Introduction
Supporting people has become a significant challenge for the NHS as the proportion of people with long-term diseases increases. Chronic conditions consume approximately 70% of the health care expenditure (Costa et al., 2021). In 2022, the government would spend ÂŁ15.9 billion on long-term care, an increase of 94% (Costa et al., 2021). Patients with long-term conditions account for more than half of all GP consultations, six out of ten outpatient sessions, and more than seventy percent of all hospital bed days in England.
To reduce the impact that long-term conditions have on the health care system, the NHS had to develop a technique to empower these patients to self-manage their conditions. However, isolation, loneliness, and depression keep bringing these patients back to the hospitals and utilizing the country’s Gross domestic product and GP consultations. One of the techniques employed by NHS to reduce health care usage is social prescription.
Social prescription refers to community services to support non-medically related conditions and symptoms such as loneliness, depression, obesity, etc. Here, the patient’s health responsibility is transferred from the health care system to the patient. Patients have to learn t self-manage their conditions. Social prescribing has been shown to help reduce health care usage. However, there are still unanswered questions about its adoption. First are the factors that should influence referral to SP programs.
Another problem is determining the impact of the referrer on the attitude of patients towards community services. This paper seeks to address these questions. However, the paper’s main aim is to help determine the sustainability of SP. Although it helps save health care costs, it is not yet well defined what additional costs are involved in its implementation. This paper will try to answer how sustainable SP is and if it is a technique that can help the NHS deal with the burden on health care usage.
Research Aim and Objectives
- To analyze the involvement of social prescribing among people with long-term conditions
- To assess the data and opinions of why the role was implemented in the first place.
- To assess whether the implementation has reduced the rates of GP appointments and admissions to the hospital.
- To evaluate whether the social prescriber has had an effect on a patient’s attitudes and practice of the community services.
- To critically analyze data as to whether this role is sustainable in the NHS and to present findings and recommendations.
Literature Review
Social prescribing is gaining a high adoption rate in medical practice today. However, its benefits and associated costs are not yet adequately defined. Bickerdike and others carried out a systematic review of articles published between 2000 and January 2016 to find evidence for the benefits of social prescribing. Their results showed that although social prescribing is the current practice today, the recent evidence fails to show its benefits and value for money (Bickerdike et al., 2017). Their paper showed a gap that researchers should consider to help close to providing more evidence on the effectiveness of social prescribing.
In an almost similar paper, Husk and others aimed to identify the approaches to social prescribing that work. They conducted a systematic review of nearly 200 documents (Husk et al., 2020). Their review broke down social prescribing into three stages: enrollment, engagement, and adherence (Husk et al., 2020). They used the papers to develop statements that showed the factors that influence each stage of social prescribing. In enrollment, their paper shows factors like if the program is considered beneficial to the patient, if the referral is provided in a way that matches the patient’s needs, and if any concerns the patient has been sufficiently answered by the referrer (Husk et al. 2020). In engagement, patients are likely to engage if the program is accessible and if their transit to the first session is supported (Husk et al., 2020). Lastly, patients are likely to adhere to the program if a skilled and knowledgeable leader leads the program and if the program helps improve their condition (Husk et al. 2020). Husk still notes that there was not enough evidence in the reviewed papers to make inferences on the effectiveness of any models and approaches to social prescribing.
In a mixed-methods study involving semi-structured interviews, analysis, and a longitudinal survey, Dr. Kellezi measured the effectiveness of social prescribing. The two studies used in the paper measured the perspectives and attitudes of health caregivers towards social prescribing, the perception of patients, and the health care usage of patients involved in social prescribing programs (Kellezi et al., 2019). The paper showed that social prescribing helped reduce loneliness in patients by giving them meaningful connections with society (Kellezi et al., 2019). The paper also observed reduced health care usage among patients involved in social prescribing (Kellezi et al., 2019). This paper gives some evidence on the benefits of social prescribing but has limitations such as the small size of participants and lack of a control group.
Similarly, Tierney and his team found that social prescribing helped reduce a patient’s dependency on GPs (Tierney et al., 2020). Their research started with electronic database searches, google searches, and a Freedom of Information request to all Clinical Commissioning Groups in England (Tierney et al., 2020). The over 200 articles they reviewed found that social prescribing helped increase the confidence, trust, and sense of belonging in patients. This new sense of belonging gave them more power to self-manage their situations without overlying on general practitioners (Tierney et al., 2020). They observed that social prescribing would help reduce healthcare usage when well applied by assisting patients in dealing with their non-medical-related issues.
Skivington and others conducted a study on social prescribing to identify the benefits and challenges involved in its implementation. They found the benefits of social prescription included shifting the burden of care from the general practitioner to the patient and the community link practitioners (Skivington et al. 2018). However, they found some associated challenges, such as the capacity and funding of community link projects. Here, they showed that although social prescribing may reduce the cost of health care, the cost is just transferred to the community link projects (Skivington et al. 2018). Without enough capacity and funding, social prescription projects will head to failure.
In this regard, social prescription cannot be taken as a magic bullet that will help solve the problems in healthcare. If not properly implemented, it can be a transfer of issues (problems) from the health care system to community link programs (Skivington et al. 2018). Such a transfer would indicate an acceptance of defeat on the NHS. Again, the paper recognizes that social prescribing requires a lot of time, commitment, and skill from the community link practitioners. Many community link practitioners lack the training and skill to deal with complex medical issues and patients and may not always offer them the best care. Their capacity to provide the best care was a challenge (Skivington et al., 2018).
One of the problems that social prescribing seeks to solve is loneliness. Foster and others did a study to determine the effectiveness of social prescribing in helping patients with loneliness. The research found that social prescribing programs helped reduce loneliness in most patients (Foster et al., 2021). The paper helped show that although social prescribing can be beneficial, more research is required to determine the condition of patients after they leave the programs (Foster et al., 2021). However, the paper also raised concerns such as the sustainability of the solutions, especially after patients left the social prescribing program. Similarly, the availability of facilities where patients can be signposted was also an issue (Foster et al., 2021). Again, the question of the skills that the community program leaders require was also raised in the paper.
Generally, the literature review shows that social prescribing has benefits and challenges alike. The extent of the cost-benefit balance of the approach is still under investigation. Similarly, almost all the available literature leaves gaps in the overall effectiveness of the policy. These gaps show that there is still work to develop a clear picture of the benefits of social prescribing vis-Ă -vis the associated costs. Most of the papers seemed to be systematic reviews, and there is a lack of quantitative data to show the effectiveness of social prescribing. The number of quantitative studies carried out with enough population and control data is not enough to give a concrete answer on the effectiveness of social prescribing.
Methodology
Research Design
The research used semi-structured interviews to get information from referrers, community link practitioners, and patients. Here, the questions were not set in order and in written form, but there were specific themes for each group of participants. The data collected was mainly qualitative, and analysis tools such as ANOVA were used to show the relationship between the dependent and independent variables.
Research Population
The research conducted in-depth semi-structured interviews with five general practitioners, seven community link practitioners, and 15 patients. The research population was kept as small as possible because of time and money constraints. Random sampling was used to select the participants. A random sample helped avoid bias and ensure that the selected population represented the general population well. Factors such as the age of the participants and location were considered to reduce the traveling costs involved in the research. In cases where an interview could not be carried out physically, online tools such as Google Meet and Zoom were used. The five general practitioners were selected to help show the criteria when referring patients to social prescription. The community link practitioners were asked questions regarding the services offered to patients and the general response they observed. The patients were selected to answer questions regarding how effective they believed the social prescription program was.
Data Collection
With the help of the community link practitioners and leaders, the 15 patients took the UCLA-3 item questionnaire to measure loneliness. This helped give an inductive approach to the research. This scale provides the participants with questions to answer, and scores range from 3 to 9. Patients that score above are deemed to be lonely. The patients took the questionnaire two times, three weeks apart.
Similarly, community belonging was measured using a single question that has been used in a community survey before. The question asked patients if they feel that they belong to that Community after thinking about a particular community and the people who live in it. Sa Likert scale was used to present the patients’ answers, with one showing they did not feel they belonged and four showing that they thought they belonged to the Community.
Seven communities were presented to the participants, with the option for participants to say they are not a member of any group. Adherence to social prescription programs was also measured. Adherence refers to the continued participation in the programs as required by therefore and the community links practitioner. Adherence was measured using the number of groups that the patients were part of and the number of sessions that the community links practitioner reported that patients attended. The length of the sessions was also considered.
The last point of interest to be measured was health care usage. There was insufficient funding to support a complex and expensive data collection method. Therefore, the research relied on the answers of the GPs and the patients. At the beginning of the referral, patients were asked how many times they had been in hospital for three weeks. The research then observed how many hospitals visits they made for the next three weeks of the study. The GPs were also asked to give their general views and figures on how they feel social prescription programs helped reduce health care usage.
Data Analysis
A repeated-measures ANOVA analysis was carried out to determine program adherence and health care use. This analysis compared the number of groups the patient belonged to with the number of hospital visits. A similar analysis with the same objective was also carried out for the number of sessions attended, measured in hours, and the number of hospital visits. Here, the zero hypotheses was that patients with high levels of adherence to community programs would have lower health care usage. Except for two interviews with service users, all interviews were conducted online. The researcher had never met the interviewees before, which helped assure their confidentiality and anonymity and thus reduced the chances of bias and wrong answers.
Support, delivery, and sustainability of services were the main points of attention for topic guides. These factors and research show that telephone and online interviews may yield as good data as face-to-face interviews led to the decision (Foley 2021, p. 625). At least 48 hours before the interviews, participants were emailed an information sheet and a permission form to help them better understand the research and their role in it. Before beginning the interviews’, informed permission was obtained, generally by recording the subject’s consent verbally, because the interviews were mostly conducted online. Interviews ranged anywhere from 30 minutes to 90 minutes.
Using NVivo 11 for data management and coding, the audio recordings were transcribed verbatim from the original recordings. The researcher used iteratively constructed coding frameworks to conduct an interpretative theme analysis of the transcripts. Model six in V.3.0 of PROCESS macro was used to measure the relationship between group adherence and loneliness. The zero hypothesis was that patients would be less lonely on the second take of the UCLA-3 item questionnaire with more adherence than the first take at the beginning of the study.
Ethical Considerations
The most significant ethical consideration in this study was confidentiality. The study dealt with important and sensitive medical data for the participants. Protecting this data was of utmost importance (Surmiak 2018, p. 395). All the data collected from the interviews was well protected to avoid landing in the wrong hands. All the data included in the research was kept as anonymous as possible. Another important ethical consideration here was consent. The study had to get all the participants to sign consent forms before the interviews showing that they agreed to contribute to the study and permitting the researchers to use the collected information in the research—lastly, the research to treat all the participants with respect. Interviews were arranged at the participants’ convenience. Where participants could not make it for a physical meeting, the interviews were conducted online. The researchers ensured that all participants were treated with respect at all times.
Findings
Table 1: Showing the Data from Findings
The table above shows the data collected from the patients. The loneliness was measured using the UCLA-3 item questionnaire, which gives scores between three and nine with patients with six and above considered as lonely. Most of the data were collected from the interviews with the practitioners and are included in the discussion below.
Discussion
Referral
One of the research objectives was to determine the data and opinions that lead to social prescribing. This information was collected directly from the general practitioners involved in the study. The practitioners noted that they consider the nature of the patient’s problems to determine if community link problems would help them. Patients that seem lonely and secluded from society are encouraged to join these groups (Clements-CortĂ©s and Yip 2020, p. 328). The general idea from the practitioners was that the referral mainly depends on the availability of a facility and a program that the GPs believe will be beneficial to the needs of the patient. Here, it became clear that referrals heavily depend on the practitioners’ knowledge and awareness of the experience of the referral programs. Therefore, it is essential to keep GPs informed and aware of the programs available for patient referrals.
Adherence
Factors affecting adherence were collected from the interviews with the general practitioners and the community link practitioner. One of the identified factors was that patients would only adhere to social prescription programs when they are convinced that the program offers benefits that can help improve their condition. It was clear that the referrers have to collect as much information about the programs as possible to present the patients with accurate and sufficient information to make an informed decision.
Again, it was noted by the community link practitioners that the first session was also a significant determinant of continued adherence to the program. Patients who felt that the program did not meet their needs and helped their condition in the first session were less likely to continue with it. However, when the patients felt that they were well received in the program and that it was in line with their needs, they were more likely to adhere. Here, it became clear that the community program leaders have a significant role in ensuring adherence (Clements-Cortés and Yip 2020, p. 328). These community leaders need training on dealing with the patients and ensuring they tailor the program to meet their needs.
Another factor affecting adherence was the presence and accessibility of facilities. The patients noted that they were ready to participate in the social prescription program as long as it was at their convenience. Most of the patients were unwilling to go out of their comfort to participate in these programs. Therefore, for the social prescription program to work, there need to be facilities that are easily accessible by the patients. The NHS will have to ensure that facilities are well placed within communities to serve as many patients as possible.
Benefits of Social Prescription
There were several benefits of social prescription that were observed in the study. The benefits were observed from the perspective of the GPs, the community link practitioners, and the patients. Some of the most significant benefits are discussed below.
Reduced Health Care Usage
Patients reported the number of hospitals visits they had made in the three weeks before the study and observations during the three weeks of the study. There was a significant reduction in hospital visits for the patients involved in the social prescription programs. Interviews with the patients showed that they felt more connected to the Community and fulfilled and did not find any need or triggers that would lead them to visit the hospital. The interviewed GPs also reported a reduction in health care use by patients that adhered to the social prescription programs. They attributed this to the self-care that comes with the social prescription programs and that the patients no longer think that any little trigger is a reason to visit the hospital.
The community link practitioners also attributed the reduced hospital visits to the sense of Community that the patients gain from the programs. They highlighted those patients meet others in the programs and they can share their progress, and this reduces the urge to rush to the hospital on every small trigger. According to patient feedback, this social engagement was critical to the pleasant experience of the route. Following the social cure approach, the psychological and social resources arising from rich group-based social interactions were seen as the cause of SP’s sound effects. As a necessity for any positive health outcomes, the community facilities played a significant role in providing a friendly and encouraging environment and welcoming attitudes, acceptance from activity groups, and a broader feeling of community connection (Skivington et al. 2018.
The research was able to test these correlations using our patient survey. Group memberships significantly impact health care use, and our data suggest that this effect is influenced by community belonging, which positively impacts loneliness. These variables predict the use of health care services, even after adjusting for age, gender, marital status, and educational attainment. To put it another way: Our findings support the beliefs of healthcare workers and patients about the importance of SP.
Improving Patient’s Health and Conditions
The primary purpose of the social prescription programs is to help improve patients’ health. The measure that was used here was that of loneliness. At the beginning of the study, the patients recorded higher loneliness scores than at the end of the program. These positively affected the patient’s health. In this regard, it became clear that social prescription programs positively impact the patients’ general health.
Challenges of Social Prescription
Cost of the Programs
One of the aims of social prescription programs is to reduce the cost of health care. This came about because the budget required to support patients with long-term conditions has increased. However, this paper presented a concern that SP does not necessarily reduce healthcare costs but instead transfers them to a different place. The community link practitioners noted that it was expensive to run the SP programs and that the increased number of patients was more brutal and more costly to maintain. There was not enough evidence of the total costs of running the SP facilities, and therefore, it is hard to compare if they reduce the cost of healthcare or are just a new expensive problem.
Overwhelming the Community Program Leaders
The research showed that one factor that determines adherence to SP is how effective the program is in helping the patient improve their condition. The programs need to be well-tailored to meet the patient’s needs. This requirement requires that the people leading the community programs be well-skilled to meet the expected standards. Most of the program leaders are not trained to handle these patients. The lack of training poses a challenge to the effectiveness of the programs (Skivington et al. 2018. For SP programs to be highly effective, the program leaders will have to be trained to deal with patients and help in improving their conditions. This training raises the question of cost again, as it will be expensive to implement and prepare all the facility providers.
Referrer Influence
The research showed that one of the factors affecting adherence to SP programs is how the prescription is given to the patient. Here, the referrer must ensure that they provide a medication that meets the patient’s needs. The social prescriber impacts the patient’s attitude towards the SP program. The social prescriber is the first point of contact the patient has with the community services. When the prescriber has enough knowledge about the community services, they can create a positive attitude in the patients. Here, it becomes essential that GPs and nurses are well informed about the community services s that they can give precise prescriptions to the patients and thus create a positive attitude to ensure maximum adherence levels.
SP Sustainability
This paper raises concerns about the sustainability of SP programs and if the NHS is in a position to use it as a long-term solution to health care issues. Although the programs help reduce the direct health care costs, especially in managing long-term conditions, the paper has shown that these costs are transferred to the community services. There is not enough evidence to show how much is saved. However, the requirements necessary to make community services effective such as GP training, community leader training, and facility provision, raise the costs (Costa et al., 2021). Here, further research is needed to determine all the costs associated with setting up effective SP programs and if these costs are lower than what is saved on direct healthcare usage. With the current evidence, it is still hard to determine if SP is sustainable in the long run.
Limitations and Challenges of the Study
The research was limited by the constraints of time and money. There was no budget for complex data collection techniques and the observation time was also limited. Similarly, the research population was small as it was costly to arrange interviews with all the participants. Another limitation of the research was the data collection methods. There were not enough resources to use complex data collection, and the research majorly relied on the participants’ word of mouth. This over-reliance on the participants’ opinions and the small research population created a risk of the participants’ bias influencing the research results. To reduce the likelihood of discrimination, the participants were assured of confidentiality and that all their answers would be kept anonymous in the research.
Conclusions and Recommendations
This research showed that although there are benefits to SP programs, such as reduced cost of health care and improved patient outcomes, there are still challenges that can make the program’s sustainability a bone of contention. These challenges include the costs required in creating accessible community centers and training the community link practitioners to offer services that meet patient needs. The research showed that adherence to social prescriptions is determined by how it is prescribed to the client. Here, referrers have to be well-knowledgeable to induce a positive attitude in the patients. The research concluded that more research is required to determine the exact costs of implementing SP and compare them to the charges that the NHS saves from the reduced hospital usage to determine if the projects are sustainable in the long run.
Recommendations
This paper recommends that community link practitioners be trained to get the necessary skills to tailor the community services to the patient needs to increase positive outcomes. Similarly, general practitioners should be equipped with information on the available facilities in the region and how the services can benefit their patients to ensure that refers to create a positive attitude. Lastly, more research on the actual costs of running these community centers is recommended as it will bring the information necessary to answer the sustainability question.
References
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Costa, A., Sousa, C.J., Seabra, P.R.C., Virgolino, A., Santos, O., Lopes, J., Henriques, A., Nogueira, P. and AlarcĂŁo, V., 2021. Effectiveness of social Prescribing programs in the primary healthcare context: a systematic literature review. Sustainability, 13(5), p.2731.
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Foster, A., Thompson, J., Holding, E., Ariss, S., Mukuria, C., Jacques, R., Akparido, R., and Haywood, A., 2021. Impact of social prescribing to address loneliness: A mixed-methods evaluation of a national social prescribing program. Health & Social Care in the Community, 29(5), pp.1439-1449.
Husk, K., Blockley, K., Lovell, R., Bethel, A., Lang, I., Byng, R., and Garside, R., 2020. What approaches to social prescribing work, for whom, and in what circumstances? A realist review. Health & social care in the Community, 28(2), pp.309-324.
Kellezi, B., Wakefield, J.R.H., Stevenson, C., McNamara, N., Mair, E., Bowe, M., Wilson, I., and Halder, M.M., 2019. The social cure of social prescribing: a mixed-methods study on the benefits of social connectedness on quality and effectiveness of care provision. BMJ Open, 9(11), p.e033137.
Skivington, K., Smith, M., Chng, N.R., Mackenzie, M., Wyke, S., and Mercer, S.W., 2018. Delivering a primary care-based social prescribing initiative: a qualitative study of the benefits and challenges. British Journal of General Practice, 68(672), pp.e487-e494.
Surmiak, A., 2018. Confidentiality in qualitative research involving vulnerable participants: Researchers’ perspectives. In Forum: Qualitative Social Research (Vol. 19, No. 3, pp. 393-418). Freie Universität Berlin.
Tierney, S., Wong, G., Roberts, N., Boylan, A.M., Park, S., Abrams, R., Reeve, J., Williams, V., and Mahtani, K.R., 2020. Supporting social prescribing in primary care by linking people to local assets: a realist review. BMC medicine, 18(1), pp.1-15.
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