The recent International Social Prescribing Conference showed how the diverse skills of multiple disciplines and sectors can contribute to social prescribing, and enhance integrated health and social care in Australia.
The contributions of the Aboriginal community controlled sector, general practitioners, nurses, pharmacists, allied health professionals and others were highlighted, reports Dr Ruth Armstrong for the Croakey Conference News Service.
Ruth Armstrong writes:
One of the strengths of the recent Australian Social Prescribing Institute of Research and Education (ASPIRE) conference in Sydney was the people it brought together under the banner of Environment, Activity, Connection, Health (EACH24).
Health professionals from multiple disciplines – including academics, researchers, arts practitioners, sport and exercise leaders, nature therapists, public sector workers, health administrators, consumer representatives and more – gathered for three days in June to listen to each other and share ideas about how to work together to improve health and wellbeing via social prescribing.
There was much to discuss. While Australia is well off the blocks, with many examples of Primary Health Networks and other government, non-government and community entities funding social prescribing trials and ongoing programs, there is not yet a cohesive national approach.
However, when it comes to interprofessional teamwork and integrated health and social care, one sector in Australia has much to bring to the table – the Aboriginal and Torres Strait Islander community controlled sector.
Holistic and organic approach
Speaking at the conference, Dr Uday Narayan Yadav shared some of the story of his research journey to a social prescribing project he is working on as a research fellow at Yardhura Walani, the National Centre for Aboriginal and Torres Strait Islander Wellbeing Research at Australian National University.
Yadav’s interest in chronic disease management took him to Nepal during his PhD studies, but the community feedback was that his project was too clinical – they wanted something that addressed holistic wellbeing.
Encountering the concept of social prescribing in the search to meet this brief, he and his colleagues then undertook a rapid review of social prescription interventions for addressing the unmet needs of individuals living with long-term chronic conditions. Of 15 studies globally, 14 were from the United Kingdom.
When Yadav turned his attention to Aboriginal and Torres Strait Islander peoples’ health, he realised something important: Aboriginal Community Controlled Health Organisations (ACCHOs) were unlikely to use the term “social prescribing,” but they were doing it.
“In the Indigenous world, we call this the holistic approach [addressing the social and the cultural determinants of health]. We don’t use the term social scripts and social referrals, but it happens in a very organic way,” he said.
“If you look at Redfern Aboriginal Medical Service [the first Aboriginal community-controlled health service in Australia] in the 1970s, they started with holistic care.
“Social prescription emerged in the UK according to the literature. That’s true as for academic evidence, but you can see many ways in which it was happening in different Indigenous settings and disadvantaged communities before it was invented in the UK.”
Yadav and colleagues’ further research into the ACCHO sector has confirmed what he had noticed informally. Social prescription takes many forms – see slide below – including practical assistance with transport, food and cooking, gardening, electrical and other household work and much more.
The group has undertaken a further systematic review of the evidence for what works and what doesn’t in chronic disease prevention and management for Aboriginal and Torres Strait Islander People, and Yadav has received an NHMRC grant for the ongoing work.
“We should learn best practice from what’s been happening in the Indigenous space to inform the better Australian health system before we roll out social prescription,” he said.
Making the links and playing to strengths
Workforce was a recurring theme at the conference. Social prescribing brings the dual promises of enhanced access to integrated health and social care for people in under-served communities, and relief to an exhausted clinical care workforce.
The diverse range of attendees at the conference is also indicative of the potential power of linking the clinical health workforce with an expanded range of social health organisations and practitioners, in a way that is meaningful for patients. The conference explored ways of doing this.
Many, but not all, social prescribing initiatives include the role of a designated link worker, who liaises between patients, health professionals and community organisations. Other programs ask clinical staff to get involved in “signposting” to appropriate services.
At a symposium on the last day of the conference, Genevieve Dingle, Professor at the School of Psychology, University of Queensland, talked about the value of link work.
Citing a British study of GPs’ attitudes to, and experience with, social prescribing for people with mental health needs, Dingle said the GPs recognised the utility and value of social prescribing but also often felt they lacked the capacity and formal training to effectively engage with community services themselves.
Link workers, when available, were seen as key.
Dingle also said work internationally and in Australia was providing knowledge about the tasks, skills and experience of link workers.
In a qualitative study from her own group, link workers described the skills they needed as primarily interpersonal skills – establishing trusted relationships, removing barriers to participation, and building confidence.
She noted that social workers were an obvious fit for deployment in the social prescribing space as they already have the appropriate training and knowledge.
Programs embedding social workers in general practices are already being trialled in Australia.
Dingle posed a question to her allied health colleagues, “What can the rest of us bring to the table?” inviting an occupational therapist, a nurse, and a pharmacist to join her in considering how each of their disciplines can contribute to getting the best out of social prescribing in the Australian context.
These discussions about the assets of the allied health workforce were timely, given the government funded, independent National Scope of Practice review that is currently taking place in Australia.
Via a wide range of consultations and submissions, the review is looking at the ways in which everyone who makes up our primary care workforce – including GPs, nurses, pharmacists, Aboriginal Health Workers and all the allied health professions – can bring the full range of their professional skills to the primary care table.
Harnessing psychology’s super powers
When Dingle teaches her psychology students, she keeps framing in mind.
She reminds students of the social determinants of health and the Aboriginal and Torres Strait Islander domains of social and emotional wellbeing – to bring perspective to the small but worthwhile part that psychological therapies play in the bigger picture.
As to what psychologists can bring to the social prescribing table, Dingle had plenty of ideas. She said it was unlikely they would step into the link worker space as psychologists were “too thin on the ground”, especially in rural areas.
However, psychologists had skills and strategies, she said, that could be used to support the link worker workforce.
Theory
Dingle said psychology could assist in developing and understanding the theoretical basis for models of social prescribing.
She cited a recent review from the UK of theories that have been used to inform the development and evaluation of social prescribing projects.
One powerful theory to explain social prescribing outcomes, she said, was the social identity and health framework, also known as the social cure theory.
In a nutshell, she said, “part of our identity, how we see ourselves comes from those communities and groups that we feel really strongly embedded within”.
Extending this, it has also been shown that the groups that we belong to very much influence our health and wellbeing, and that can be both positive and negative influences.
Applied to social prescribing, this can be powerful.
“Once you’ve joined your group, it really doesn’t matter what the group is. If you want to go to parkrun, or you want to go to community choir, or you want to do nature-based activities… the important thing is that the group opens up the resources from the group, to both give and receive different forms of support,” said Dingle.
Further reading
Tackling loneliness together: A three-tier social identity framework for social prescribing
Research, evaluation and professional support
Dingle said research and evaluation skills were an obvious asset that psychologists could bring to the party.
She suggested that social prescribing program leaders could partner with psychology departments to embed evaluation in the programs, benefitting the programs, adding to the evidence and providing real-life research and learning opportunities for higher degree psychology students.
Dingle noted that psychologists, like other Australian health professionals, are regulated by the Australian Health Practitioners Regulation Agency (Ahpra), with strong structures for supervision, continuing professional development and ethical standards, but that there was currently no professional organisation or agreed standards for link workers.
Carrying the burden of clients’ psychosocial problems can be wearing or even lead to burnout. Link workers interviewed for Dingle’s qualitative study reported lack of access to regular supervision and training and, often as the only link worker in the service, having no one with whom to debrief.
She noted that the UK has a national network of link workers offering support and training and that formal avenues should be developed in Australia, to suit our own landscape and context.
Dingle suggested that psychologists add a social prescribing lens to the strategies they already use in practice.
This could include adding social goals to motivational interviewing, behavioral activation using nature, creative or group activities, helping people overcome cognitive barriers to participation, and including social activities in relapse prevention plans.
Dingle went on to present social determinants of health screening and activity planning tools that can be used by psychologists who want to add a social prescribing element to their practice.
Jumping on board with Occupational Therapy
Dr Michele Bissett, occupational therapist and associate professor at Southern Cross University, Gold Coast, told the conference that OTs’ remit was to keep people engaged and performing well in the occupations – for self-care, productivity or leisure – that are important to them.
This made social prescribing a good fit, she said, with the literature revealing a range of potential roles for OTs, including advocacy, participation and support, and educating and supervising link workers.
Many OTs would say they are already working to connect people with the things that interest them and bring them good health, she said, and the rise of social prescribing had the potential to foster a sense of allyship.
“What we have in our profession is a core belief and understanding in doing things and connecting things – connecting people to things that have value and meaning to them.
“We’re already in that boat. We’re sailing. So let’s all just jump on it together,” said Bissett.
Bissett said many OTs worked in acute care settings, where a return to basic self-care functions was prioritised over patients’ leisure activities, social health, and individual goals.
This made the idea of a social prescribing community an exciting opportunity to address “some of the needs that have probably been overlooked for very long time,” in concert with link workers whose scope of practice extends beyond the traditional health system.
Bissett reminded delegates of Ahpra’s recent statement on the need to embed interprofessional collaborative practice across the continuum of healthcare settings.
OTs will definitively be at the social prescribing table, but Bissett was looking forward to welcoming others to the party.
“As we continue to collaborate across and beyond the health sector it will be a really interesting space we’re going to move into in the next decade or so,” she said.
Looking beyond acute nursing care
Christina Aggar, Associate Professor in the School of Health at Southern Cross University and Conjoint Associate Professor, Northern NSW Local Health District, agreed with Bissett that interprofessional education was on the rise.
She saw social prescribing as “a communal effort in a communal place,” noting that, as part of this community, nurses had “a very broad reach”.
“We work in the front line of disasters, in disability, with the homeless. We work in aged care… We work with families. We work with vulnerable communities, so we are well placed to work with our colleagues in other professions and disciplines to implement social prescribing,” she said.
Nurses have trusting relationships with patients, good assessment skills, and are experienced in coordinating care with other health professionals. Their advocacy skills make them suited to working alongside other healthcare professionals to provide social prescriptions, she said.
Community nurses, particularly those in rural areas, often have extensive knowledge of other community services.
Aggar said Australian nursing students are schooled in the SDOH, but not generally in social prescribing, whereas in the UK social prescribing is in the curriculum, with a novel way of teaching it by giving students their own social prescription to improve their understanding.
Like Bissett, Aggar saw great potential for social prescribing for people who fall between the gaps in acute tertiary care.
“We have a large ageing population with chronic conditions, multiple comorbidities, and generally it’s the acute care setting that’s their first port of call where they start this journey of their chronic condition.
“It’s a net. A net where we can capture people before they get lost in the system and they end up back in our front door 30 days later.”
She asked delegates to consider the case of a 76-year-old man with previously good social connections, who experienced delirium in hospital after a knee replacement.
After discharge the delirium recurred sporadically, and the patient and his wife lost the confidence to return to activities they had previously enjoyed, including walks and social activities.
Eventually he became housebound, with his wife as his sole carer, and had several more hospital admissions for his comorbidities – all exacerbated by physical inactivity, social isolation and loneliness.
When his wife became exhausted and could no longer care for him, the man entered residential aged care.
Aggar wondered aloud if the outcome could have been different if a link worker had been available to support the man and his wife with some social prescriptions at that first admission.
She noted that carers should not be left out of the equation, as they have high health needs and the system relies on them.
She said that the scarcity of GPs OTs, nurses and other health professionals seen in many Local Health Districts should spur us on.
“We need to work together,” she said, “We need to get this right, and we need to start educating our professions to understand social prescribing.”
Pharmacist roles
Pharmacist Jenny Kirschner is the founder of PALS (Pharmacy Addressing Loneliness and Social isolation) and is also Chief Practice Officer (Australia) of the International Social Prescribing Pharmacy Association (ISPPA), a global think tank about how pharmacy can be involved in social prescribing.
She agreed with the other speakers that pharmacy needed to be part of a “social prescribing ecosystem,” with “all of us leaning in.”
Pharmacists were very well placed, she said, with high levels of community trust, and “over 5000 community pharmacies in Australia, delivering advice at 350 million individual patient visits annually.”
The average Australian visits a community pharmacy 18 times per year, generally in close proximity to their home.
Importantly, she said, pharmacists and pharmacy staff are often at the coalface of the loneliness epidemic. People come in, “spread their scripts on the counter” and settle in for a chat.
Kirschner has made it her business to make sure that the research on loneliness and health is filtered into the pharmacy curriculum. She said the Pharmaceutical Society of Australia has recently agreed to roll out loneliness training to practicing pharmacists.
Loneliness is also directly related to medication use, she said, with a recent Swedish study linking it to polypharmacy, and an increased use of opioids and benzodiazepines. She suggested pharmacists include questions on social health in medication reviews.
Kirschner wrapped up with an example of a creative social prescribing collaboration in suburban Melbourne between a community pharmacy and the Bolton Clarke Connect Local initiative, a free program linking over 65’s to activities and services to promote social connection.
The program rolled out on Loneliness Awareness Week 2023, with posters in the windows about Connect Local, and co-designed, simple, accessible education for staff on how to raise loneliness with clients, and encourage participation in the program.
Members of the Connect Local research team were on hand for the week to liaise with staff, who introduced them to clients, to chat and to see if they were interested in the next step.
Reflecting on the pharmacist’s role in caring for lonely patients and preparing them for social prescribing, Kirschner had one more thing to say:
“It’s very much about showing vulnerability, yourself, as a healthcare professional, to be able to allow someone to feel safe, and then be vulnerable and feel from that place. And so, you know, in the pharmacy. I walk around. Always walk around the counter, and kind of sit next to someone who’s waiting, and have a discussion with them.”
Further reading
Perceptions of Pharmacy Involvement in Social Prescribing Pathways in England, Scotland and Wales
The Role of Pharmacy in Social Connection and Sharing Belonging
See the #CommunityControl success stories at Croakey.
• All photos, except the feature image, by Dr Ruth Armstrong
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