MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Yesterday, I heard my ‘good friend’ Dr Michael Dixon (see here, here and here, for example) talk on the BBC about the “new thing” in healthcare: social prescribing. He explained, for instance, that social prescribing could mean treating a diabetic not with medication but with auto-hypnosis and other alternative therapies. At that moment, I wasn’t even entirely sure what the term ‘social prescribing’ meant, I have to admit – so I did some reading.

What is social prescribing?

The UK ‘Social Prescribing Network‘ defines it thus:

Social Prescribing is a means of enabling GPs and other frontline healthcare professionals to refer patients to a link worker – to provide them with a face to face conversation during which they can learn about the possibilities and design their own personalised solutions, i.e. ‘co-produce’ their ‘social prescription’- so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary and community sector. It is an innovative and growing movement, with the potential to reduce the financial burden on the NHS and particularly on primary care.

Does social prescribing work?

The UK King’s Fund is mildly optimistic:

There is emerging evidence that social prescribing can lead to a range of positive health and well-being outcomes. Studies have pointed to improvements in areas such as quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety. For example, a study into a social prescribing project in Bristol found improvements in anxiety levels and in feelings about general health and quality of life. In general, social prescribing schemes appear to result in high levels of satisfaction from participants, primary care professionals and commissioners.

Social prescribing schemes may also lead to a reduction in the use of NHS services. A study of a scheme in Rotherham (a liaison service helping patients access support from more than 20 voluntary and community sector organisations), showed that for more than 8 in 10 patients referred to the scheme who were followed up three to four months later, there were reductions in NHS use in terms of accident and emergency (A&E) attendance, outpatient appointments and inpatient admissions. The Bristol study also showed reductions in general practice attendance rates for most people who had received the social prescription.

However, robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative, and relies on self-reported outcomes. Researchers have also highlighted the challenges of measuring the outcomes of complex interventions, or making meaningful comparisons between very different schemes.

Determining the cost, resource implications and cost effectiveness of social prescribing is particularly difficult. The Bristol study found that positive health and wellbeing outcomes came at a higher cost than routine GP care over the period of a year, but other research has highlighted the importance of looking at cost effectiveness over a longer period of time. Exploratory economic analysis of the Rotherham scheme, for example, suggested that the scheme could pay for itself over 18–24 months in terms of reduced NHS use….

END OF QUOTES

Is there no harder evidence at all?

The only Medline-listed controlled study seems to have been omitted by the King’s Fund – I wonder why. Perhaps because it fails to share the optimism? Here is its abstract:

Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use. We used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use. At 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent. Changes in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.

So, there is a lack of evidence for social prescribing. Yet, this is not why I feel uneasy about the promotion of this “new thing”. The more i think about it, the more I realise that social prescribing is just good care and decent medicine. It is what I was taught at med school 40 years ago. It therefore seems like a fancy name for something that should be obvious.

But why my unease?

The way I see it, it will be (and perhaps already is) used to smuggle bogus alternative therapies into the mainstream. In this way, it could turn out to serve the same purpose as did the boom in integrative/integrated medicine/healthcare: a smokescreen to incorporate treatments into medical routine which otherwise would not pass muster. If advocates of this approach, like Michael Dixon, subscribe to it, the danger of this happening is hard to deny.

The disservice to patients (and medical ethics) would then be obvious: diabetics unquestionably can benefit from a change of life-style (and to encourage them is part of good conventional medicine), but I very much doubt that they should replace their anti-diabetic medications with auto-hypnosis or other alternative therapies.

4 Responses to Social prescribing: introducing quackery through the backdoor?

  • Perhaps the very term Social Prescribing is a tautology. It seems to indicate that the illness lies within Society itself and some sort of semi professional help is required. A social Disease. A failure of caring, a prioritisation of debt over indebtedness to family and friends. Lonliness and alienation leads to emotional, social and physical distress. An ageing population struggles to be no burden. But often is. In all senses.

  • The controlled study looked for evidence of psycho-social benefits from social prescribing – without success. So what about direct medical benefits of SP?

    My Medline search for reviews of hypnosis for diabetes produced nothing of note.

    I too caught the interview on R4. I wonder what basis Dixon has for plugging a treatment on national radio, for a serious medical condition, for which serious evidence seems to be lacking?

    Social prescribing on the NHS could potentially provide some benefits, but given the current crisis of provision of social, medical and mental health care services I don’t see it happening any time soon. As for non-evidenced therapies it should not happen at all.

  • Dr Michael Dixon is chairman of the CoMIH (College of Medicine and Integrated Healthcare).This has as its objective the ‘integration’ of a wide range of complementary and alternative healthcare modalities (CAM – which have no basis in plausible reproducible evidence based principles), with conventional medicine. The latter has moved on from its now outmoded past, and does its best to be evidence based – but these modern attempts are not helped by enthusiasts for ‘vitalism’ and other forms of pseudoscience and fake medicine. Perhaps as CoMIH is now finding little impact from its promotion of CAM, it is turning to ‘social prescribing’ as the next great advance’.

    Many of us recall that Dr Michael Dixon was involved with the Prince of Wales’ ‘Foundation for Integrated Health’, which has closed. He then founded the CoM, and I thought I might like to join as its objectives seemed (on the face of it) reasonable and worthy. I tried, but was unable to find out, what this new ‘college’s’ constitution was. I suspected Dr Dixon’s position as chairman was self-appointed.

    In recent years the CoMIH’s original objectives of integrating ‘the best complementary medicine’, including homeopathy, chiropractic, osteopathy, acupuncture, reiki, herbalism and the rest, have quietly avoided emphasis. But their influence remains.
    As its website tells us, the CoMIH intends going ‘beyond conventional medicine’: “Meanwhile, please encourage your friends and colleagues to join the College and become part of a movement that goes beyond conventional medicine” ‘Beyond the Syringe’, a satirist might say.
    And more:

    “Nurses earn the confidence of their patients and are often best placed to advise them on alternative care”, writes Professor Dame Donna Kinnair:” Nurses and midwives are in a unique position to ensure that every patient is able to access holistic care.
    “The provision of integrated nursing is the offer of care, advice and treatment that relieves both mental and or physical suffering and supports a patient’s well-being…In recent years, there has been a move away from what is sometimes referred to as the ‘medical or disease-specific’ model of healthcare. For many of our patients, traditional medicines or clinical interventions are complemented by the use of a variety of herbal remedies, nutrition, acupuncture, mindfulness practices and yoga to name but a few.
    Many of our patients will seek alternative ‘cures’ to long term conditions, a cancer diagnosis or a mental health condition. The College of Medicine supports practitioners to learn about available treatments and the impact of such treatments.” (A false claim, as the CoMIH fails to provide the evidence of the ‘impact’ of the pillules, pin pricks, pummelling and preternatural powers professed by CAM proponents).
    Professor Kinnair advises: “The move to have closer integration between all practitioners seeking to improve health and care – so they can learn from each other – has always been the goal of the College of Medicine.”

    So there we have it. CoMIH wants to see medicine and nursing not co-operating, but integrating.
    Retrogressive or what?

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