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How social prescribing can improve health and wellbeing

Introduction by Croakey: The great disruption caused by the COVID-19 pandemic is prompting a rethink of many aspects of life, from the ways in which we work and learn to the provision of healthcare. 

The pandemic has also been a “timely catalyst” for Australia to consider the role of social prescribing in addressing longer term impacts of isolation and community disconnection.

Non-medical issues can have a profound impact on patient health and wellbeing, write Jayne Nelson of IPC Health and Janelle Devereux of North Western Melbourne Primary Health Network, and that’s where social prescribing comes in.


Jayne Nelson and Janelle Devereux write:

Most patients who present to GP clinics have non-medical issues that affect their health and wellbeing.

In some cases, these non-medical issues can profoundly impact a patient’s health. While GPs know that addressing these issues can make a substantial difference to their patient, they don’t always have the time or expertise to do so. 

Social prescribing is an integrated model of care that links clinical care to supportive community-based programs or activities to improve a person’s health and wellbeing. Some common examples of social prescriptions include peer support groups, meditation, volunteering, art, and recreational activities.

Social prescribing is being offered to local communities in Melbourne’s west through a partnership between IPC Health, North Western Melbourne Primary Health Network (NWMPHN) and Brimbank City Council.

Holistic needs

Based on successful programs in the UK, the social prescribing partnership is a great opportunity to test whether a person-centred approach that provides space for people’s holistic needs to be understood and met, works in the Victorian setting.

Social prescribing offers an exciting new possibility to address the root causes of people’s poor health and wellbeing outcomes, going beyond addressing signs and symptoms of physical illness or injury.

The free social prescribing program for Brimbank residents involves local GPs or other health providers referring clients to IPC Health’s Wellbeing Coordinator, Catherine Cotching. Catherine works with the client to understand their needs and goals and helps them access local community sources of support.

Mentoring patients

Over a relatively short period of time – usually fewer than three 45-60 minute sessions the Wellbeing Coordinator becomes an advocate for the client; an educator; and a mentor who encourages and reassures them. The Coordinator’s objective is to support that person to be able to better support themselves.

The Wellbeing Coordinator can also potentially prevent complex health risks from escalating or deteriorating.

In the past nine months, the social prescribing program has received 138 referrals and IPC Health currently has around 240 community groups/resources available that Catherine can link clients into. Catherine’s broad knowledge and dedication to finding and linking people with suitable groups has been the key to the pilot program’s successful operation so far.

Ms Catherine Cotching (right) with IPC Health GP Dr Sara Nairn.

Hidden challenges

In times of crisis, the focus is rightly on basic needs, like safety, housing, food and financial support. But it is important to recognise that poor health, such as mismanaged chronic health conditions, can also limit a person’s ability to have their basic needs met.

Hidden challenges for people during COVID-19 include:

  • Keeping up with current service changes such as operating hours or telehealth;
  • Health literacy – not understanding or evaluating needs accurately (for example, avoiding the doctor because of fear of exposure to COVID-19);
  • Digital literacy – difficulty accessing telehealth services;
  • Social isolation risk – COVID-19 may have changed a person’s usual support networks, cutting them off from family and friends or making them fearful of accepting in-home support services due to safety risk.

During this pandemic, people turn to trusted sources for advice and support. NWMPHN is spreading the message that “It’s OK to see your GP” and important to stay in touch with your healthcare providers, while IPC Health and Brimbank City Council have been vital entry points for not only health services but also social and community supports.

Expanding social prescribing

The disruption created by COVID-19 has also presented a unique opportunity to fast-track the expansion of social prescribing, particularly with the most vulnerable clients at IPC Health. It is an opportunity to bring together knowledge and expertise across various disciplines.

Wellbeing Coordinators liaise directly with clients to understand their individual needs and form specialist teams to address health and wellbeing.  This is only possible when time is dedicated to establishing rapport with the client and working collaboratively with them.

The support services may include online social catch-ups, food or medical and other supply deliveries, financial counselling and other support services.

The social prescriber reduces the demand for GPs and health professionals to address their client’s non-medical issues, enabling them to spend more time on their clinical care.

At IPC Health, this is referred to as the ‘Wellbeing Coordinator’, while UK’s Social Prescribing programs commonly use the title ‘Community Link Worker’.

The social prescriber can assess a client’s social, financial, and life-management needs and support them to connect to appropriate services and groups in their community.

Non-clinical focus

IPC Health’s Catherine Cotching said that social prescribing – with its focus on non-clinical issues that affect people’s health – provided a better service and different approach to traditional care services.

In her previous role as a Hospital Admission Risk Program Care Facilitator, Catherine saw hundreds of clients with avoidable hospital presentations. The focus of this role was on the bio-medical aspects of their health, but often the client’s issues were also of a socioeconomic nature, for example financial, legal, or housing related.

Catherine found that people were often not aware of the many opportunities and support services available in their local community. She said:

I have discovered more and better services to refer clients to than I was able to in my Hospital Admission Risk Program Care Facilitator role.”

The clients who benefit most from a social prescription often need additional support and information to get them started. They may need to be told about services to relieve life-burdens, counselling to prioritise their goals, encouragement, and a supported introduction into a community activity to ensure their first experience is a positive one.

Social prescribers have the time to talk to their clients to better understand the broader experiences in that person’s life that may be having an impact on them. At IPC Health, the Wellbeing Coordinators have a combined knowledge of medical and community assets and bring the benefits and skills from both areas to supporting clients.

Next steps

The importance of integrating health care and social supports, as in our Social Prescribing model, is now critical and it will continue to be as we recover together from the impacts of COVID-19.

Social prescribing helps provide care for some of the most vulnerable people in our community and aims to build participation, confidence, and skills. It focuses on prevention and early intervention and is an innovative solution for the challenges our communities face, such as chronic illness, mental health issues and isolation.

The social prescribing partnership is currently evaluating the results and impacts of the trial, with a view to see how it can be scaled up and replicated if positive early results and support from clients and practitioners are borne out in a full review.

This includes identifying the key factors that make social prescribing successful in the local context, such as cross-sector collaboration, mapping of local services and resources and communication between care providers.

With IPC Health embracing social prescribing as a sustainable whole-organisation approach and NWMPHN seeing it as an important part of making system level health improvements, we can envisage a future where social prescribing becomes a normal part of better, all-round care in our communities.  

Jayne Nelson is CEO IPC Health and Janelle Devereux is Executive Director Health Systems Integration, North Western Melbourne Primary Health Network.

Further reading about social prescribing in Australia and internationally:

https://healthvoices.org.au/issues/may-2020/walking-and-talking-our-way-to-good-health-social-prescribing-and-prevention/

https://croakey.org/primary-care-push-for-a-social-prescribing-scheme/ 

https://croakey.org/iso-a-spur-to-think-about-social-prescribing/  

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