FOR MOST OF his life, Frank Frost would go to the doctor and leave feeling worse. When the now-retired lorry driver would ask GPs for help managing his diabetes and obesity, most – as Frost recalls – would “tell him off” for not eating more healthily. Often, they suggested his problems were permanent. “They told me I’d be on insulin for the rest of my life,” he says.
Discouraged, he didn’t think he could improve his health, and for many years he didn’t try. His divorce didn’t help, nor did his always-on-the-road lifestyle. “For 30 years, I’d have 12- 15-hour days, living on takeaways and sandwiches six days a week, and then at the weekend I’d just want to get drunk,” he says.
But five years ago, Frost had an encounter that would change how he managed his health. When he moved to Sheffield and found Ollie Hart – a tall, chiseled-jaw GP much younger than him – he also found a new understanding of what healthcare could be. Instead of reciting clinical answers, Hart asked Frost personal questions. Instead of suggesting a prescription drug, he talked about the next local park run.
Frost still had reservations about doctors; when he started a controversial diet that – according to a book he had read – could reverse his diabetes, he was nervous to tell Hart. “I didn’t want him to say, ‘Oh, you can’t do that, you don’t know what you’re doing,’” he says. But Hart offered non-judgmental support. “He even read the same book as me,” Frost says, smiling through grey beard bristles.
After spending a few sessions on Frost’s interests, Hart started revealing some of his own, like cycling. And when he intuited that Frost was “sort of bored and fed up with his life,” he offered him an unusual prescription: a cycling course in his neighborhood. “It wasn’t really about controlling his diabetes as much as it was about helping him to get out and do something,” he says.
Frost found Hart’s enthusiasm contagious, but he still had some doubts. He was new to the area, didn’t know the roads, and was worried his fellow cyclists would be too advanced for him. But he soon found refuge in his cycling prescription, which was led by Pedal Ready, an organisation that largely caters to adults who are just starting to get on a bike again. Over time, beyond cycling skills and new friends, Frost also saw tangible health benefits. He lost 20kg and got to a point where he could do what other GPs had once deemed impossible: he came off his insulin.
There’s a term for the kind of prescription Hart offered Frost: a social prescription. Social prescribing doesn’t just serve patients with obviously “social” issues, such as loneliness or social anxiety, but can also help those with physical issues, like dementia or cancer. The name comes from foundational research by Michael Marmot and Richard Wilkinson that suggests a person’s health is largely determined by social factors, like their work, environment and relationships. Social prescribing aims to address these factors, known as “social determinants”, by offering people prescriptions not in the form of a pill bottle, but as activities in their local community. These can include exercise groups such as Frost’s cycling course, but also music lessons, gardening projects, nature walks or even help to get a job or housing.
Though the idea of social prescribing has existed in the UK for a couple of decades, the cascading health consequences of a year in isolation has energised interest in the practice. And, as Covid-19 rapidly burns both ends of the healthcare candle – more patients in need of care, and a health service stretched to capacity – more health workers, policymakers and patients see social prescribing as part of the answer.
IN 1938, WITH the world still reeling from an economic depression, a group of Harvard University researchers wondered: what makes a healthy and happy life?
It’s a question that has captivated the earliest philosophers, artists and faith leaders – but for the first time, psychiatrists sought empirical answers. In their lab, they gathered 268 second-year students (then all men), and analysed their health through exams and questionnaires. They repeated the process every two years, and eventually recruited the men’s children (and more than one thousand others) to take part, too.
In its 80-plus years observing 1,300 people, the Harvard Study of Adult Development repeatedly found that the greatest predictor of a person’s long-term well-being is their social relationships. The then-dominant view credited “genetics” for healthy adult development, but the study found that the people who were healthiest at age 80 were the ones most satisfied in their relationships at age 50. It also found that ageing adults who had strong social support experienced less mental deterioration than those who lacked it.
In 1984, a young clergyman named Andrew Mawson discovered firsthand the roles that social relationships have in maintaining good health. He had been called to Tower Hamlets in London, one of the UK’s most deprived communities, to take over as minister of the United Reformed Church. He didn’t have much initial support, or much of an idea of where to begin. “We had £400 in a bank, some rundown buildings, a derelict park behind us, and about a dozen people – all over 70 – there greeting me in the congregation,” he recalls.
But Mawson says he gained a sense of clarity – and outrage – when he met a woman from the community named Jean Vialls, a 35-year-old cancer patient who additionally suffered, he says, from “all of the complications that poverty brings.” Mawson intuited that Vialls needed a more patient-centred approach to treat the many sources of suffering in her life, not just the cancer. And when he saw that the support she was receiving from health and social services was not enough, he summoned Vialls’ friends to give her nature’s oldest and simplest form of care: companionship.
Vialls’ friends may have helped make her numbered days more liveable, but she soon succumbed to her cancer. What followed, Mawson remembers, was a tense boardroom meeting held in the Royal London Hospital, where health and policy officials blamed Vialls’ death on administrative negligence and poor internal communication. But for him, it was indicative of something bigger. “Human beings are social creatures, and health is about human relationships,” he says. The conventional medical model – diagnose, treat, repeat – wasn’t enough.
Driven by that conviction, Mawson spent the 1990s creating what would become the UK’s first integrated health institution, the Bromley-by-Bow Centre, in his church. The centre had two radical premises: it would be run by, for and with the local community; and it would address social determinants of health, not just the physical consequences. His first priority was to make sure Bromley’s architecture reflected its founding premises. Instead of a “boring NHS box,” the centre was constructed like a castle – made of the same handmade bricks used at Glyndebourne opera house, and filled with finely crafted wooden chairs. In lieu of a lifeless waiting room there was a cafe, a garden, a dance studio, an art gallery.
There was just one thing Bromley-by-Bow’s community-run doctors’ office didn’t have when Mawson first conceived it: actual doctors. That changed in 1997, when GP Sam Everington joined Bromley’s cause.
Everington, a self-proclaimed rebel against the conventional GP doctrine, says Bromley’s patient-first approach resonated with him immediately. “I used my first name, I never wore a tie, I shared my notes with my patients, which, 30 years ago, was pretty unheard of,” he says. He had grown up in a family of seven children and spent summers picking mushrooms, climbing mountains and swimming in the lakes on his grandfather’s farm in Norway. “When you’ve had family getting together your whole life, you think it’s normal, but actually it’s not normal for a lot of people,” he says. “So my parents taught me, if you’re lucky in life, you have a duty to help other people.”
He initially pursued a career in law, but soon decided the barrister life wasn’t for him. Still, when he started his medical career in the 1980s, he never lost his eye for justice. When he was a junior doctor at Royal London Hospital, he spent Christmas Day sleeping on the streets to protest long working hours. A few years later, he co-wrote a paper for the British Medical Journal (BMJ) exposing the field’s racist hiring practices. Along with fellow doctor Aneez Esmail, now a professor of general practice at the University of Manchester, the pair submitted applications identical in experience and qualifications to nearly two dozen senior NHS positions, and found that those with English-sounding names were twice as likely to be shortlisted than those with Asian-sounding ones.
The act earned Everington and Esmail charges and threats, albeit unpursued, from the General Medical Council. But his reputation as a GP remained and eventually reached the ears of Mawson. “You need the best GPs in tough communities, and someone eventually said, ‘You need to go talk to Dr. Sam Everington,’” Mawson says.
For Everington, Bromley’s radical directive to address the social determinants of someone’s health was common sense. “I’d always felt that what we learned in medical school was a bit wrong – to label someone a diabetic or an eplileptic, and to focus so little on who that patient is and what they care about,” he says. Besides, he adds, most patients forget much of what their doctors tell them (one study found that 40 to 80 per cent of medical information given to patients is “forgotten immediately”).
And so, Everington says, a better approach – one which Bromley has used to treat 43,000 patients since its opening, and which has inspired thousands of other Bromley-style centres around the nation and world – is to offer treatments that respond to a patient’s individual passions. He describes it as less “what’s the matter with you” and more “what matters to you.” On a practical level, it means GPs helping patients to fulfill both their basic needs: health, but also food, shelter, employment, and their more personal ones: friendship, community, a sense of purpose.
FRANK FROST FOUND these latter needs met when Hart directed him to the local cycling group. His initial social prescription was for a specific cycling course, but when he made friends with his fellow trainees, the crew evolved into “the chain gang” – a 20-strong group that regularly organises rides around Sheffield’s Peak District, usually on old railway tracks.
Frost says that the sense of community the group provides has held each of them accountable to carry on cycling. “We all look out for each other – if someone needs to go slower, we never leave them. If someone needs their bike fixed, there’s a guy who’s a mechanic,” he says. Throughout the Covid-19 pandemic, they kept in touch, even when they couldn’t ride. “It’s turned into quite a friendship group as well.”
All of these changes, Frost says, are thanks to Hart inspiring him, and generally being “a really great bloke.” But Hart says there is a real science to social prescribing. “We know that a person’s sense of self-worth and meaning in their life has a really big part to play in their health,” he says.
Recognising the growing body of research linking health to social factors, NHS England recently committed to direct 900,000 people to social prescribing channels by 2024. So far, the NHS estimates, 60 per cent of clinical commissioning groups in England currently have social prescribing schemes. Hart works with South Yorkshire and Bassetlaw Integrated Care System. He says he’ll often ask patients what they’re doing to look after themselves, and try to detect both verbal and nonverbal cues in their response. Are they “buzzing” to share what they’ve been up to? Or do they seem overwhelmed, lost or lonely?
James Sanderson, the CEO of the National Academy for Social Prescribing, an independent organisation supporting local social prescriptions, says GPs are well-suited to direct social prescribing. “It's that professional knowledge that combines with the individual's own likes and interests that creates that magical opportunity of connection,” he says. He points out that surveys often reveal GPs to be among the most trusted people in their community.
But not all GPs have the community infrastructure or bandwidth to integrate social prescribing like Hart does. “You’ve only got ten minutes with [a patient], and that’s not enough time to really go through those social issues around isolation and loneliness,” says Mohan Sekeram, a GP in East Merton. “So you end up looking at the medical aspect, because that’s what we’re trained at doing, and often the patient doesn’t get the treatment they need, we don’t give them the treatment they deserve, and they come back a few weeks later.” That cycle bodes poorly for an already overstressed NHS, especially since lonely people are nearly twice as likely to visit a GP.
To address this, Sekeram, who helped facilitate a social prescribing pilot in his practice, says having access to “link workers” – community experts who facilitate social prescribing – has made a difference. GPs can refer patients to link workers, or in some schemes, patients can refer themselves directly. “[Link workers] can spend an hour with the patient and really see the root cause issues to come up with a plan,” he says.
Beyond helping patients, research suggests that having link workers available to offer and manage social prescriptions could also help alleviate the burden on the health system. In a 2018 survey by the Royal College of General Practitioners, 59 per cent of GPs agreed that social prescribing would reduce their workload; one evidence review showed demand for GP services dropped among patients given social prescriptions. NHS England recently decided to fund the salary of two link workers for every 30,000-50,000 patients in each primary care network of local health and social care providers.
Still, the NHS has a tall order in addressing the unprecedented, overlapping health crises sparked by the pandemic. One 2020 study found soaring rates of anxiety and depression during early social distancing measures. Alcoholism also appears to be on the rise, with the British Liver Trust receiving a 500 per cent increase in support calls since last March. And perhaps the nation’s most ubiquitous lockdown byproduct is its ever-worsening epidemic of loneliness – a condition studies have linked to dementia, stroke, cardiovascular disease, chronic stress, poor sleep and even premature death. The solution is not as simple as just putting people with other people; a recent 55,000-person survey on loneliness suggests the quality of those relationships, not quantity, is what matters.
AKEELA SHAIKH KNOWS what it’s like to be lonely, but not alone. Four years ago, the Bolton-based mother of two stopped feeling like her “cheeky, loving self” and started becoming defensive and depressed. Though she had plenty of people supporting her – friends urging her to socialise, her husband and children encouraging her to cheer up – she ignored them. “I couldn’t get out of bed… It was a nightmare,” she says.
Shaikh had a number of stressors in her life at that time: a sick mother and mother-in-law, a painful back injury. But she wouldn’t gain clarity until 2018, when a nurse connected her with Joanne Gavin, then a link worker with Bolton Community and Voluntary Services. “She cried the first time I ever met her,” Gavin remembers of that first appointment.
As Gavin got to know Shaikh, she learned a bit about the woman behind the tears, like the fact that she’d been working since she was 16 years old. So when Shaikh was forced to give up her job as a healthcare aide because of her back injury, that absence – Gavin intuited – hurt her even more than the physical pain. “I don’t think people realise how badly not working affects people,” says Gavin, who now works in a similar prescribing role with employment and health service provider Ingeus.
Looking back on that time, Shaikh agrees. “I just felt like I couldn’t do anything for anybody, and there were days where I’d look out the window and think about ending it all,” Shaikh says. Her husband and daughter “went behind her back” to get every form of care possible: dozens of doctors, medication for depression and different forms of therapy. But nothing clicked until Gavin helped Shaikh to see that what she really needed was a chance to feel like herself again.
Gavin offered Shaikh a social prescription aimed at helping her to do just that: a volunteer office administrator post at Lagan’s Foundation, a charity supporting children with feeding and heart troubles, where Shaikh could channel her care for others into something bigger. She loved it immediately; it was a chance to use her people skills without putting physical stress on her back. Lagan’s Foundation ultimately created a position for her to work there full-time.
“If I wasn’t referred to Joanne, I don’t know what I would have done,” Shaikh says. The two remain friends and keep in close contact. “She totally changed my life, and it just shows how a person that wanted to kill herself is now living a normal life like everybody else."
FRANK FROST AND Akeela Shaikh are not anomalies. Dozens of anonymous beneficiaries have success stories to share: “Lucy”, a lonely woman in her 60s from outside of Cork, found much-needed companionship through a local crafting group; “Susan”, a 27-year old single mother from Manchester, “got her life back on track” when her prescriber helped her to find safe housing and a job; “Ray”, a 50-year-old struggling with alcoholism and anxiety, found comfort through the YMCA and his prescriber’s listening ear.
But the very different circumstances – and prescriptions – of the Lucys and Susans and Rays make it difficult to measure the large-scale impact of social prescribing. Studies and reports have linked social prescribing with lower A&E admissions, fewer subsequent GP visits and better patient outcomes. One two-year pilot in Rotherham reported a 50p return on investment for each pound invested, but forecast that this would increase with every year as benefits would likely persist long-term, with costs recouped after two years and greater savings made thereafter.
But while local pilots show promise, multiple systematic reviews suggest the approach needs more robust and uniform evidence to be considered a truly effective, investment-worthy pursuit. When it comes to showing results, one of social prescribing’s greatest virtues – its intensely individual nature – may also be its greatest flaw. “Social prescribing is being widely advocated and implemented, but current evidence fails to provide sufficient detail to judge either success or value for money,” concludes a widely-cited BMJ review from 2017. “If social prescribing is to realise its potential, future evaluations must be comparative by design and consider when, by whom, for whom, how well and at what cost.”
Everington and Mawson, however, warn against compromising the integrity of the approach just to get consistent data. “People in government always want to see something that’s neat and replicable, and they don’t understand that what you’re actually replicating is a value set of helping people follow their passions,” Everington says. Mawson argues that getting good data and retaining local control aren’t mutually exclusive. He imagines an Uber or AirBnB-style database, through which social prescribing beneficiaries could rate their experiences. “In this way, the local community gets empowered and funded to look after itself, and you get real-time data on what activity is funded and what impact it has,” Mawson says. He believes funding should go directly to the socially prescribed activity – not just link workers, and definitely not what he calls the “expensive assurance documents no-one reads.”
This local autonomy can become particularly crucial if, for example, a pandemic completely disrupts business-as-usual. Eithne Foley, a social prescriber with Le Cheile Family Resource Centre near Cork, Ireland, had only been in her role for two months before Covid-19 uprooted her usual routine of meeting people – in-person, over six sessions – before connecting them with a local social group.
When Covid shut down those groups, Foley and her colleagues got creative, offering “Health and Wellbeing Zoom cafés”, each week a different theme, to help stimulate bonding online. She says the Zoom offering has also encouraged new people to join, including some who were too self-conscious to show up in-person, or who lived too far away. “If there were a knitting group, it used to be only people within driving distance could attend,” she says. Still, Foley knows online-only events attract a self-selecting group, and that nothing replaces in-person connection. And then there’s the fact that nearly 3 million people in the UK don’t use the internet.
In August 2020, the UK government awarded the National Academy for Social Prescribing £5 million to help tackle Covid’s psychological toll. In December, it gave another £5.5 million to seven sites facilitating nature-based social prescriptions – everything from tree-planting projects to community gardening – with pilots launching throughout 2021. It aims to help people hit hardest by the coronavirus pandemic, including those living in deprived areas, people with mental health conditions and BAME communities.
In South Yorkshire, home to one of the seven winning sites, Madvee Seechunder understands what that connection to nature – and other people – can do. She says the pandemic made her feel lonelier than ever, as she had no access to the internet, no phone service and limited English. But what she did have was a longing to meet people and learn new things. Her social prescriber, Debbie Bishop, who works with the South Yorkshire Housing Association, promptly connected her with a free internet phone and an introduction to the local women’s activity centre, where she could take English language and IT classes. She also found her a free spot on a local ‘Empowered in Nature’ excursion, where she joined a mindfulness workshop offering crafts, cooking and discussion in the forest.
“I got to see parts of Yorkshire I’d never seen, and meet people who also experience anxiety and depression,” Seechunder says. “It made me realise we can all experience mental health issues, and I felt normal.”
FRANK FROST NOW leads the cycling group he’d first linked up with through his social prescription, and he even occasionally helps Hart to teach incoming medical students about social prescribing. “I was awful to my body when I was younger, and if I can do it, anybody can do it,” he says. But he acknowledges that it took years before he realised what was possible. “I’m not blaming anybody, but the NHS is a massive monolith,” he says. “It takes them a long time to understand when there’s a new thing, and I wish everyone in the NHS were like Ollie.”
Now, Hart – along with Sekeram, Everington, and other UK social prescribing experts – advises other social prescribing schemes around the nation and world. One such place is Ontario, Canada, where the Alliance for Healthier Communities launched a year-long social prescribing pilot in 2018 and saw a 49 per cent decrease in loneliness among the 1,100+ participants. Kate Mulligan, who oversaw the pilot and directs the centre’s policy and communications, says those insights inspired the “wrap-around supports” now offered at Covid testing pop-up sites. “When you’re being tested, you’re also being screened for social isolation, and other social determinants of health,” she says. “It’s like ‘you're here for an emergency, but while you're here, let's make sure you have what you need,’ and that can be very material determinants of health like food, but it can also be a connection to a supportive community.”
Australia has had similar successes. Jayne Nelson, CEO of community health service IPC Health, says she was inspired by Mulligan’s work, and modeled a pilot after it in Melbourne. Though smaller in scale, the pilot found all 200 participants referred to a social prescription felt more optimistic about the future, more closely connected to others and more able to deal with their problems.
Social prescribing has also spread to Finland, South Korea, the Netherlands, the Philippines, and other places. As more local and global leaders try to implement it with their own constituencies, founding doctor Everington urges them to come and see social prescribing in action, through the stories of patients experiencing it.
His go-to story is about a patient he treated four years ago, where a social prescription took them both to a train station. “Stratford station, Platform 8,” he recalls.
The patient had terminal cancer. But instead of being preoccupied with “what was the matter”, Everington spent the man’s remaining days focused on what mattered to him: his family, his career and his artifacts (Everington recalls his particular pride for a 50-year-old bottle of whiskey). “He told me he was a great trainspotter, and wanted one last attempt to trainspot,” he says.
And so, Everington followed that passion with a prescription his medical school days had never trained him for. He and the patient’s daughter found a wheelchair, and gave her father his last wish: a final chance to trainspot there on platform 8, in front of his loved ones, before he died a few days later. The trainspotting trip may not have been able to help with the physical illness, but it did something else.
“Part of it is understanding that we’re all going to die,” Everington says. ”It’s the quality of life that counts.”
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This article was originally published by WIRED UK
