Towards meaningful connections

NHS England has announced its 'Long Term Plan', drawn up 'by frontline staff, patients groups, and national experts to be ambitious but realistic'. At its heart is a move toward more personalised care and 'social prescribing', with the appointment of 1,000 link workers to refer patients to activity or social support groups to help with their general wellbeing. The new staff are intended to remove a burden from doctors and other clinicians in primary care (half of GP appointments do not concern a medical condition directly). They are expected to be handling 900,000 patient appointments per year by 2023-24. But is the move based in sound psychological evidence?

Dr Kate Hamilton-West (pictured) from the Centre for Health Service Studies (University of Kent), a Reader in Health Psychology and Faculty Director of Medical Social Sciences, has explored social prescribing through her research. While she sees the plans as a positive idea, she said social prescribing was being rolled out 'well ahead of the evidence', with concerns over the supply of services, regional variability, training and competency needs and access to patient data.

'There's not enough good quality evidence to show it works, and we have to consider what kind of skills, training and competencies these link workers need to be able to provide an effective service,' Hamilton-West said. 'If people are going to be linked up with existing community and voluntary organisations there's an assumption those groups will be out there and will be sufficient for the range of needs people might have when they go to see their GP; that they'll be set up in a way that they can take referrals. A lot of these organisations are quite small scale and run by volunteers.'

Hamilton-West said evaluations of such services tend to be small-scale and methodologically limited – often evaluating programmes which already exist, using available data, rather than carrying out a controlled trial. 'There's been one systematic review so far which found there was insufficient high-quality evidence to make any conclusions about effectiveness. But I think there's also a lot of issues around the availability of the type of evidence that commissioners and providers need. While researchers tend to look at things like safety and effectiveness and so on, providers want to know things like, how do I set this up? What staff and resources do I need? What's the budget? What type of skills and training do people need?'

Hamilton-West and her colleagues have carried out assessments of social prescribing services to discover whether a service is ready for the assessment of outcomes. 'Quite often these programmes are set up with an aim to improve health and wellbeing, but that can be difficult to quantify… each person has different areas of need and the support received is highly variable, so you'd need to think about what it is you'd expect to improve. There's a lot that needs to be worked out in terms of how you can generate an evidence base.' 
A goal is the reduction of workload for GPs and other primary care clinicians, but Hamilton-West questioned whether this will truly be the case. 'For it to work, GPs need to refer patients into the services and know they're going to receive the support that's relevant to their needs: that would involve some kind of monitoring or follow-up of patients. It's not just an easy route out of primary care. The other thing we found is that it seems to work better if the social prescribing service is co-located with the primary care practice… the services needed to do quite a lot of work to keep themselves on the radar of GPs and other referring clinicians.'  

Professor Catherine Haslam and Professor Alex Haslam (both University of Queensland), who last year published The New Psychology of Health: Unlocking the Social Cure (along with a May 2018 special issue of The Psychologist) shared their thoughts on the announcement. Catherine said it was a positive step to introduce link workers – particularly for those whose loneliness or isolation is entrenched and those who have had negative social experiences. 'In these contexts social prescribing is a good initial step, provided the experience is positive… some work by our colleague Gen Dingle shows that such activities increase people's openness and desire to pursue further opportunities for social connection in future. However, I also think we need to go a little further to support and empower people to manage their own social worlds independently to provide a longer-term solution. This is where our Groups 4 Health program comes in, which gives people the knowledge and skills to manage their social networks in ways that support health.'

Alex, while calling the news an 'interesting and positive development', identified a key issue from the group's published work on Groups 4 Health. 'Social prescribing is going to be a lot more effective if there is less emphasis on the "prescribing" and more on making the "social" meaningful. This is a complex issue, and solutions can't simply be taken for granted by practitioners. At the same time, working out, and testing, effective ways to make social connections meaningful – and hence useful as a psychological resource – is the focus of our Groups 4 Health program. Significantly, we now have evidence of the efficacy of this program in reducing mental health problems associated with social isolation.' 

For more see www.longtermplan.nhs.uk