From the many stories, discussions and insights shared at the recent International Social Prescribing Conference, Dr Ruth Armstrong identified eight key lessons, as she reports below for the Croakey Conference News Service.
Ruth Armstrong writes:
At the recent EACH24 conference in Sydney, we heard many stories about the impact of social prescribing. One of the most powerful and resonant voices was that of Liz Newton.
Newton, now a Lived Experience Leader and Patient Partner at the NSW Agency for Clinical Innovation, described the transformative experience of a single conversation with a doctor in an outpatient hospital department about seventeen years ago.
At a low ebb, physically, emotionally, and mentally, she attended an appointment for an MRI, and after the procedure the doctor took her to a bland consulting room “with a single flickering light and a whiteboard,” sat with her, “human to human,” and asked about her life.
On the whiteboard he drew what she told him – work, home, a friend, a pet…
The doctor introduced her to the concept of the domains of wellbeing – spiritual, physical, emotional, psychological, relational – and they both agreed that Newton’s whiteboard diagram had many gaps.
From there, armed with this new understanding, linked back into her GP, and supported by a counsellor and a friend, Newton set out to fill her life with things that nourished and connected her, and her health began to improve.
Newton was speaking on one of two panels convened to discuss “why the time is now” for social prescribing in Australia on the first day of the conference.
Ably prompted by moderator, award-winning health journalist, Sophie Scott OAM, eight experts contemplated some timely issues to consider as social prescribing ramps up in Australia.
The panels introduced themes that recurred throughout the conference, some of which will be the subject of future Croakey articles.
Below are eight things we learned on the day.
1. Social prescribing is about change
Dr Elizabeth Deveny, current CEO of Consumers Health Forum of Australia, was CEO of Southeast Melbourne Primary Health Network (PHN) between 2015 and 2021, where she gained extensive experience in commissioning social prescribing initiatives.
She noted that, at its heart, social prescribing was about change – changing the way health professionals think about patient care, helping people change the way they think about their own health and what they need to do to become healthier, and changing relationships. This includes relationships between clinicians, consumers, care coordinators and families/carers.
Deveny told the conference, “we have an illness system, not a health system”, and that people need help with all the things that impact on their health and wellbeing – not just with managing illness.
Accordingly, the chronic disease management programs in general practice that Deveny commissioned from the PHN involved care coordinators including nurses, social workers, pharmacists, and others, who were contracted to discuss with the patients what else, apart from clinical care, could be done to support them.
Deveny described how the care coordinators were able to form collaborative relationships with the clients:
The way we were able to change the relationship with the care coordinators and the clinicians and the families, the consumers and carers, meant that there were some really significant changes that occurred in people’s lives.”
She gave the example of a man who often missed medical appointments, did not always follow lifestyle advice (such as regular walking), and had suboptimal clinical outcomes.
When his care coordinator asked if there was anything he needed to help him get to appointments and follow advice, he revealed that his role as a carer for his wife was preventing him from attending to his own health needs, and that he would like support around that.
Deveny said one thing that added to the programs’ success involved a funding change. The PHN provided “brokerage funds” for general practices to make small discretionary purchases – for instance “childcare or a bicycle” – to meet patients’ practical needs.
Deveny said this flexibility for person-centred decisions to be made and actioned was valued by both the healthcare workers and the patients.
Building social prescribing into an otherwise predominantly traditional care coordination approach – with a pretty clinical view on things – meant that “people found it almost liberating being able to do the things that perhaps they had previously wanted to do, but the MBS didn’t allow it”, she said.
2. Social prescribing is the ultimate in shared decision making
In a theme that was to recur throughout the three-day conference, Newton told the delegates that being asked what she needed, and having the ability to choose activities and supports for herself, was a game changer.
She said of that first consultation with the hospital doctor, “I’ve never been spoken to in health contexts like that before. I’ve never been given choice, options, and I’ve never been given the impression that I had some agency over my own wellbeing.”
Deveny agreed, saying that, for some, the term “prescribing” had undertones of a top-down process. She said the term needed to be “unpacked so people understand it’s not about someone telling you what you need to do, but rather to help you find your own way forward.”
As social prescribing becomes more widespread and is incorporated into systems of care, she said the challenge would be to make sure it is always be centred on individual needs.
Leanne Wells, Chair of ASPIRE’s Community and Consumer Expert Panel, has been involved in the consultation process for the Commonwealth feasibility study into social prescribing.
She said that the term prescribing had also been debated as part of these consultations but was ultimately retained as it embedded social interventions as a core part of the treatment plan.
She said, “generally speaking, people take it very seriously when they’re given a script for a medication… The whole idea of the social prescription is to recognise that a social prescription – hobbies, friends, those sorts of solutions – are as much a part of your healthcare as medication.”
Touching on the theme of the need to form relationships between clinical workers, peer workers, link workers and consumers, Newton went further:
For this to work and for the conversation be real, rather than me just deferring to the expert, the expert needs to show vulnerability back to me – connection and relationship. Because that feeds the snowball and trust and willingness.”
3. Social prescribing is an opportunity to use the skills and the strengths of the peer and community workforce
Jack Heath AM, Director, and Founder of the Love Of Humanity Advisory, was CEO of SANE Australia for eight years. He told the conference that the skills and strengths of people living with mental health challenges had often been unappreciated.
He said social prescribing represented an opportunity to use these abilities, not just to assist people in their own recovery, but in peer work and as link workers, who serve to bridge the gap between clinical services and a range of community-based non-medical supports for patients’ personal, social, emotional, financial, and other needs.
But Heath acknowledged that, while “this really is the moment in time”, with institutional and political will for social prescribing, there were challenges around the degree of support and funding models for people who are doing the link work and peer navigators.
Workforce was a recurrent theme on the panel and over the course of the conference. Dr JR Baker, Chair of ASPIRE and CEO of Primary and Community Care Service (PCCS), said in his opening remarks, “the health system [is] under pressure, with a workforce that’s exhausted, people who are increasingly lonely or depressed and many existing systems [are] toppling over.”
Most models of social prescribing in Australia have relied on GPs working with practice nurses or other health professionals who act as link workers. While these models can attract funding through Primary Health Networks, funding pathways are less clear in the community space.
A comment from the floor articulated the dilemma around this. The audience member reflected:
“Social prescribing relies on an ecosystem of local initiatives, like choirs, boxing clubs and so forth… A lot of those initiatives are struggling, some died in COVID, a lot of them are running on the smell of an oily rag. But at the heart of [these organisations] you will find expertise in how to sit with someone and how to bring people together.
“We’ve heard about the need for training health staff. I think there’s an opportunity to look at investing in the expertise of those people locally. The conversation at large holds the expertise with health workers, when the expertise is in our community!”
4. Social prescribing can help build resilient people and communities for our troubled future
Cindy Smith, CEO of the Australian Association of Social Workers, spoke urgently of the findings of the World Economic Forum Global Risk Report citing the rise of misinformation and disinformation, extreme weather events, social polarisation, cyber security breaches and interstate conflict as near risks.
She said now is the time to use the principles of social prescribing to mobilise community.
Smith told the conference, “we’ve got to understand again, to go back to those principles of community development, health promotion, connecting communities.
“We know how to do this. The research is there. We need governments. We need consistent funding to allow the multiple workforces to get together and achieve what must be done, not only to support people individually, but to build in resilience.
“Because the next few decades are going to bring things that our generation has not seen before.”
5. In a built environment where urban planning has failed us, social prescribing can re-connect people with the things that sustain us
Thomas Astell-Burt is the Professor of Cities and Planetary Health at the University of Sydney’s School of Architecture, Design and Planning, and ASPIRE’s Expert Chair of Nature-Based Solutions.
He pointed out the “massive collateral damage” that has occurred to our collective health with the lack of investment healthy, sustainable, and livable communities.
“We’ve locked people into communities where you cannot go for a walk, go to the park, go to school without being dependent upon a car. We need to address these fundamental pressures on society.”
Astell-Burt said people have become so disconnected in these environments that they need help to re-connect with the things that nourish them, such as parks, libraries, and other community spaces, but particularly with nature.
He cited his own team’s national study of more than 5,000 people, which found that one in three Australians may spend less than two hours per week in any natural environment.
A good example of a program to help boost people’s time in nature, he said, is the PaRx scheme in Canada, a national initiative in which health professionals can register and receive resources to write nature-based prescriptions for patients.
Astell-Burt, along with a group of collaborators, has also begun the co-design process for a Medical Research Future Fund (MRFF) supported randomised trial of nature prescriptions for cardiometabolic disease management.
6. Participation is key
Asked about the impact of arts-based prescriptions on health, Professor Genevieve Dingle, Clinical Psychologist and University of Queensland academic, said it was a “huge topic” but that the role of the arts and creativity in health was gaining momentum.
She said her own research and that of international colleagues showed beneficial effects from “being involved in an ongoing way with something that is creative and meaningful to you, for example a community choir.”
She said these effects could be mediated in several ways – “learning new things, listening to other people, coordinating with other people, synchronising, being active, having a role to play, and being expected to turn up and make a serious contribution – then being applauded by an audience that cares. All those things are very important for a sense of who we are and what our place is in our community, and how we can contribute in a meaningful way.”
7. Social prescribing is a way back to integrated health and social care and the social determinants of health
Professor Yvonne Zurynski leads the Health System Sustainability Stream at the Centre for Health Resilience and Implementation Science at the Australian Institute of Health Innovation, Macquarie University.
When asked where social prescribing sits as part of improving access to the tools to help people have more flourishing, happier lives, she told the conference that this raised an important question around the social determinants of health.
With the nexus between the health system and systems of social and community care being somewhat frayed, she said social prescribing presented an opportunity to make healthcare person-centred.
“When you go to your GP, they probably have about five to eight minutes to spend with you. It’s difficult for them delve into those more nuanced determinants of your health and understand your situation and your needs.
“Despite talking about being person-centred, it’s very difficult to implement in the medical system, so embedding social prescribing, I think, is a fantastic opportunity… The time really is now to leverage that, and the opportunities are there to build evidence of new models of care that include social responding.”
8. Australia has an opportunity to build an evidence base for social prescribing
When asked about the evidence base for social prescribing, Zurynski told the conference that, while there is enough data to indicate that it has much potential, rigorously developed evaluations, including economic evaluations, were still “thin on the ground”.
With discussions underway in the UK about how to evaluate their national social prescribing initiative, she said Australia has an opportunity “to actually embed evaluation as we implement social prescribing, so that we’re building the both capacity and the evidence base.”
Dingle, who led an ARC linkage-supported evaluation of the Southeast Queensland social prescribing trial and has long been a researcher in the social prescribing field, said that randomised controlled trials can be difficult to execute, because of the multiple referral pathways and reliance on various trusted relationships.
For the Southeast Queensland trial, they were able to use a parallel control group of frequent GP attenders which inevitably led to some differences in the groups at baseline.
Eight week follow-up showed small changes only but at 18 months “there were really good effects on outcomes such as loneliness, social connectedness, health and wellbeing – across the board,” suggesting that it was important to take a long view.
The topic of evaluation was much discussed throughout the conference, and research project outcomes were presented. While evaluation will continue to be complex, Zurynski reiterated that it was vital.
She said of future programs in Australia, “it’s not good enough just to implement and not create evidence about that implementation and learn from it. Funding allocation should include a component for evaluation, including economic evaluation.”
“After all, it’s the funders who are investing, and they should be able to see return on their investment.”
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