Social prescribing programmes are proposed with strong cost-effective potential for general practice. They have been widely promoted since 2006 when the Department of Health advocated the introduction of social prescriptions for those with long-term conditions. Through social prescribing programmes, patients are linked to alternative sources of non-medical support within the community via social workers (also known as “navigators”, link workers, community navigators etc). In the latest NHS Long Term Plan (NHS England, 2018), it is highlighted that “within five years over 2.5 million more people will benefit from social prescribing”.

An important question that merits attention is the evidence base for social prescribing programmes. In the last decade, we’ve seen a proliferation of papers with previous reviews conducted on the topic attempting to fill out the gap in the literature. Kilgarriff-Foster and O’Cathain, (2015) attempted for the first time to map the overall evidence base on the impact of social prescribing by conducting a scoping review. A more recent review (Bickerdike et al., 2017) explored the effectiveness of social prescribing for people with mental health difficulties, with little convincing evidence identified.

So far, previous studies have not reached consensus on the impact of the programmes. Thus, this review by Pescheny et al. (2019) sets out to examine the latest literature published since the last review, including additional qualitative evidence and exploring more outcomes relevant to service users.

Methods

An inclusive set of criteria were used to assess the eligibility of the studies with no restrictions applied on the outcome measures, study design, and quality of the studies. Studies were eligible if they:

• Assessed social prescribing programmes on a primary care setting in the UK , where primary care staff referred patients to a “navigator” 
• Were written in English

The authors conducted a thorough literature review of eligible studies on multiple electronic scientific databases, the grey literature and reference lists until June 2018.

The study adopted a two-stage screening process with an initial screening of titles, abstracts and summaries and a full-text screening performed at a second stage. In both stages, the screening was performed by one reviewer and a random sample of 25% of the sample was screened by a second reviewer. A similar procedure was followed for data extraction. The Mixed-Methods Appraisal Tool was used by two reviewers to assess the methodological strength of the studies and the validity of the findings. 

The authors conducted a thematic analysis, which is a method of narrative synthesis and allowed them to identify service user outcomes and categorise them into themes.

Results

In total, 7,676 papers were identified through scientific databases and 800 through the grey literature. Following the two-stage screening process, 16 studies were included. 

Overall, the majority of papers identified by the authors (10 out of 16) adopted a mixed-methods study design. 

The results of those studies were explored through the following emerging themes: 

Health and wellbeing

• Consistent improvement was reported in qualitative studies for physical and mental health and well-being outcomes such as blood pressure, weight loss, reduced cholesterol and sugar levels.
• Opposing that, mixed findings emerged from the quantitative studies. For example, half of the papers identified a significant improvement.
• There was a limited number of studies that recorded beneficial effects on general health, pain and quality of life.
• The findings on general wellbeing were contradictory and there were no effects on the prescription of medication.

Health-related behaviours

• The studies on health-related behaviours were more consistent with improvements reported in a number of health-related behaviours such as physical activity.
• Qualitative studies reported the beneficial effects that social prescribing had on service users regarding the establishment of a supportive environment, engagement with the services and engagement in health-behaviour change.

Self-concepts and feelings

• This theme was exclusively informed by qualitative and descriptive studies.
• Participation in social prescribing programmes was associated with beneficial effects in self-esteem, self-value, self-confidence and feelings of worthiness.

Social interactions

• The users of social prescribing services reported beneficial effects on social interactions and cultural engagement due to their participation.
• Nevertheless, the findings of the three quantitative studies did not agree with the qualitative results.

Day-to-day functioning

• A number of the included papers (primarily qualitative) reported beneficial effects of the service users on day-to-day functioning activities such as employment assistance, welfare and practical support. 

Conclusions

The authors concluded that the current evidence base is “considerably behind practice”, but also emphasise that evidence about the impact of social prescribing services remains inconclusive:

In order to assess the success of social prescribing services, more high quality and comparable evaluations need to be conducted in the future.

Strengths and limitations

 This review has several strengths, including: 

• The usage of a wide range of sources of the available literature.
• The coverage of literature published up until 2018.
• The coverage of a wide range of mixed study designs, which was not limited to findings of effectiveness.

Nevertheless, as in all studies, there are some limitations worth acknowledging:

• The methodological quality of the included studies was generally low. As mentioned by the authors, the lack of detailed reporting of key aspects of the studies such as data collection tools and results, just to name a few, represented one of the key challenges for assessing the quality. 

• The authors aimed to identify studies that referenced any service user outcome. However, in their search strategy they restricted the keywords to health and well-being outcomes. It is therefore likely that research focusing on non-health and well-being outcomes (e.g. social effects) was not included in the review.
• They do not report the sample sizes of the individual papers included in the review and thus comparative assessment is difficult.

Implications for practice

The mixed findings of the review hinder our ability to drive implications for practice. The current state of literature suggests that the available evidence is not fully-qualified to allow for an informed judgement on the success or failure of the social prescribing programmes. 

The sample sizes of the quantitative studies included are small and the applied tools used to measure service use are diverse. Additionally, the reporting of specific details in the papers was limited and so limited in assessing the contribution of the programmes. Conversely, qualitative findings reach some agreement.

It becomes clear that the current programmes are lacking vigorous and comparable evaluation. The creation and adaptation of a common evaluation framework is critical for the success of social prescribing schemes. Given the nature of the programmes, we also need to consider what are the wider social gains of the schemes. Can those be measured? Their long-term impact should not be overlooked. A number of resources on recommendations are available from the Social Prescribing Network (2017).

Another important understudied issue is the financial aspect. Social prescribing programmes were developed with the intention to reduce burden on general practices. A technical report by Folley et al., (2017) showed “average reductions following referrals to social prescribing themes of 28% in GP services, 24% in attendance at A&E and statistically significant drops in referrals to hospitals”. Given the lack of established economic evaluations for the schemes, we need to address the question: are they value for money?

The role of the navigator in the programmes is instrumental. The plethora of the social prescribing models employed different ways of how link workers were used. Thus future research needs to fill out this evidence gap. Are there specific aspects that are critical in the role of the navigators such as delivery methods, number of consultations, training etc? Wildman et al. (2017) highlight the importance of highly developed personal skills of the link workers and sufficient time spent with patients. Future schemes need to employ evidence-based approaches, which are yet to be fully-explored.

The NHS has set up a biggest investment in social prescribing than any other national health system. For me, the potential of the social prescribing programmes is compelling, but the quality of the evidence needs to be improved!

Conflicts of interest

None.

Links

Primary paper

Pescheny, J. V. et al. (2019). The impact of social prescribing services on service users: a systematic review of the evidence. European Journal of Public Health. doi:10.1093/eurpub/ckz078

Other references

NHS England, (2018). The NHS long term plan. London: NHS England.

Kilgarriff-Foster A. and O’Cathain  A. (2015). Exploring the components and impact of social prescribing (PDF). Journal of Public Mental Health, 14(3), 127-134. 

Bickerdike, L. et al. (2017). Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open, 7(4), e013384. doi:10.1136/bmjopen-2016-013384

Polley et al. (2017) Making Sense of Social Prescribing (PDF). Social Prescribing Network.

Polley, M.J. and Pilkington, K. (2017). A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications (PDF). University of Westminster.

Wildman, JM et al. (2019). Link workers’ perspectives on factors enabling and preventing client engagement with social prescribing. Health Soc Care Community. 27: 991– 998. https://doi.org/10.1111/hsc.12716