As primary care looks to increase the use of social prescriptions, Nursing in Practice editor Amanda Nieves explores the role of nurses in implementing this key change.
Social prescribing seems to be the latest buzzword in primary care. The NHS Long Term Plan raised it as part of a ‘fundamental shift’ in primary care services, and the Government’s aim is to refer at least 900,000 people to social prescribing within five years and overall give 2.5 million people access to social prescribing.
Health secretary Matt Hancock has always said his ambition is for every patient in the country to access social prescriptions on the NHS as readily as medical care. To that end, he announced last month the creation of a government-funded national academy to support social prescribing projects.
Headed by Professor Helen Stokes-Lampard, outgoing chair of the Royal College of GPs, and backed by £5m of government funding, the National Academy for Social Prescribing is developed in partnership with Sport England, Arts Council England and voluntary sector partners. Its aim is to ‘standardise the quality and range of social prescribing available and increase awareness of the benefits of social prescribing’.
The Department for Health and Social Care insists that where social prescribing is being used it is working; patients with long-term conditions who have access to social prescribing link workers have said they are less isolated, attended 47% fewer hospital appointments and made 38% fewer visits to A&E.
But despite the evidence, the uptake of social prescribing is still low. Research has found that only 60% of clinical commissioning groups (CCGs) use social prescribing for patients with anxiety, mental health problems and conditions such as dementia.
Mr Hancock is undoubtedly hoping that the availability of funding for social prescribing link workers through the new primary care networks will help boost uptake. The aim is for the link workers, employed by the PCNs, to develop tailored plans and connect patients to local groups and support services.
The plan is to have over 1,000 trained social prescribing link workers in place by the end of 2020/21, and even more by 2023/24.
Nursing leaders believe that practice nurses have a vital role in ensuring the success of this new type of healthcare. As practice nurses are already caring for patients with long-term or chronic conditions, they can help identify those who might benefit from this care. They also have the connections in the community to find out which services and groups are available.
|What is a social prescribing link worker?|
Social prescribing enables all primary care staff and local agencies to refer patients to a link worker and supports self-referral. Working under supervision of a GP, link workers give patients time and focus on what matters to them, as identified through shared decision-making or personalised care and support planning. They also connect people to local community groups and agencies for practical and emotional support.
Source: Social prescribing link workers: Reference guide for primary care networks (NHS)
Lack of awareness
Dr Michelle Howarth, senior lecturer in nursing at Salford University and lead of the Nursing in Social Prescribing Special Interest Group, believes that nurses are ‘ideally placed’ to support the implementation of social prescribing, through collaborating with link workers and the voluntary sector.
She told Nursing in Practice: ‘At the moment, the majority of socially prescribed services and interventions are provided by the voluntary sector with non-recurrent funding. So link workers are funded to hold a wellbeing conversation as part of the Universal Personalised Care Model, but where they refer patients will differ according to the community assets that are locally available.
‘Nurses could have a key role in learning more about community assets to support social prescriptions and raise the profile of the voluntary sector.’ But, she said, ‘there are a lot of myths about social prescribing’.
Dr Howarth polled audience members at the recent Queen’s Nursing Institute (QNI) conference and found that very few nurses at the event were working with a social prescriber in their network. When asked what they thought were the challenges in social prescribing, they mentioned ‘lack of awareness’, ‘knowledge’, ‘understanding’ and ‘engagement’.
Furthermore, 50% of the nurses she polled were unaware of or unsure about the comprehensive model for personalised care that social prescribing is part of.
While a majority were familiar with the link worker role, only 5% were currently working with one to implement social prescribing.
How will link workers be funded?
Primary care networks will receive funding to employ additional staff under an Additional Roles Reimbursement Scheme (ARRS). The ARRS will cover 100% of costs for social prescribing link workers. The sum invested in the ARRS will rise from £110m in 2019/20 to a maximum of £891m in 2023/24.
Source: Health Foundation: Understanding primary care networks
The way forward
How can social prescribing become standardised? Practice nurse Katy Smyth told Nursing in Practice that one solution could be to add social prescribing to the nursing curriculum.
‘I think it shouldn’t be left until you have graduated and already have a job in nursing. I think we need to focus much more on prevention of ill-health and keeping people living well or living well with chronic conditions. I don’t think there is enough focus on that and certainly with the Long Term Plan, it is not going to work with half the workforce. Everybody needs to be focused on how we can implement this. Whether they are working in primary care, the hospital or discharge planning, everybody needs to be involved,’ Ms Smyth said.
From the higher education point of view, Dr Howarth said, ‘We can do our bit by looking at curriculum design. We are currently working with a number of organisations including the QNI and NHS England to look at how we can lobby for placements to expose students to third-sector organisations so they are not always going to the acute care sector, and that they encounter non-medical social prescribing when they go out with community nurses and district nurses.’
Joyce Pickering, a practice nurse in Devon who helped set up a social prescribing model in her area, told Nursing in Practice: ‘A high percentage of people that come to see the GP are not doing so for medical need, but more a social need. Social prescribing works by steering these people to more appropriate services.’
Ms Pickering was inspired to formally initiate social prescribing in her area to meet her patients’ needs – especially older patients and those who needed help managing long-term conditions. After attending a leadership course organised by NHS England, she left with the mission of developing a business plan which, if successful, could be granted funding for implementation.
After checking what was already available in the voluntary sector or ‘asset mapping’ and consulting with the GP partners, Ms Pickering developed her model around one key thing – that each patient referred to social prescribing would have a half-hour appointment with a dedicated link worker, one day a week, for a 12-week period.
She explained to Nursing in Practice that any link worker must have certain skills: ‘To be a good social prescriber or link worker you have to have really good communication skills and be trained in health coaching. Clinical people, for example, nurses and doctors, have been taught to try to fix people and we are very ready to say “if you do this, this and this, that will improve your problem”, whereas social prescribing is trying to empower people to come up with the answers. We are trying to facilitate and give people information so that they can take back more control of their own health.
‘It is about getting to know that person and really listening. Sometimes the patients just want to talk, and all sorts of things will come to the surface.’
The results so far are compelling. In conjunction with researchers at Plymouth University, Ms Pickering has been collecting data from the very beginning. The initial 12-week data review found that of 201 appointments offered, only 12 were no-shows. The key reasons for attending were anxiety, low mood, stress, social isolation, type 2 diabetes or risk of developing diabetes, help with shopping and weight loss.
A breakdown for 36 patients for whom data were collected showed 80.5% had lost weight, with 52.7% experiencing 1-5% body weight loss and 27.8% experiencing 5-10% body weight loss.
Ms Pickering said some patients have come off their blood pressure medication ‘because they have lost so much weight by improving their lifestyle and exercising’.
Patients reported feeling ‘empowered’ and ‘back in control of their health’, with a reduction in alcohol consumption and less social isolation.
Devon is not the only area with a successful social prescribing model. Social prescribing has been operating in parts of Greater Manchester for several years, and the Greater Manchester Health and Social Care Partnership is supporting all 10 boroughs to set up a full social prescribing scheme in 2019/20.
Data released in October showed that 5,850 people received a social prescription between April and June this year and more than 300 GP practices (around two-thirds of the total in the area) are now making social prescriptions.
In addition to that, more than 100 link workers are in post, and Greater Manchester is on track to double its target of supporting 13,000 people through social prescribing this year.
Ms Smyth told Nursing in Practice that in the East Lancashire CCG, social prescribing has been in use for several years. There is a community voluntary model and nine link workers across the county who are all linked. Over £2m has been invested in 600 local community groups and charities to support social prescribing.
Planning for the future
Ms Pickering says: ‘The hospitals are struggling. I have worked in general practice for a very long time. It has always been challenging, but even I am starting to think: where are we going next? It is really tough. Social prescribing could be a big help.’
Dr Howarth says raising awareness about social prescribing and collaboration with link workers ‘will help the practice nurse community to empower patients not just to regain control of their health – but also invigorate and promote their own wellbeing.’
The common theme is that without social prescribing taking some of the strain, the current level of patients seeking care at the GP or A&E is not sustainable.
Six tips to set up social prescribing in your practice
1 Know what’s happening locally
Do a lot of homework and find out what is already on offer in the voluntary sector.
2 Speak to your GPs
Investigate their biggest concerns. What groups
3 Social prescriber/link worker
Be prepared to support the link worker in your practice. They might be new to the area and will rely on you to help them find out what is available in the voluntary sector already or what might be particularly helpful to the cohort of patients.
4 Cost it properly
Don’t ‘guesstimate’. Assess how much time you need to run the service, what the cost is for the healthcare professional who will run it and who will supervise that person.
5 Do your research
There are a variety of models around the country, such as signposting, light social prescribing, medium social prescribing and holistic social prescribing. Do some investigation and figure out which is best suited to your area and patients.
6 Collect data
Make sure from day one that you capture all your data so that you can measure success. Make sure some of the data collected is feedback from the patient such as mood and patient satisfaction, as well as objective measurements such as weight loss, number of GP visits and blood pressure.
Source: Joyce Pickering, a practice nurse in Devon