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Social prescribing for people and communities with high needs

From an innovative primary healthcare service in Queensland, to neighbourhood carers clubs and an engaging rural community health and arts project – the diversity of settings and methods for social prescribing was on show at the recent International Social Prescribing Conference.

Dr Ruth Armstrong reports below for the Croakey Conference News Service.


Ruth Armstrong writes:

The team at Inala Primary Care, a not for profit health service in the south-western suburbs of Meanjin/Brisbane, sees the results of injustice every day, according to CEO Tracey Johnson.

Inala is classified as one of the Greater Brisbane’s most disadvantaged areas, with many residents living in social housing, a high proportion of persons born overseas and a large Aboriginal and Torres Strait Islander community.

Amongst the 7,000 users of the health service, said Johnson, are people facing lifelong discrimination, those who have had to flee foreign wars, people who aren’t safe in their own homes because of elder abuse or domestic and family violence, those who fall foul of, or are exploited by, financial and credit systems, and others.

As a result, Inala staff have long defined healthcare as evolving “well and truly beyond the medical model,” and have a mission to deliver excellent care to patients and communities.

Johnson, who has a background as a lawyer, began her presentation on the formation of a health justice partnership at Inala Primary Care at the recent EACH24 Social Prescribing conference in Sydney by observing that:

“Justice for all starts with our First Nations people. The injustices that they’re served too often get seen in the courts, and we get to see that in general practice, with high rates of incarceration, mental health issues, and other things that that comes with.”

Inala Primary Care’s health justice project involves embedding a lawyer in the practice, who works there every day and offers legal supports for issues that affect people’s health.

The service helps people deal with government entities such as the Queensland Mental Health Commission, and disability supports, Centrelink, or domestic abuse, discrimination, and employment exploitation.

Referrals can come from clinical staff and social workers within the practice, external organisations, or the patients themselves. It’s a “no wrong door” approach that has been particularly useful for those in abusive domestic situations, who can now obtain confidential legal advice in the safety and privacy of a medical setting.

While there is no doubt that legal and justice issues impact heavily on health, Medicare and the legal system are in some ways strange bedfellows. The project has required extensive training for health and legal staff, and careful guarding of patient confidentiality and legal privilege. Referrals and case conferencing can only occur with patient permission.

Patient education – helping them understand that legal advice is something that will assist them – had also been required.

Funding is essential but challenging.

“Medicare is, in fact, a sickness system,” Johnson told the delegates. “It is not a wellness system, not a health system, and it certainly doesn’t fund justice.”

As well as being good for the patients’ health, Johnson said that having referral pathways to address some of the complexity in their patients’ lives helps avoid staff stress and burnout.

“For me, having an embedded legal service is part of what’s making our service more attractive to grow our team and do more work with more people who need it,” she said.

A “failed project” with important outcomes

Inala’s health justice partnership is just one example of the broad range of social prescribing initiatives we heard about at the EACH24 conference. All over Australia, innovative projects are seeking to address one of the more challenging social determinants of health.

Keir Paterson is CEO of Neighbourhood Houses Victoria, and Secretary of the Australian Neighbourhood Houses & Centres Association. Australia has 1,064 neighbourhood and community houses and centres, more than 400 of them in Victoria.

Paterson entitled his presentation “How to make friends” because Neighbourhood Houses Victoria discovered via Google search data, that this was one of the top five most searched phrases leading to their site.

In his view, social prescribing was a means to an end, with the end being connected, sustainable and self-supporting communities. He quoted the 2023 Ending Loneliness Together State of the Nation Report:

“Although cultural and community engagement activities hold great value, we must go beyond attendance towards a focus on nurturing community, where we feel we can rely on others for support and assistance.”

Paterson described a project that was originally funded to connect carers with employment opportunities, in which ten Victorian Neighbourhood Houses participated. Poverty, he said, was a huge issue for carers, along with poorer health outcomes and higher rates of social isolation than the non-carer population.

In terms of its prespecified outcomes of getting carers back to work, the program ultimately did not meet its targets, but the concept of neighbourhood carers clubs emerged as the brainchild of staff member and project manager, Kristine Rawlinson.

Initially, some carers who were contacted to participate in the project did not want to join a designated carers group due to stigma, or their need for distraction and escape, rather than a focus on caring.

Many had very little time to participate or lacked confidence to enter a group situation. Getting people into an activity they enjoyed so that they could connect with other people became the priority, and activities were individually tailored by asking a very simple question: “What do you want? What fills your bucket?”

Referrals came from many sources – jobs agencies, other community organisations, carers groups and elsewhere.

Some participants did end up finding paid employment, while others experienced much needed respite. Being recognised and prioritised for their work was important to many (including receiving a VIP member card to access the carers club and neighbourhood house activities).

Paterson screened a few minutes of this short film, Not Just a Carer, which demonstrates the meaningful connections that carers have been able to make via the Carers Club programs.

 

Paterson cited some important learnings from the program that applied to social prescribing in general. These included:

  • The need for a person centred, strengths-based approach, by which participants can access a large range of activities and services and are free to choose.
  • Having pathways for participants to form long-term relationships, with ongoing connection or progression – for instance, to volunteering, peer work or teaching –encouraging community involvement a sustainable way.
  • With any social prescribing or cross referral program, we should ask ourselves, “Are we actually building dependence or community? Are we developing the connections between people and organisations that will allow them to flourish and connect with their communities on an ongoing basis, or are we making them dependent on a programme that has a start and a finish, and what happens after that finishes?”

NHV regularly reports data on the financial value to the community of what they do, and it stacks up very well, but Paterson reflected that it’s hard to put a value on twenty years of connection, as represented by the women in the slide below.

Further reading: Social isolation and loneliness – a neighbourhood house perspective, David Perry

Podcast: Care Factor, Kristine Rawlinson

A home for healthy ageing

When it came time for occupational therapist and PhD candidate Hannah Forbes to present at EACH24, she handed over to one of her research subjects, Lauri Badge, figuring a living case study would be a good way to illustrate the importance of joining community-based clubs and exercise programs to promote health, wellbeing, and healthy ageing.

Forbes’ research is one of the GrandSchools projects, centring on intergenerational living and learning spaces.

Badge, who was born in 1927, has been participating for more than four years in a community-based group education programme that sees him doing regular fitness and aquatics at Mingara Recreation Club in NSW.

But it’s not all about the exercise – Badge said the connections he’s made with other participants, especially a few good friends whom he looks forward to seeing (and who hold him to account if he doesn’t attend) are just as important as moving his body.

He told the delegates: “Ageing has one great problem…you can do physical work, but you also need the social contact. If you don’t do the two together, both will fail.”

As far as getting started is concerned, Badge said carers – be they family, formal carers, or others – are key. He has seen people come and go from Mingara without making connections but having a carer to “get in the water with you” and make some introductions can make all the difference.

He summed up his experience at Mingara in the following way: “Suddenly, I belong. I’m part of the furniture. Wherever I go in the building, someone’s sure to say hi, and people will walk up and say, you’re a legend, you’re an inspiration. I don’t think any of those things. I think I’m just trying to have some fun with the time I’ve got left.”

 

Community-led social prescribing project that changed culture

Sitting in South Australia’s Mallee region, on the lands of the Ngarkat People and bordering Victoria, is the small town of Pinnaroo, population 754.

Professor Robyn Clark, a cardiovascular researcher from Flinders University, knows the place well, having led the evaluation of a three-year community-led arts and health initiative that saw “blokey” farmers writing poetry, a 400-strong crowd at a “vivid” night and residents tripling their participation in the arts.

Pinnaroo’s residents have limited access to healthcare, and the community conceived of the project as a way to improve health through arts and culture. Clark was brought in on a shoestring when arts advisor Maz McGann suggested, “whatever they did, they needed to measure it”.

The decision was made to use professional artists, with 105 coming to town over three years. There have been more than 120 different activities, with 1,075 logged attendances from the community.

Women have formed about three quarters of attendees, but many men have also gotten involved, sometimes with the organisers using clever drivers, like the need to fashion farmyard scrap metals into a display of 240 metal poppies for Anzac Day.

Now I just need to remind you that wasn’t art, Clark joked in the final plenary. “It was welding.”

All aspects of the project, including every part of the evaluation, were co-designed with the community over a period of two years. Trust, built up on successive visits by the evaluation team, was vital and Clark’s student-heavy research team – trainee nurses, physiologists, bio-scientists, exercise physiologists, the nutritionists – found the experience “life changing.”

With a lot of effort, they comfortably exceeded their sample size for yearly health assessments – 564 in all, over the three years.

The full report can be found here; highlights include fewer alcohol days, fewer smokers, less hypertension, and decreased rates and severity of depressive symptoms in adults, with arts participation. Adults aged over 65 years reported an increase in physical activity.

However, overall physical activity, cholesterol levels and obesity did not improve.

Self-reported quality of life improved and an economic evaluation found that, for every dollar spent on the Pinnaroo project, $2.30 was returned to the community.

With the support of the community, the Pinnaroo project team is seeking funding to continue.

“The project was inspired and led by a team from a rural community,” said Clark. “The strength of community is what drove its success.”

Looking around, and upstream

In another interesting presentation, Dr M Mofizul Islam, Senior Lecturer in the Department of Public Health at La Trobe University, presented his findings on where the “weak links” might lie in the social prescribing programs currently in use.

He identified as weaknesses: quality control of the services being prescribed, lack of individual feedback to prescribers, inadequate evaluation, lack of role definition and clarity, challenges with client engagement and over-estimation of the benefits. He suggested several fixes for the weak links.

He said social prescribing could achieve much, but gave a word of warning that it should not be seen as all we needed to do to address the social determinants of health (SDOH). Social prescribing was just one avenue of addressing the SDOH, and was not a panacea, he suggested.

Speaking on the last day of EACH24, and drawing from a recent discussion paper she has published, Dr Candice Oster provided a possible way forward.

A senior research fellow in the Caring Futures Institute at Flinders University, Oster had a message for delegates about ensuring that social prescribing does make a meaningful contribution to addressing the SDOH.

She cited a recent expert consensus definition of social prescribing which had two parts: bridging the gap between clinical and non-clinical services, and mitigating the impacts of adverse social determinants of health and health inequities by addressing non-medical health related social needs

 

With the first half of the definition, Oster said there was a potential for “lateral consequences” as we scale up social prescribing.

This would occur if the capacity of non-clinical supports and services were exceeded or if a support that was identified for a particular patient just didn’t exist in their area. The discussion paper gives international examples of possible resourcing solutions for this.

Regarding the second half of the definition (mitigating the impacts of the social determinants of health), Oster said that in using social prescribing we need to consider “upstream consequences”.

She said it was important to avoid the “fantasy paradigm” of assigning personal responsibility to individuals for addressing social and structural issues over which they have little or no control, and ultimately blaming them.

“We need to separate out narratives around mitigating the effects of social determinants of health from narratives around addressing the causes of health inequities.”

We could do this in Australia, she said, by leveraging the community and political power of health practitioners, by collecting and disseminating data, and advocating for action on the social determinants of health.

“Social prescribing models do have the potential to stimulate and direct natural funding, and they also have the potential to inform upstream actions by communicating social determinants of health to government and policy makers and lobbying for actions on the social determinants of health that are affecting our community,” she said.

• All photos, except the feature image, by Dr Ruth Armstrong


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