Social prescribing involves empowering individuals to improve their health and wellbeing and social welfare by connecting them to non-medical and community support services. It is an innovative and growing movement, with the potential to reduce the financial burden on the NHS and particularly on primary care (The Social Prescribing Network).
How to fix social prescribing?
Nigel Rose, Strategic Lead (Commissioning)
On 14 July, Macc is holding a Voluntary Sector Assembly about social prescribing where we will be helping the VCSE sector to write a manifesto about what we collectively want from social prescribing. This article is my personal take on some of the issues. I was heavily involved in the planning stages of social prescribing in Manchester five years ago and have kept touch with it ever since. However, I’m not going to discuss here how the Manchester social prescribing service works. This is a companion piece to an article I wrote just before the pandemic started which you may want to read first (article below).
There are many models of social prescribing and I’ve put a few references at the bottom of this article in case people want to read about some of them. However, the underlying principle of all social prescribing schemes is the same as is the aim. The difference is in how this aim is reached.
The underlying principle is that people with long term health/social care needs require more than help to fix whatever the problem is e.g. diabetes, dementia, drug issues, debt. They need help to live a decent life, with all the things that make a life worth living; whether that is a nice home, taking the dog out for a walk, having a good relationship with your family or making model cars. The lack of a good quality life causes serious chronic problems and leads to more and worse illness.
The aim of all social prescribing schemes is to link people with local, city-wide and national assets. Some of these assets are VCSE organisations, though many are not.
So, the problem for social prescribing is how to do this so it works for everyone.
Let’s start with the massive, huge elephant in the room question. What happens when the local assets don’t exist or are spread inconsistently across Manchester? Some places have lots of pubs, cafés, parks, community centres and some places don’t. What happens then?
Obviously, social prescribing can’t fix all of these gaps, the responsibility lies with all of us and especially with those people who are responsible for deciding where funding goes in Manchester. Everyone knows that there are huge gaps and yet the health care system spends very little on 'prevention' services. Instead, it tries to fix the problems that could have been avoided.
In my opinion, the role of social prescribing is to provide the missing data that feeds into health and social care planning. Do not underestimate the importance of this. Anyone in the health service will tell you that nothing happens without data. The data that social prescribing can provide in the systematic way that VCSE organisations cannot, is both about individuals and about local assets. For individuals, it can provide data at a neighbourhood level about what people want to improve their wellbeing such as friends, jobs, nice housing, hobbies, somewhere to walk the dog, and exercise. Even more importantly, it can provide data about what does and doesn’t exist in neighbourhoods and what the priorities are, by linking the individual data with the local asset data. This analysis can then be used to provide the justification for more funding for local assets. The aim must be to bring all the neighbourhoods in Manchester up to an adequate level, not to divert money from one neighbourhood to another and spread the small pie even further.
Some social prescribing schemes think the answer is to pay for referrals. I’m not going to deal with why this is a terrible idea in this article but happy to have that discussion with anyone who thinks that it’s a good idea. Suffice to say that this kind of per capita funding has been a disaster for the health service.
The next issue I’ll focus on is the model for linking people with local assets. There is a simple model that might appear to be the obvious solution, but I think this model is fundamentally wrong. The simple model is to provide a referral service and one to one support. A social worker contacts the service, a worker carries out an assessment and then provides some one-to-one support including referral to local assets. The problem with this model, if that is all there is, is that it does nothing to change the overall system, in fact it reinforces it. The whole health and social care system works on an assessment and referral model. Social prescribing needs to be different and more like the holistic and creative models present in many VCSE organisations. One consequence of this referral and 1:1 service is that there is already an extensive movement to 'professionalise' social prescribers so they can fit more easily into the existing system (and get paid more).
The role of social prescribing should be to support the process of transformation in health and social care. They should be the people who really know and understand what is happening in neighbourhoods and make sure everyone else knows. They are, or could be, the experts in locality that advise everyone else and spread information about local events throughout the support system. So, if someone working as a physiotherapist at the hospital or a GP or a social worker needs some information about local walking groups, they should be able to phone up for advice. Anyone who works in a strength-based way needs this kind of expert advice and there is general agreement that health and social care professionals need to be moving towards strength-based working. If you work for a drug user support service in the city centre, wouldn’t it be great if you could ask someone about what is happening in Blackley where your client lives. No health and social care professional can possibly know what is happening everywhere and though online databases work to some extent, they are not trusted and often are out of date. People need other trusted people they can talk to.
In order to play this role of providing expert advice to the health and social care system, the social prescribing service has to be working with organisations within the area. They need to be embedded and part of local communities, not another outsider coming in, they need local information and understanding rather than another career path. There are many other people in neighbourhoods who play some role in providing information about what is going on locally, from libraries to local newsletter publishers and faith groups. Social prescribing has a critical role in supporting the information infrastructure and making sure that the information gets to where it needs to be.
The final point that I want to make is about the role of social prescribing in bringing the people who use their services together. Let’s take an example. Imagine that a social prescribing service identifies a number of people within an area that want to go walking but there is no walking group. There are then a number of options. In a one-to-one service that’s it, no walking group, nowhere to refer and so no service. One option could be to run a walking group. Perhaps that can be a short-term solution. Another solution is to help people to set up their own walking group. A further solution might be to use the connections with local groups to work with them to get a walking group going. The point here is not that there is a right solution but that a social prescribing service should be thinking creatively about to help the people they are working with and working collaboratively with local organisations and supporting development. Solutions will vary from one place to another.
For me, the heart of social prescribing is about employing local people who reflect the range of communities within a neighbourhood, who can act as the bridge between health and social care staff (many of whom who will not be local) and the communities that they work with.
What is social prescribing, King’s Fund - https://www.kingsfund.org.uk/publications/social-prescribing
Social prescribing Ecosystem, Torbay Community Development Trust - https://ageingwelltorbay.com/2020/07/10/social-prescribing-ecosystems-report-2020/
Rolling out social prescribing, National Voices - https://www.nationalvoices.org.uk/sites/default/files/public/publications/rolling_out_social_prescribing_-_september_2020_final.pdf
How best to develop social prescribing? London South Bank University - https://www.lsbu.ac.uk/__data/assets/pdf_file/0018/251190/lsbu_asset-based_health_inquiry.pdf
Social Prescribing and the VCSE sector in Manchester
Nigel Rose, Strategic Lead (Commissioning)
Four years ago, Macc was heavily involved in putting together a bid for money through Greater Manchester Health & Social Care Partnership for a prevention bid. Not all of it was funded but out of it came Health Development Co-ordinators in neighbourhoods, about £1 million in VCSE funding (the 2019 OPeNS funding programme) and social prescribing.
The social prescribing part of the bid was tendered out as Be Well, initially in north and then more recently in central and south Manchester. Be Well in north was originally run by Greater Manchester Mental Health NHS Foundation Trust but following a recent re-tendering, Be Well across the whole of Manchester will now be run by Big Life, a VCSE organisation. Big Life has sub-contracted to a number of other VCSE organisations who bring local knowledge and connections with Manchester’s neighbourhoods.
There are many versions of social prescribing but all have at their core the same idea, that linking people with long-term needs to community assets will help to improve their wellbeing. Health and social care services, though vital, are only part of the solution. It’s about how we live the rest of our lives. The term community assets is used to mean any local services or amenities whether VCSE, statutory or private that might be of help to someone. This could be a gym, knitting club, park or a sports club. Many will be associated with or run by a VCSE organisation.
The model adopted in Manchester has three elements. The first is a one-to-one service where a referral is received, an assessment is made and then the worker provides some support including coaching, sign-posting and possibly more direct support to enable involvement with other community assets. The assessment is a critical part in that it is a holistic assessment that assesses both needs and strengths, and focuses on what the person themselves wants to achieve. The second element is providing advice to other health and social care professionals within a neighbourhood or across Manchester about what community assets are available. The third element is providing information, such as newsletters, for their own staff, for other health and social care staff and to people in the area about what’s available in their neighbourhood. The concentration of work so far has been on the first element.
In the relatively short time that social prescribing has been running in Manchester, there have been many significant successes. Be Well is working with large numbers of people and has developed good working relationships with many GP practices and has been working very much in a strength-based approach. The introduction of social prescribing has also raised some important issues, many of which were predictable and were discussed prior as part of the planning process. However, at that time, there was insufficient evidence and understanding of the issues to address them. This is no longer true.These issues are:
1) Pressure on VCSE organisations - The upshot of the sector being recognised for the critical part they play in wellbeing is that some organisations are now being overwhelmed by referrals. Though some general funding is provided through Manchester City Council for VCSE organisations through the Our Manchester VCSE Grants Programme, and through the associated OPeNS fund, there is still a shortfall. There are organisations who are having to refuse referrals as they have no further capacity. There is rising anger about this and calls for increased funding to the VCSE sector in line with the increased demand.
2) Equality - There are many neighbourhoods who lack significant VCSE support in a number of areas. For example, there may be good support for older people in the area but little or nothing for people with dementia or for carers. There may be lots of organisations but very few that cater appropriately for people from the huge variety of BAME communities in Manchester. For social prescribing to work properly, there needs to be equal access to VCSE support in every neighbourhood.
3) Referrals - When Be Well began it only accepted referrals through GPs. This had some justification to begin with as it can be difficult to ensure that GPs are fully integrated with other health and social care services. However, as social prescribing continues, there are understandable demands from VCSE groups who are accepting referrals to be able to refer directly to social prescribing. They want it to be a two way process.
4) City-wide VCSE - Be Well is not only referring to neighbourhood organisations but it is also referring to city-wide organisations which specialise in mental health, support for LGBTQ communities, for victims of domestic violence or support with benefits. Inevitably, referrals are increasing for these organisations and this needs to be recognised and additional funding found.
5) Mental health crisis - One of the 'unexpected' (not to many of us) issues that Be Well has picked up is the lack of mental health services. They are coming across increasing numbers of people with serious mental health problems that are unable to access services or who have been discharged. This reflects the lack of community support for people with serious mental health problems following discharge. It cannot be up to Be Well to fill this gap and a big question remains about how the invaluable information gathered by Be Well will be used to inform future commissioning and funding.
It is still relatively early days for Be Well and social prescribing in Manchester and it is still very much in the learning stages. There is huge potential for building on the work being done and a great deal still to explore. However, there is only funding for one more year and continuation funding has yet to be agreed.
The adoption of social prescribing recognises the critical part that VCSE organisations play in the health and wellbeing of people in Manchester which is a major step forward. It’s now time to look at our role in social prescribing and the issues it has brought which is why we are calling on the VCSE sector in Manchester to produce a social prescribing manifesto at our next Voluntary Sector Assembly on 30 March. To register your interest in the event and for more details, please visit our website.
If you want to find out more about this work, please contact Nigel at firstname.lastname@example.org.