It comes as no surprise to GPs working in areas of socio-economic deprivation that patients in these areas experience worse health outcomes. Research quoted by the British Academy¹ suggests that socio-economic factors have the largest impact on health, up to 40%. This i s double the impact of the standard of clinical care. 

As GPs, we encounter patients at all stages of ill health, from the early, undifferentiated malaise to concrete clinical diagnoses. GPs are the clinicians who treat the physical and mental manifestations of societal dysfunctionality. GPs will be familiar with the expectation of patients, requiring an expertise in housing, social welfare, education, the whole range of psychological supports, alleviation of loneliness, addiction, domestic violence, behavioural issues with children, bullying, anti-social behaviour and environmental issues. 

This expertise is assumed by patients, while the GP usually struggles and relies on a small compendium of a handful of local resources. Worse still, how many of these physical or mental health manifestations generate a prescription, contributing to the medicalisation of life? It is not hard to see that there is a significant unmet need, with neither the patient, the doctor, nor society at large particularly gaining from the status quo.

Social prescribing

Social prescribing refers to the process of accessing non-medical interventions; it is a mechanism for linking people with non-medical sources of support within the community to improve physical, emotional and mental wellbeing.  

Bromley by Bow,² a community centre in Tower Hamlets in London has been in existence since 1984, it contains three participating GP practices and it has become a leader in the field of social prescribing. Closer to home a project has been running in Donegal³ and more recently in Dublin 8 with the Fatima Health Group. 

Dr David Robinson, consultant geriatrician in St James’s Hospital has also headed up a local area mapping project for Dublin 8, with a website⁴ that allows clinicians to generate social prescriptions, having filtered assets based on patient needs from an interactive map.

The evidence base for social prescribing to date shows a mixed picture. A review by the King’s Fund⁵ shows analysis has generally been limited to small pilots, and whereas improvement in anxiety scores and quality of life indicators have been positive, cost benefits have been harder to prove.

The power of prescription

A complex relationship exists between GP and patient.  The act of prescribing is an important part of the social construct of the consultation.  Approximately two-thirds of general practice consultations result in a prescription. Jane Ogden in her textbook, Health Psychology⁶ explores factors around adherence. In Ogden’s text, she references studies by Horowitz and Horowitz and Armstrong and Savage.

The study by Horowitz and Horowitz in 1993 established improved health outcomes (in this case, post-cardiac event) in patients who were compliant with treatment, regardless of whether it was placebo or beta-blocker: “Patients who expect treatment to be effective engage in other health practices that lead to improved clinical outcomes”. 

In addition, they suggested that the power of adherence may not be limited to taking drugs but may also occur with adherence to recommendations of behaviour change. This highlights the potential power of the prescription to affect change. 

The study by Armstrong and Savage in 1990 compared directive consultation style versus sharing style in relation to patient satisfaction. The results suggest that a directive consulting style was associated with higher levels of patient satisfaction than a sharing consulting style.

Though somewhat counter-intuitive, this may underline the potential for direction from a GP in relation to a social prescription to be viewed favourably, increasing the chances of adherence.

GPs at Tallaght Cross

Our practice is a four-GP practice located in Tallaght Cross with a branch practice in the Mary Mercer Centre, Jobstown. Medical card holders account for approximately 90% of our patients. The majority of our patients currently live in Jobstown and the immediate surrounding areas. These areas are beset with severe deprivation and the social determinants of health are very evident in their impact on our patients’ health. 

As a practice we decided to use in-house expertise to develop a social prescribing stream within the practice. Through our practice nurse, Maura Lee, we had established strong links with community based activities and support groups local to our surgery which have been very helpful to our patients over the years.  In addition, one of our practice admin team, Brenda Nolan, has a background of a degree in social science and has worked with the Peter McVerry Trust and youth work organisations in the Tallaght area and was ideal for the role of social care co-ordinator. 

Dr Mike O’Callaghan collaborated with Ms Nolan to develop a bespoke software package to manage the social prescribing initiative and extracted crucial data from our practice management system.

Social prescribing – GPs at Tallaght Cross

The project commenced in October 2016 and involved the social care co-ordinator mapping  community-based activities and supports in the west Tallaght area; 292 such community assets have since been mapped and deep knowledge of eligibility criteria, services offered and referral pathways attained. These include parental supports, smoking cessation, Men’s Sheds, literacy agencies, counselling, addiction supports, crochet and knitting groups and art workshops. One remarkable aspect of this process was feedback from many of the assets to the effect that this was the first time they had had direct contact with a GP practice. Referrals commenced in December 2016.

A protocol has been designed allowing GPs to code patients as requiring a social prescription. Verbal consent is obtained for the patient to be contacted by the social care co-ordinator and the process is briefly explained by the GP. The social care co-ordinator generates a daily register of referred patients with a brief description of the scenario by running a report on the practice management software. 

A novel software programme was designed to record all work performed by the social care co-ordinator. The co-ordinator then contacts the patient to arrange a telephone contact or a one-to-one contact that takes place in the practice. In addition, the social care co-ordinator contacts the patient three to four weeks after initial contact to follow up and address any issues that may have arisen. 

Upon completion of the intervention, a summary of the patient’s interactions is printed from the social prescribing programme and scanned into the patient’s regular medical file. The programme stores scanned images of leaflets and contact information, which can be easily printed and handed to the patient.

Analysis to date

Patient cohort

To date, 55 patients have been referred to the social care co-ordinator by the GPs in the practices. Of the 55 patients, 25 are male and 30 are female. Average age of patients referred is 45 years. The patient age range spans 14 to 79 years. Patients under 18 interact with the social care co-ordinator either with or via their parent/guardian in all cases. 

Patient cohort behaviour 2016

We have compared the cohort of 55 patients’ GP attendance and medication usage to age-matched peers for 2016, and we intend to repeat and build on these analyses as 2017 unfolds. 

Patient contacts

It has taken an average of 3.4 days for contact to be initiated following referral by the practice GPs.

Of 205 patient contacts to date, 152 (74%) have been telephone consultations, while 39 (19%) have been conducted in one-to-one meetings. Miscellaneous tasks (eg. recording DNAs, sending reminder letters or resource information to patients) account for 14 (7%) of the items recorded.

Resource areas

To date details relating to 292 support organisations, charities and groups in the Tallaght area have been entered into the social prescribing programme. 

Organisations focusing on addressing mental health difficulties are the most commonly discussed resources, with social isolation and homelessness being additional frequently covered areas (see Table 1 for top five resource areas discussed). 

Outcomes

Examples of engagements with social prescribing include a middle-aged woman who was lonely and isolated but found a new lease of life by joining a line-dancing group and an older male who had lost his independence within his family setting and is now thriving with a renewed interest through the Men’s Shed and a gardening group. A number of patients have been linked to literacy and further education resources. Counselling services and support groups have been identified. A key factor here is the wide knowledge our social care coordinator has of the resources available so that the social prescription can be tailored to the precise needs of the patient, taking into account how someone wants to receive or engage with a service.

At this stage, it is too early to measure hard outcomes such as attendance and medication use. Anxiety scores and other quality of life tools will be introduced in the next phase.  All we can comment on currently is individual ad- hoc patient feedback and reflections of the participating GPs. 

From the patient viewpoint, feedback has been overwhelmingly positive, with patients expressing an interest in the services they have been referred to, usually with good engagement. Even if the process for them is at the beginning, at the very least that it does is open their eyes to possibilities they were unaware of, be that in social or psychological support, further education or practical help with the challenges of their daily lives. 

They comment on being followed up by the social care co-ordinator and there is a sense perhaps of being valued, listened to, respected. As GPs we feel there is often a new dynamic in the consultation, that more options are available to us, and less of a fear of opening up a ‘Pandora’s Box’. It is also astounding how few of the local assets we were aware of.

Discussion

The characteristics of the cohort who avail of social prescribing is noteworthy, with a preponderance of medications associated with mental health issues and a higher consultation rate than age-matched peers in the practice.  

Much of the social prescribing activity is conducted through phone calls, which traditionally have not been particularly well documented in previous GP research.

The resource areas discussed tally with the medication profile of the social prescribing cohort and also give valuable insight into the range of non-medical services most needed by patients. This may have implications for future planning of such services.

This is very much the start of a process. As the process continues we will examine whether social prescribing impacts on consultation rates and medication use. We intend to survey patients to assess the impact on their well-being. We will perform a cost analysis of the resources invested in the initiative to date. We are not advocating that social prescribing becomes a standard of care without additional resourcing to general practice; however, we hope to contribute to the body of knowledge around social prescribing, particularly, whether the evidence supports resourcing a social care co-ordinator within the practice team.

Health inequalities show no sign of diminishing, neither do the myriad social problems that affect our most vulnerable patients. Perhaps social prescribing may have a role in forming stronger connections between our patients and resources within their own communities, at a time when they are most needed. 

References

1. British Academy. “If you do one thing” Nine local actions to reduce health inequalities. 2014
2. http://www.bbbc.org.uk/bbbc-social-prescribing
3. http://www.healthequity.ie/org-donegal
4. http://www.locidokey.com
5. https://www.kingsfund.org.uk/topics/primary-and-community-care/social-prescribing?utm_source=twitter&utm_medium=social&utm_term=thekingsfund
6. Health Psychology. A Textbook. 4th Edition. Ogden