discussions
tended to reach a reasoned understanding of what constitutes SP after considerable
deliberation. But even then people did not necessarily agree on all aspects of SP or whether
their experience of SP matched any broadly agreed criteria. To capture the range ofapproaches to SP across the city this report outlines different models below. This is anattempt to capture and present the range of SP offerings available across the city. Most of
the offerings do not conform to the definition of SP suggested by Brandling and House(2007). This model of SP I will call: Social Prescribing holistic. Projects in this category sharecertain clear features:




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





There is a direct primary care referral, usually from a GP practice, to an external SP
provider. This is often formalised in terms of a letter, form, an on-line application oreven a telephone call.
The SP provider has a clear local remit and draws on local knowledge of local
services to connect beneficiaries to important sources of support and aid.
The SP intervention has been developed and sustained jointly over time and in its
present form represents a product of joint partnership work between the primarycare provider and the SP provider.
The SP provider addresses the beneficiary’s needs in a holistic way. A patient may bereferred to a SP project to improve diet, but in doing so the SP project will look at allneeds and may offer support in terms of e.g. budgeting, nutrition, loneliness etc.
There are no limits to the number of times a beneficiary is seen on a SP project.
Time parameters may be set but the number of sessions offered can be more or lessdepending on the needs discovered in the holistic approach.
SP projects seek to improve beneficiary’ well-being. They may not necessarily
initially be concerned with addressing mental health issues (although some are).
Most beneficiaries who attend SP projects have undiagnosed mental health issues.
Although in adopting a holistic approach the SP project may delineate the mental
health needs of the beneficiary and these will be addressed or sometimes abeneficiary will be referred on to mental health services.

Below I outline the different models of social prescribing that are practised in Bristol and thesurrounding area. There are 57 GP surgeries in BristoI (Shepherd, 2010) of which 12% (n=7)
are known to practice some form of SP. There are probably more but there may be some
not yet known to the author. All the projects would describe themselves as socialprescribing. However they do not necessarily contain all the elements I outlined above in
16

Social Prescribing Holistic model. They contain some elements and may even be in atransition to another model.

Social Prescribing as Signposting
In this model the SP project is doing little more than signposting beneficiaries onto
appropriate networks and groups who may assist an individual beneficiary to address theirwell-being needs. All SP models have an element of signposting in their delivery. GPs candirectly refer to the project and leave the patient to their own devices to access and follow
through on the local well-being offerings available. Or the SP project may seek to address
beneficiary needs independent of the GP and will simply share the space of the practice but
not necessarily have any regular or formal link with GPs. The activities that they may bereferred too could include: a gym, a cooking project, peer support or a variety of counselling
opportunities etc. The practice may not have a strong direct relationship with the SP project
and their maybe little follow-up and/or feedback. The projects will have only minimalevaluation of outcomes.

Local examples:

The Social Mirror Project, Knowle WestThis is actually a tablet (IT) application that has been developed to help beneficiaries
measure, visualise, and see the potential for change by allowing them to access online
and offline networks of well-being support. Using funding from the Nominet Trust, the
RSA Action and Research Centre are delivering the project in different UK settings andare currently applying for NIHR Innovation funding to support the continued
development of their tablet based app’ which they have piloted in two GP practices in
Knowle West. In essence it is a brokerage approach with the SP project highlighting
gateways for beneficiaries to access.

Well Aware, The Care Forum
This is a useful, on-line, free at the point of access, guide to thousands of health,wellbeing and community initiatives in Bristol, South Gloucestershire, Bath & North
East Somerset, North Somerset and Somerset. It is enthusiastically run by the Care
Forum, a health and social care voluntary organisation who provide a mixture offrontline services and support to individuals, groups and organisations. It also provides
a Mental Health Employment Portal for beneficiaries to access.
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Bristol Mind
Bristol Mind have also got plans to develop their own support/planning/brokeragefunction for Personal Health Budgets for Mental Health.

To be effective SP very much depends on staff having good knowledge of what services areavailable in their local community. Mapping local, community groups and services into
electronic health directories to facilitate signposting and referral helps SP projects todevelop their knowledge base of what is available (Coulter 2013:16). However to beeffective SP projects tend to also employ local, trained, community health trainers to assist
in the development and implementation of a signposting project. As well as providing avariety of support services alongside the database they also take up the opportunity to
improve beneficiary lifestyle by linking advice and practical support around: smoking, stress,
diet, alcohol, physical activity and obesity. This approach has been developed byHealthWORKS in Newcastle. A recent evaluation of this project revealed that: 70% of allreferrals did engage with a link worker of which 91% set goals. Of those that were set goals
41% achieved their goals, but 59% did not. Monitoring data shows 69% of patients, based oncompleted records, experienced an increase in SWEMWB score and that 64% have achieved
an increase in confidence in managing their long-term condition (ERS, 2013:54).

Social Prescribing Light
This is perhaps the most common form of SP. These are community and/or primary-carebased projects which refer at risk or vulnerable patients to a specific programme to addressa specific need or to encourage a patient to reach a specific objective e.g. exercise on
prescription, prescription for learning and Arts on prescription (see Aldridge and Lavender,
2000; Friedli and Watson, 2004; Tyldesley and Rigby, 2003; and Millin, 2003).

Whitchurch Surgery
Is a 'Wellbeing (Social) Prescription' project, not a walking group run under the
auspices of the RSVP. It is an extension to their surgery based groups in Bristol, South
Gloucestershire, North Somerset and Bath & North East Somerset that hosts
volunteers to support a variety of activities around a surgery. The initiative is new andonly recently developed in response to a local need to address social isolation throughwalking. It should not be confused with Walk for Health a Bristol wide initiative that18

invites local groups to establish their own walking groups. There is no evaluation of
the work they do but it has an enthusiastic pioneer.

LinkAge
LinkAge has existed in Bristol since 2007. LinkAge works with people aged 55+ in theirlocal communities across the city of Bristol. Initially, the programme aimed topromote and enhance the lives of older people through a range of activities. This
includes fostering social awareness and encouraging older people to share their skills
with both young people within the community and their families. In a sense it aims toinspire older people and people within the local community to share time andexperiences with older people who for one reason or another have become isolated.
Based around five hubs across the city it employs a community development worker
to develop local well-being activities at community venues. However it does not haveany direct links with GP services although one of its hubs has been shown tosignificantly reduce isolation, promote well-being and increase physical activity rates(Kimberlee et al, 2012).

Social Prescribing Medium
The best example of this approach can be found at the College Surgery Partnership in
Cullompton, Devon. It was developed by senior partner Michael Dixon who had been a GP in
Cullompton for 26 years. He has been chair of NHS Alliance, representing primary care, PCTs
and practice based commissioners since 1998. Other national roles also include chairing the
National Life Check Board and being a member of the National Stakeholder Forum. He is a
Senior Associate of the King's Fund and Honorary Senior Fellow in Public Policy at
Birmingham University. Like other SP initiatives their SP project includes the employment ofa Health Facilitator. This role developed out of an exercise on prescription scheme
developed by the local surgeries and the local Council ten years before.
The health facilitator sees referred patients. Using Life Check and other tools the facilitator
provides advice on exercise, nutrition, diet etc. She promotes self-care using an on line
Thought Field Therapy programme (rather like CBT) and also signpost to voluntaryorganisations or self-help groups e.g. for specific disease areas - e.g. patients with heartdisease, diabetes and fibromyalgia or specific needs - e.g. a Knit and Natter group for people
who are socially isolated, an amblers group for the overweight and unfit, creative writing,printing and book reading groups for patients needing directed activity/socialisation.

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Although the project has a clear local remit in that it works within a distinct geographicallydefined neighbourhood and it is the product of joint partnership work. It does not obviously
seek to address the beneficiary’ needs in a holistic way instead it aims to address certain
needs or behaviours identified by the GP.

Social Prescribing Holistic modelThis model is sometimes known as the Bromley-By-Bow Model. In essence it is a flexible
model and represents the development of a project that had previously delivered at a lower
level of SP. Thus these SP projects tend to evolve flexibly over time. They have also evolved
organically in partnerships between GP surgeries and largely third sector organizations. They
are innovative and are seen by local practitioners to be a catalyst for enabling healthproviders to think much more creatively and holistically about addressing people’s wideranging mental health and social care needs within a non-stigmatising and empowering
approach (CSIP 2009:9). They have frequently emerged to meet an acknowledged local neede.g. somatoform patients, vulnerable families, high attendees, people with certain mental
health issues. They have also emerged because the GP practice accepts that an alternative
solution should be considered to address a perceived health need or issue that they
themselves cannot immediately address in the normal appointment time. In acknowledging
the issue they also accept that the SP project offers a potential solution to the issue.
These projects are frequently built over a long time. They are not a quick fix or a bolt-on.
They are a reasoned intervention developed in partnership. The Bromley-By-Bow SP
approach evolved out of the development of a local Healthy Living Centre built in 1999. The
approach sought to break down barriers that had traditionally separated services in a bid tomeet the diverse needs of their patients. Primary Care services are run as a GP partnershipand their other services operate as a charity with their own distinct but connected
governance arrangements. GPs have a referral letter on their desk top and they tick what aclient needs are e.g. anything from dietary advice through to welfare advice, housing advice
etc. (Beavers, 2013:5). GP Dr Everington from the local CCG argues that:

From a GPs perspective it broadens the armoury of what they can prescribe,
gives an alternative to a drug prescription and also reduces GP’s workload.
(Beavers, 2013:5).

Locally there has been an attempt to develop criteria and/or a description of a SP service.
Referrals are taken from NHS (where ‘medical’ services aren’t working or are not the besttreatment type). In essence it sees SP as having the role of identifying the issues that have20

triggered a health or wellbeing issue such as depression. This by necessity means thatpractical, emotional and social support is often offered to beneficiaries. They can accesshelp around debt, legal, family, benefits, housing, etc. This includes ensuring beneficiaries
are engaged/represented at statutory meetings such as: Common Assessment Framework
meeting or a family court. The SP worker may even act as an advocate with services ordepartments (e.g. housing). Support on the project is offered through one-to-one support
and group work. There is no additional prescribing of drugs or clinical services. And theholistic projects usually have an array of activities available for beneficiaries to receive.
Referrals can be made and beneficiaries can often enjoy tasters and peer support to get
involved with activities: like therapeutic activities (arts, gardening, etc), volunteer or
befriending opportunities. All the way through projects demonstrate to their beneficiaries
the progress made and distance travelled (Social Prescribing in Bristol: Working Group,2012).
Below there are brief outlines of local projects that match the SP holistic model.

Project: Developing Health & Independence (DHI) Wellbeing Project at The Orchard Medical
Centre.
Location: Kingswood, South Gloucestershire
Sessions: Unlimited
Funding: Local Authority
This project has been running for four years. It has funding to sustain its existence until April
2014. 90% of referrals are drawn from medical centre clinicians. The majority of patients areseen in the surgery but some will receive a home visit or telephonic support. Complexity ofpatient needs means the number of 1 to 1 sessions offered to beneficiaries extend both innumber and time. The worker takes a holistic approach to addressing beneficiary needs. The
full time Health Worker is supported by a part time audit worker. The project also facilitatesvarious group sessions: Into Action, Art Group, Yoga 4 Health etc.. And it is embedded indeveloping multi-agency approaches as well as signposting to other activities and projects.
Two additional volunteers support existing patients who are historical high users ofstatutory services and who struggle to make or maintain change (DHI, 2013).

Project: Positive Minds: Hartcliffe Health and Environment Action Group
Location: Hartcliffe
Staff: One health worker and volunteer support
Sessions per beneficiary: 1-12
Funding: Local Authority

21

Positive Minds, started in 2009 arising from Healthy Lifestyles Network project to help
establish independence from primary and secondary mental health services for thoseexperiencing isolation, depression, anxiety; and also those moving out of secondary care.
Positive Minds provides one-to-one support to help reduce the impact of mental andemotional stress. Their beneficiaries include referrals from a local GP practice. They havetheir own signposting database of local resources. Beneficiary’ needs are addressedholistically. They work with beneficiaries to develop personal action plans to bring about
positive change. This includes signposting to local groups, organizations and community
activities to help support the development of positive mental health. The project puts on
occasional activities with the local NHS staff like the Living Well Day event that encouraged
local residents to consider positive simple ways of promoting well-being. This is basedaround the new economics foundation’s Five Ways to Well-Being which involved tastersessions around Tai Chi, massage and relaxation.

Project: New Routes
Location: Keynsham
Staff: One full time co-ordinator and two part time co-ordinators.
Funded by: B&NES Council and the DH Health and Social Care Volunteering Fund.
Delivered: The Care Forum
Sessions per beneficiary: Usually up to three assessments but can be between 1-12 sessions.
The idea behind New Routes came from a local GP who was looking to provide a holistic
alternative for GPs to use with those patients who were taking up time and who may havecomplex non-medical needs. Eligible patients on the programme include people with: low tomoderate mental health issues, those who are housebound and/or lack of mobility, thosewith physical health conditions which inadvertently cause a decline in mental health andwell-being, the unemployed or low income, those recently made redundant, long-term sickor retired and carers or ex-carers, those with learning and physical disabilities and othervulnerable adults. Three GP practices refer on to the programme. Beneficiaries are often
met in the surgeries, in their home or at other locations.

Project: Pathways to Health
Location: Knowle West Health Park
Through focused individual support, family support and group-based activities, Knowle
West’s Pathways to Health project adopts a holistic approach to improving health and wellbeing. It works with people with poor physical health or weight management issues, people
with low level mental ill health, and people with diet-related health risks. The projectdelivers its services from the local Healthy living Centre. Knowle West Health Park
22

Community Interest Company developed from the Knowle West Healthy Living Centre,
which opened in 2001. It is established was a three way partnership between the local
community, the PCT and Bristol.
Knowle West Health Park has undertaken a comprehensive piece of work to develop an inhouse monitoring and evaluation system. This made use of before and after questionnaire
health related measures. Overall the data show a marked contrast between quantitative
measures and the self-reported qualitative data (Jones et al, 2011). Using a paired T test fora sample of 73 respondents, there were no clear statistically significant changes in mental
health (sleeplessness, feeling depressed); physical activity (activity level, breathlessness);and healthy eating (fruit and vegetable portions). Nevertheless other data suggest positive
results in terms of self-reported outcomes. For the Pathways to Health participants wereasked to state their personal goals at the outset of activities. Table 1 shows the importanceof physical activity and mental well-being related goals for many participants. At follow up,
82.9% (30 of 41 reporting) had completed the project activities and 73% of these individuals
stated that they had achieved their main goals.

Table 1: Participants personal ‘ultimate goals’ for the Pathways to Health project activity.
Sample n=67 Jan-Sept2009. Participants could identify multiple goals
Ultimate Goal
Lose weight
Get fit / Increase exercise
Look after self / Get well / Time for self
Increase mobility
Beat depression
Reduce cannabis smoking
Relaxation / Reduce anxiety
Stop smoking

%
39
20
20
12
3
3
6
10

(Source: Jones et al, 2011:146)

Project: Branching Out
Location: Wellspring Healthy Living Centre
Staff: Two full time one male and one female Health Worker.
Funded by: Various including the Tudor TrustThis project is based in Barton Hill at the Wellspring Healthy Living Centre which was
founded by local residents in 2004. It evolved from several initiatives aimed at addressing
beneficiary well-being developed through the centre. It serves one of the most deprived
communities in England. It also has a very ethnically diverse client base: 17% of beneficiaries
were from an ethnic group other than white and 9% had a first language other than English.
91% (n=115) said their first language was English. The Branching Out programme evolved
23

out of earlier well-being projects that sought to address the needs of adults who suffer fromanxiety and depression. Most beneficiaries are referred onto the project by one of five GP
practices in the Easton area. A few beneficiaries self-refer. The project works with both men
and women. Two health workers offer one-to-one sessions for up to three months.
Individuals will be seen on a regular basis and offered support in an array of different areas
including: advocacy, emotional support, anger management etc.

All of these holistic projects are characterised by direct referral routes from GPs. These
referral routes will have been developed over time. The mode of referral can vary. One
project has a flagging system on the GPs’ computers across three surgeries while anotherhas a specific form with suggested activities to be considered. Letters of introduction havealso been used. Actual utilisation of the prescription by the beneficiary is in all cases
voluntary. Which underlines a central tenet of SP: beneficiary engagement with the process
is important and SP exists to encourage beneficiaries to seek solutions and develop selfmanagement techniques.
The promotion of patient self-management and resilience is crucial to SP. It endeavours toensure that they have skills to look after themselves. In some ways SPs have parallels with
the House of Care model developed and tested by the Year of Care programme in 2011/2 byDiabetes UK and the Department of Health. This was piloted on more than 3000
practitioners and 60 trainers working in 26 communities around England (Coulter, 2013). It
was about developing personalised care planning. It involves clinicians and patients working
together using a collaborative process of shared decision-making to agree goals, identify
beneficiary support needs to develop and implement action plans and monitor theirprogress. In the programme the intervention is a continuous process, and not a one-off, bolt
on event (Coulter, 2013).

24

The effectiveness of social prescribing
All SP projects are enthusiastic advocates of their work. They are also confident that they
have a positive impact on beneficiaries’ lives. All SP projects can recant various good news
stories about the impact they make on clients lives. My own interviews with SP beneficiaries
reveals that the impact of SP can be enormous with clients reporting that they have beensaved from trauma and even suicide and that they have turned a corner.
Beyond qualitative evidence there has been very little systematic research into the impact
they make. It is also very difficult to make comparisons between SP projects. Particularly
those projects following a holistic model. They are all very different. There is someevidence that certain SP based around a particular issue or behaviour change can have an
impact on people’s lives. For example referrals to supported exercise programmes which
can include: gym-based activity; guided/health walks; green activity; cycling; swimming andaquatherapy; team sports; and exercise and dance classes have been seen to have a positive
impact on beneficiary behaviour. There is robust evidence (Fox 2000) to support the mental
health benefits of physical activity for clinical and non-clinical populations; but what is lessclear is what works to increase the uptake of exercise (NICE 2006).
However, a true mark of the success of SP is the effect it has on local GP practices. Many
local GPs still remain indifferent or even hostile to SP. A recalled story from one GP suggeststhat it may generate more work and greater dependency on a range of support.

A GP told me that he had a patient started coming in and asking for aprescription to get their electric meter read! (A SP Practitioner)

However my research suggests that where the full SP model is introduced and it has beensustained over time then GPs are only too happy to advocate its impact on their practiceand their workload.
I: What difference has social prescribing made to the surgery?
GP: We work in a tricky environment in health, often pressured and we see needin people’s lives everywhere we turn. We often feel helpless, and even hopeless.
We often medicalise people’s distress as that way we can understand and deal
with it more easily. Having *****around has really opened our eyes to see what
can be done with a true holistic approach, having people with the time andexpertise to get under the skin and find out what makes people tick, what theirstresses really are in life and what resources already exist to help. It is truly
25satisfying to see some patients make steps with the support of ******* that wewouldn’t have imagined. The impact on their health, mental health and healthseeking behaviour can be significant. (Practice Manager in a SP Holistic surgery)

Evidence of SP effectiveness is varied. Local SP advocates suggest that the range of impact is
as wide as the range of services with which to engage, and complex interventions such as SP
are remain notoriously resistant to elucidation through research aimed at hard outcomes(Brandling et al, 2009:455). A randomised controlled trial of the SP Amalthea Projectexamined general practice patients with psychosocial problems who were given access tovoluntary organisations. At one and four months after randomisation, those assigned to theintervention group had significant improvements in anxiety, improved ability to carry out
everyday activities and improved feelings about general health and quality of life (Grant etal., 2000). Several research projects and evaluations show that SP can improving mental
health outcomes for patients, improving community well-being and reduce social exclusion(Friedli and Watson, 2004).
The range and availability of local evidence of the impact made by holistic SP is still rather
limited. One of the local SP Holistic projects collects quite minimal impact data using theInventory for Brokerage Service Outcomes Star (IBSO). This is a self-report tool used at firstand last appointments. The data suggests that all beneficiaries report improvement on:
Health, Quality of Life, Making a contribution, Personal Dignity and Respect, Freedom from
Discrimination, Economic Wellbeing, Choice and Control and Emotional Well-being. With
the greatest improvement recorded on the latter.

26

Figure 1; Completed IBSO of all clients on a holistic SP project January-June 2013

Source: DHI (2013:6)
Data collected from another SP project as part of an independent study conducted by the
University of Bath, showed a positive trend towards improved mental and general wellbeing amongst beneficiaries. A typical beneficiary took up two new well-being activities.
One fifth of service users who began the SP project began volunteering in their community.
They also found some reduction in referrals to secondary care and to a lesser extent a
reduction in letters to secondary care. On this up to a third of all service users were fully
engaged in the SP process. Others dropped out because of a variety of reasons e.g. felt they
didn’t require the service or it was inappropriate for them, they moved away or simply
disengaged.
A third project in this model collected very minimal outcome data. This was justified on
several grounds. Like many third sector projects they felt they had minimal resources to do
the necessary research and associated admin’ work to undertake an effective evaluation.
Like other projects a lot of the outcomes that are achieved are with beneficiaries who were
struggling to get their get basic needs met. This project was concerned to get them toaddress basic literacy and numeracy needs and dealing with often acute difficulties like
debt, antisocial behaviour etc. Many of the clients that were seen were far from being job
ready so these practitioners believe that it is important that their project’s expected
outcomes should be related to the starting points of beneficiaries rather than everybody
27

being pushing towards outcomes like employment. Many SP projects work with
beneficiaries who are seen as hard to reach. They also have a multiplicity of needs. They arebased in communities that are challenged by multiple deprivation, higher unemployment
rates and lower levels of educational achievement. To these projects SP was less about
achieving specified outcomes (e.g. achieving employment or returning to work) but it wasmore about preventing beneficiaries from falling down even further thus preventing themfrom becoming a bigger drain on other resources:

You have to remember that the people who live in this community face amultitude of problems and issues that effectively force people into stagnation.
They withdraw and become a risk to their family and friends if they have any. Ifthey don’t have any then they could become a suicidal risk or prone to violence
and addiction. We stop this decline. We do this by concentrating on very simple
things first….. like… for example ….. getting out of the house and feeling safe.
(A SP practitioner)

Two of the local SP holistic projects have made a clear strategic decision to consistently
collect beneficiary information in the form of using standardised registration forms and awell-being tool to measure their impact across time. A local a social enterprise has helped
them to develop a client database to enable them to effectively monitor their delivery andevidence base their work. Some of the data below illustrate the impact that one of thesesuccessful SP projects has.
SP projects invite beneficiaries to complete a simple questionnaire at baseline and threemonths later. Their data suggests that their SP project has a profound impact on mental
health. PHQ9 scores for depression significantly reduced three months after initial contact
with the project. Comparing baseline and follow-up scores; at the start of the project 1 in 2
beneficiaries were scoring 20-27 (Severe Depression) on the PHQ-9 scale but only 1 in 20
were scoring this at follow up. A third of beneficiaries scored 0-4 (No depression) at follow
up1. A similar impact was made on beneficiary’ reported anxiety levels. At baseline almost
60% of beneficiaries had scored 15+ (Severe Anxiety) on the GAD-7 scale for anxiety atbaseline. At follow up only 1 in 10 still reported this level of anxiety2. For the Scottish
1

A paired samples t-test was conducted to evaluate the impact of the intervention on beneficiary scores on
the PHQ-9 scale. There was a statistically significant decrease in PHQ-9 depression scores from baseline(M=18.38, SD=6.42) to three months after (M=8.43, SD=6.33), t (69) = 11.39, p= < 0.001. The mean decrease in
PHQ-9 depression scores was 9.95 with a 95% confidence interval ranging from 8.208 to 11.692. The eta
squared statistic (0.65) indicates a large effect.
2
A paired samples t-test was conducted to evaluate the impact of the intervention on beneficiary scores on
the GAD-7 scale. There was a statistically significant decrease in GAD-7 Anxiety scores from baseline (M=15.39,
SD=4.67) to three months after (M=7.21, SD=5.34), t (69) = 12.83, p= < 0.001. The mean decrease in GAD-7
Anxiety scores was 8.81 with a 95% confidence interval ranging from 6.901 to 9.442. The eta squared statistic(0.70) indicates a large effect.

28

government the marker of success for SP is where they can evidence base the impact they
make to improve mental health and wellbeing (Scottish Development Centre for Mental
Health, 2007:7).
Similar significant improvements were found in terms of reduced social isolation. Using the
Friendship Scale at baseline 67.8% of beneficiaries were scoring very isolated on the
Friendship scale. At follow-up this had halved to 35.4%.3 In terms of their general well-being
beneficiaries on the SP programme report an improved sense of well-being compared towhen they started their SP. The table below looks at the Office for National Statistics (ONS)
Well-being Indicators. On all four measures there is significant improvement in thebeneficiaries’ sense of well-being. However even after participation on a SP project theirsense of well-being is still lower than the Bristol and regional averages.

Table 2: Office for National Statistics (ONS) Well-being Indicator scores before and after
involvement with SP.
ONS
Wellbeing
Indicator
Overall, howsatisfied are
you with
your life
nowadays?
Overall, how
happy did
you feelyesterday?
Overall, howanxious did
you feelyesterday?
Overall, towhat extent
do you feelthe things
you do inyour life areworthwhile?

Baseline(n=87)

Follow-up(n=48)
5.58

UK Adult
average(ONS, 2012)
7.4

South West
Region(ONS, 2012)
7.52

Bristol
Region(ONS, 2012)
7.3

2.63

3.26

6.06

7.3

7.28

7.18

6.0

3.56

2.9

2.99

3.21

3.8

6.02

7.6

7.77

7.47

3

A paired samples t-test was conducted to evaluate the impact of the intervention on beneficiary scores on
the Friendship Scale. There was a statistically significant increase in connectedness in the Friendship Scalescores from baseline (M=8.63, SD=6.01) to three months after (M=13.17, SD=4.28), t (69) = 5.62, p= < 0.001.
The mean increase in the Friendship Scale scores was29Beneficiaries on the project also report an increase in their physical activity with significant
improvements in the number of people taking moderate exercise. On this SP project a thirdof beneficiaries were meeting the NHS target of 5x30 minutes of moderate exercise a dayeach week. When at baseline no beneficiary met this standard. This is against a backdrop in
Bristol where the Quality of Life survey suggests that people in Bristol are actually
undertaking less exercise than before.

Of concern is a rise in the proportion of people who are overweight and obese,
and a fall in exercise levels, participation in active sport and creative activities(Bristol City Council, 2011:4).

Importantly the SP project is also able to report on GP attendance and prescription data at
one referring GP practice. Although the analysis of the prescription data is still on-going,
preliminary results reveal a clear drop in GP attendance for most SP beneficiaries. The data
below suggests that 6 in 10 beneficiaries had less GP attendance in the 12 months after
joining the programme than in the 12 months before. Half the beneficiaries made lesstelephone contact with their GP.

Table 3: GP attendance data before and after involvement with SP.
Number of consultations
After 12 months
Fewer
The Same
More

Face to Face(n=37)
60%
26%
14%

Telephone(n=40)
50%
24%
26%

The table above confirms the views of the GP referrers I have interviewed for this research
who believed in their practice SP is having an impact.

Without doubt I am seeing certain clients less than before. It is having an impact
with them which provides me with hope that social prescribing has made a realdifference to our practice.
(A referring GP)

30

Forthcoming research results can be anticipated from a MSc. project started in January 2013
which is exploring the impact of SP has on patients who are high users of A&E and thosewith long-term conditions.

Costs
There has been very little research to explore the cost effectiveness of SP. The Amalthea
Project which was based around 26 GP surgeries in Avon using the referral services of a
Health facilitator is the most recent investigation. This was very much a SP medium project.
It worked with 90 beneficiaries who were referred to a voluntary organisation to manage
their access onto a SP project. It is one of only a few projects to have been comprehensively
evaluated, using a randomised controlled trial and economic evaluation. As reported abovereferral to the Amalthea Project and subsequent contact with the voluntary sector resulted
in clinically important benefits compared with usual general practitioner care in managing
psychosocial problems; but at a higher cost. Beneficiaries of the project were seen to be lessdepressed and less anxious but their care was more costly compared with routine care andtheir contact with primary care was not reduced (Grant et al, 2000:419):

Psychological interventions in primary care can, but do not necessarily, result insavings in mental health prescribing.

However this study did not look at the long term savings made beyond a year and did notcompare the costs to what would have happened if the patients had been referred to a
specialist and secondary care (Thornett, 2000).
Are RCTs an appropriate way to measure the cost effectiveness of SP projects? Current
policy guidance and recommendations suggests that it is important to assess the potential
saving of future costs (Freidli, 2007:9). SP fits in with the long-term strategic reorientation
towards promoting health, independence and wellbeing, and in essence practitioners
believe that by investing in SP now it will reduce future costs of ill health. Thus there areseveral critics who argue that short-term economic evaluations are limited in concludingthat it costs more than usual general practitioner care.

Experience of the Hackney Well Family Service, a family support project we havedeveloped jointly with the Family Welfare Association, suggests this is shortsighted. It fails to take into account of the long-term benefits to the community,31

and the consequent reduced burden on all support services, when the cycle ofdeprivation can be broken (Goodhart, 1999; 525).

This need for a long term view on costs has been realised in one of the SP Holistic projects
discussed in this consultation. Their analysis of their own experience suggests some generaltrends towards reduced resource utilisation over 12 months or more, although these results
were inconclusive, they came with the caveat that SP should be evaluated on a long-termbasis as outcomes are often slow when working with isolated and often poorly motivatedclients (The Care Forum, 2012). This is because SP beneficiaries frequently require a
considerable amount of time to enable the SP worker to address their multi-faceted needs.
But, if these needs are not addressed and a person reaches a crisis point, it then becomesmuch more difficult and costly to restore their health, employment and social status, with asubsequent exacerbation of economic and health inequalities (Freidli, et al 2007:45).
We should also remember the extra value that these projects can potentially bring which
are not immediately quantifiable in a simple cost benefit analysis. Adopting a Social Return
On Investment (SROI) approach as recommended by the Cabinet Office for assessing third
sector value (Cabinet Office, 2009), it is possible to quantify the broader value that theseprojects achieve. SROI approaches compare the monetary benefits of a program orintervention with the program costs (Phillips, 1991). SROI represents a development fromtraditional cost–benefit analysis in the late 1990’s and sought to fully valorise all social
impacts of any intervention (Emerson, 2000).
One of the key impacts that SP practitioners claim is that for many beneficiaries they (thepractitioners) are often the only support they have in the community. Without the SP
project patients run the risk of causing society more costs because of the inevitable decline
in mental health if left they are left untreated. In particular, these patients run the risk of anincrease in the chances of a Major Outcome Occurring e.g. suicide. Many beneficiaries whocome onto SP holistic projects report suicidal tendencies.

I was at my wit’s end. I was like……. Things were so bad I could have topped
myself. I just had nowhere to go. I had such a row with my partner, it was bad I
just smashed things up. (A SP Beneficiary)
Somebody I have met has brought me back to life. The woman downstairs (thedoctor in the GP surgery) didn’t give me any help at all. (A SP Beneficiary)

Platt et al (2006) have argued that the average cost of a completed suicide for those ofworking age only in England is £1.67m (2009 prices). This includes intangible costs (loss of32

life to the individual and the pain and suffering of relatives), as well as lost output (e.g.
employment), (both waged and unwaged), police time and funerals. There are also costs tothe public purse from recurrent non-fatal suicide events. Overall it is estimated that costs
are averted to £66,797 per year per person of working age where suicide is delayed. Figures
will vary depending on the means of suicide attempt. One recent English study indicatesthat only 14% of costs are associated with A&E attendance and medical or surgical care;more than 70% of costs are incurred through follow up with psychiatric inpatient andoutpatient care (Knapp et al, 2011:26).
All SP projects bring to the broader community and the health services greater value. For
the LinkAge project we calculated that for every £1 invested in the Whitehall and St. George
Hub there was a SROI of £1.20. But we guessed that this was probably an underestimationof the potential return in the medium term, because the LinkAge hub was in the first year ofoperation and these projects tend to face severe challenges in their initial set-up year andthen gather momentum after a few years. By far the biggest added value that SP projects
can bring is the large amount of unpaid volunteer time provided by individuals to help
support SP activities. We parsimoniously calculated for one LinkAge hub they had worked an
additional 2,430 hours across the year. Another holistic SP project reports that one fifth oftheir beneficiaries have begun volunteering as a direct result of their involvement in a local
SP project (The Care Forum, 2012).
It is hard to make cost comparisons across SP projects. Particularly across the different SPmodels as presented here. Even intra-model comparisons are fraught with difficulty. All SP
projects are unique. Each has a different focus they have evolved in time to meet local need.
Thus amongst the holistic SP projects there are differences in staff recruited. One model
relies on a full time Health Worker with supporting volunteers. Another works with a maleand a female Health Worker to deliver gender assigned one-to-one support. These variances
can also apply to fixed costs; some projects receive benefit in kind in terms of having
accommodation and access to a telephone. One GP practice supports their SP project bycovering these costs which are a great benefit to the project. Other projects rely on externalfunding to cover these costs and sustain their work.
However I have looked at some of the reported costs involved in running the four projects
adopting the SP holistic approach in the local area. I concentrate on reported staff costs.
This of course ignores other costs like room hire, postage, telephone costs, mobile phone
usage, travel costs for those who may advocate for a beneficiary or who needs to be visitedin their home. The staff costs/beneficiary vary considerably.

33

Table 4: Cost illustrations of local SP projects
Project
Project A
Project B
Project C
Project D
Total

Annual Staffing
Budget£50,000£27,967£50,000£57,686£185,653

Beneficiaries

Cost/Beneficiary

154
125
60
129
468

£324.67£223.74£833.33£447.17£457.23

Some challenges to consider when implementing Social Prescribing
Involvement in SP is voluntary. Not all prescriptions are taken up by beneficiaries. One of
the SP Holistic projects report varying take-up rates of between 63% and 88% for different
quarterly referral periods. What happens to those who fail to follow through with theirprescription is unclear and is unreported on by GPs.
In a review of several SP projects in the county of Durham what appears to be a proven key
to success is the relationship between the primary care providers and the community
services delivering the social prescribing activities. These need to be strong and nurtured
and develop over time (White and Salamon, 2010). SP is not a bolt on or a quick fix as somelocal interviewees have suggested in the course of consultation around this report.
One of the main practical challenges in implementing SP include: agreeing referral routes
and appropriate criteria. In all holistic projects these tend to evolve over time and theyoften need considerable negotiation between the GP practice and the SP provider to ensurethat both are aware of the patients who can benefit from the service available.
Effective SP has been shown to depend on the quality of partnership, joint working and cooperation between primary care staff and the SP provider as well as statutory providers like
local authorities can be key to ensuring SP success. Cultural differences between medical
and community development models can emerge as a strong potential source of tension.
These need to be ameliorated through partnership working if SP is to be a success (Scottish
Development Centre For Mental Health, 2007:6).
There is some evidence that GPs are concerned about their liability when referring a patient
to a SP project. Although there is no discreet academic work that has been undertaken to
explore the legal responsibilities of GPs and third sector organizations, some GPs havesuggested using the term referral rather than prescription to denote the end of their
responsibility in terms of the management of an individual’s patient care (Scottish
Development Centre For Mental Health, 2007:14).

34

A key issue is the third sector’s capacity to manage SP. It is clear from my interviews withprojects across the city that many projects are operating on stringent budgets. Most haveovercome short term funding crises in order to sustain their activity. And many indirectly
rely on the added value frequently provided by their committed health worker in giving
more of their own time to deliver the SP project (Kimberlee et al, 2012). But there are also
capacity issues around maintaining up-to-date information on sources of voluntary andcommunity support. In the city the SP signposting projects are continually being updated
and at the holistic end of the SP spectrum it relies on a continued commitment from HealthWorkers to ensure they are aware of what is happening locally. In some cases they initiate
new activities to meet unmet need where none locally exists e.g. a Men’s group. But where
SP projects have struggled is in their capacity to evidence base their impact on beneficiaries
lives. The recording and evaluating of impact and outcomes has long been a struggle for SP
projects (Sykes, 2010).
Hence here has been insufficient research exploring beneficiary journeys beyond 12 months
post SP engagement. Clearly with the SP signposting projects there is a fear that all the
projects might do is transfer beneficiaries around sectors, thereby shelving underlying
problems. (South 2012:312).
Also, new GP adopters of a SP project can anticipate an initial increase in their workload
post implementation. This is not only a result of a need to develop and work on partnershipbuilding but it is also about developing the relationship with the SP provider to ensure thatpatients targeted and the referral routes developed are agreed and fit for purpose.

35

What is to be done?
A number of developments have created a potentially favourable policy environment for SP.
These include a stronger policy emphasis on public participation and patient involvement
which in essence is a central aim of SP. The government’s recent concern to promote thethird sector to help in the national improvement in well-being by getting the: many other
Associated Heath Professionals who believe they hold some of the keys to building ahealthier nation to tackle and treat long term conditions (Cameron, 2011). Additionally, themovement to holistic definitions of health which recognise the impact of psycho-social andsocio-economic factors in determining well-being, epitomised by the ONS recording of wellbeing data. And the growing demand from GPs themselves that all providers of health andsocial care, within a geographically aligned area should come together and pool resources.
(Gerada, 2013, Accessed 8th October 2013)
Similarly, the new Public Service (Social Value) Act 2012 has urged commissioners to give as
much credence to social value as well as cost. Thus full comprehension should be given to
consider improvements in social, economic and environmental well-being in the
procurement process. Chris White MP who introduced the original bill argued the aim of the
Act was to support community and volunteer organizations and social enterprises to win
more public sector contracts by utilising the added value that they bring (White, 2013).
To bring the third sector into delivering services will take time but there are long term
rewards to be realised. Traditionally, mental health services have been commissioned undera ‘block contract’; with a single overall price for all the services provided by a single
organisation. The organisation received the funding regardless of the number of patientsseen or actual care given. Incentives for better care have been built into the system with theintroduction of Key Performance Indicators and Payment by Results (PbR) in 2003 forcertain services. PbR provides a nationally set tariff which the provider organisation will
receive for each episode of care deliverd. In April 2013, the CCG Governing Body met toreview plans to re-commission mental health services for Bristol. The Governing Body
agreed that all community based services would be tendered while inpatient services would
initially be redesigned and renegotiated with the existing provider: Avon and Wiltshire
Partnership Trust (AWP). This decision was seen to increase stability in mental healthservices during the transition and enable improvements to be achieved more rapidly (Bristol
Clinical Commissioning Group, 2013). The CCG has also re-advertised the Community Access
Support Service.
Looking at the literature and exploring local practice around holistic SP projects it is clearthat their aetiology and philosophy are very different from the way that in patient services
for mental health services have been established and practised. They have emerged almost
organically from local community routes and they represent a partnership between thethird sector and GP practice to address local need. As such they are a partnership which GPs
recognise as working for them. The projects have long histories and are networked in to36

local provision to meet their beneficiary’ needs as identified through their holistic approach.
In this sense the projects that exist are already garnering local resources to meet need.
Future commissioning of SP should consider helping to sustain these existing SP holistic
resources rather than seeking to start from scratch with new initiatives for those areas of
the city that already benefit from their resource (See Appendix 2). The three Bristol based
projects highlighted are based in some of the more deprived areas of the city: Hartcliffe,
Knowle West and Easton.
For new initiatives a space should be made available for local people to decide what sort of
SP they would like. In particular what level and model of SP would suit their local needs. SP
is not a bolt-on. It is something that can be developed to suit local need and address local
issues. It maybe that a SP light approach based around signposting could be a good starting
point for a local area or a community e.g. a LinkAge hub. But this isn’t a holistic SP approachand it does not necessarily begin to build the partnership between the SP service andprimary care services. But is a starting point from which a GP/SP provider partnership may
want to start.
To commission SP holistic projects commissioners need to understand the long term impactthat these projects can potentially deliver could take some time realise. Secondly, theeconomic value of SP might be realised elsewhere other than in primary care e.g. reduced
referral to secondary care or reduced police resources. It takes time to develop theseprojects and they need funding to sustain their work in the medium term. But the lessons
we can learn from this reflection on SP is that SP projects needs to suit certain criteria:







A direct Referral, from primary care
A clear local remit to harness resources
The suggested SP project should be a joint partnership between the primary careprovider and the SP provider.
The project addresses beneficiary’s needs in a holistic way.
There are no time limits to the number of times a beneficiary is seen on a SP project.
Aim to address well-being but are likely deal with beneficiaries across and including
people in psychotic clusters.

In terms of good practice the SP projects should ensure that the:••••Primary care team are central as referrers and sometimes co-ordinators
It is important to ensure the beneficiary is referred to a named person andnot just a black hole;
Activities referred too should be located in the local community and be wellknown to the SP project workers;
There should be clear information on the project and activities and they areeasily available to access;
37

•
•
•

There should be a mechanisms available relating to referral pathways,
feedback and review processes;
SP projects should look at putting in place effective ways to track
development and outcomes;
The primary care team should clearly know what to look for in terms of who
would benefit from referral. Typically these have been:Those with vague or unexplained symptoms or inconclusive diagnoses
Frequent attenders for GP appointments
Those with multiple symptoms
Those with poor social support mechanisms
Those experiencing psychological difficulties(based on South 2012:314)

Conclusion
It is clear that over time successful SP projects have developed and evolved as local
partnerships to address a perceived need where medical interventions appear to haveinsufficiently addressed a patient’s needs. In essence SP identifies the issues that havetriggered a health or well-being issue. This could include an undiagnosed mental healthissue like depression or anxiety or other life-changing impacts like unemployment,
bereavement, familial breakdown etc. In particular, SP provides a holistic approach andoffers an integrated service that can considerably improve beneficiary well-being, including
mental health. As some fear, far from being about shifting responsibilities and transferringso-called problem patients, advocates argue that SP should be seen as a method ofextending primary care through partnership working (South, 2008:215). Evidence presented
here testifies the impact SP has had local people’s lives. This includes not only the SP holistic
approaches but the SP light approaches too. There is some dispute about SP projects’ costeffectiveness. In the short and medium term this may be hard to discern, but commissioners
and policy makers need to take into account the costs of what would happen if such services
weren't available (Knapp et al, 2011) for the most vulnerable patients often living in themost deprived communities.

38

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Appendix 1: Abbreviations

CBT

Cognitive behavioral therapy

CCG

Clinical Commissioning Group

CGP

College of General Practitioners

CSIP

Care Services Improvement Partnership

ESN

European Social Network

GAD

Generalized Anxiety Disorder

GP

General Practice/Practitioner

IPAQ

International Physical Activity Questionnaires

NHS

National Health Service

NIHR

National Institute for Health Research

ONS

Office for National Statistics

PBR

Payment by Results

PCT

Primary Care Trust

PHQ

Patient Health Questionnaire

RSVP

Retired & Senior Volunteer ProgrammeSP

Social Prescribing

SROI

Social Return On Investment

SWEMWBS

Short Warwick & Edinburgh Mental Well Being Scale

44

Appendix 2: Maps of Social Prescribing Provision in Bristol

Existing_Holistic_Pre
Existing_Holistic_Pre
scribing_2013_GP_Bristol_Quartile.pdf
scribing_2013_Bristol_Quartile.pdf

45