Social prescribing sounds great – but great for whom, in what circumstances and why?
8 January 2019
by Stephanie Tierney, Researcher in Evidence Synthesis, University of Oxford
Social prescribing centres on the non-medical needs of patients (e.g. isolation, bereavement, housing problems, debt) by linking them to local non-clinical services that can improve their well-being and situation in life. Over recent months there has been a flurry of excitement, debate and some derision within professional journals, the media and online about its virtues and value. This may have stemmed from ministerial support for its widespread implementation, and the new governmental strategy on tackling loneliness, in which social prescribing is given prominence. The strength of advocacy is such that at a recent conference, some speakers suggested that discourse on social prescribing had moved from questions about why to implement? (which implies that its value has already been established) towards ones like: How can we do it well in practice? Who is unlikely to benefit from social prescribing and why? What does a good outcome look like?
The answer to some of these questions, particularly the last one, may be aided by the Government’s recent loneliness strategy, which states that a Common Outcomes Framework will be published to improve the evidence base on social prescribing. This should capture the wider benefits referred to above, including what matters to those receiving social prescribing and how they feel it contributes (or not) to their health and wellbeing. When thinking about outcomes, a balance may need to be struck between individual narratives (revealing nuances and compelling stories), alongside aggregated data to convince others that social prescribing ‘works’.
Almost inevitably, using mixed methods to evaluate social prescribing would seem appropriate. However, gathering and then integrating qualitative and quantitative data may be hampered by the fact that social prescribing evaluations are often small-scale, meaning there is limited data to interpret and generalise. They tend to be conducted within tight budgets. In addition, evaluations may be produced to provide support for further funding of a specific social prescribing intervention, rather than adding to a global evidence base. They may not necessarily cover concerns that really matter to key stakeholders, including those using social prescribing to overcome difficulties in life.
It may help to make sense of these outstanding questions on the implementation and impact of social prescribing through a realist lens. Realist approaches include realist evaluation (a form of theory-driven evaluation) and realist review (a form of theory-driven evidence synthesis). They are both more explanatory than judgmental (works/doesn’t work); their goal is to understand and explain why, how, for whom, in what contexts and to what extent an intervention ‘works’. They do this by creating context-mechanism-outcome configurations; looking at how an intervention changes context to activate certain mechanisms to bring about specific outcomes. These context-mechanism-outcome configurations are then incorporated into an overarching programme theory to explain what works, for whom, why and in what circumstances. Realist approaches can provide guidance to service providers on how an intervention may be implemented to increase the chances that desired outcomes will occur in their setting. Undertaking a realist evaluation or review requires an understanding of such approaches, or support from someone with this knowledge. Otherwise, the end product risks being little more than a list of barriers and facilitators, rather than providing a more nuanced explanation of how mechanisms are triggered in specific contexts to produce particular outcomes.
Adopting a realist lens has certainly been helpful for our research on social prescribing; we are exploring an aspect of this form of activity – care navigators. These individuals are employed (sometimes they are volunteers) to act as a bridge between medical and non-clinical services (often in the community or voluntary sectors); they support and signpost people to relevant services to address their non-medical needs. A perusal of social prescribing evaluations identified for our review highlights that although individuals are often satisfied with seeing a care navigator, it is unclear what aspects of such services are most effective, for whom and under what circumstances. These evaluations show that social prescribing activities are well-received, yet findings tend to be limited by issues like short timescales, difficulties in determining cost-effectiveness and a focus on basic data like number of referrals. Simply knowing how many patients are referred will not reflect the diffusion of benefits that may derive from meeting with a care navigator. For example, when someone engages with social prescribing activities it can improve relationships within a family or this person may take up volunteering, thereby supporting others.
The development of a Common Outcomes Framework for social prescribing is a step in the right direction not just for patients but also for policymakers, commissioners and academics. Such a framework, coupled with appropriate explanatory research and robust evaluations, will increase our understanding of social prescribing and ideally support optimal implementation to those who are likely to benefit most.
Stephanie Tierney is a Researcher in Evidence Synthesis at the Centre for Evidence Based Medicine, University of Oxford, and is part of the School for Primary Care Research’s Evidence Synthesis Working Group.
Disclaimer: The views expressed in this commentary are those of the author and not necessarily those of the host institution or the National Institute for Health Research.