October 17, 2022

expert reaction to review on the effect of social prescribing on health outcomes in primary care and community settings

A review published in BMJ Open looks at the effect of social prescribing link workers on health outcomes and costs for adults in primary care and community settings.

Prof Peter Tyrer, Emeritus Professor in Community Psychiatry – Clinical, Imperial College London, said:

“The evidence presented in this study is compelling. Despite the enthusiastic embrace of many planners and providers, social prescribing has no basis in effectiveness or cost-effectiveness.  There are certainly reasons for thinking in principle that it might be useful and could save money, but only when it is given by competent people that are adequately trained and have a clear therapeutic policy. At present there is a hotchpotch of general advice, case management, signposting and counselling that leads to great heterogeneity and confusion.  But you would not think this from the statement made by NJS England:

‘There is emerging evidence that social prescribing can lead to a range of positive health and wellbeing outcomes for people, such as improved quality of life and emotional wellbeing’; not true.

Though there is a need for more robust and systematic evidence on the effectiveness of social prescribing (agreed), social prescribing schemes may lead to a reduction in the use of NHS services, including GP attendance (the word may not should have been added too). 

“When you then get the quote that ‘59% of GP’s think that social prescribing can reduce their workload’ you move down to the lowest evidence of efficacy – opinion only. The standard mantra that absence of evidence is not evidence of absence does not mean that social prescribing should be abandoned or reduced, but when the authorities have now set up a National Academy of Social Prescribing that is described as ‘dedicated to the advancement of social prescribing through promotion, collaboration and innovation’ it is quite shocking that research is not added.  A seat of learning in an emerging subject should have research set in stone at its core.

“What is concerning is that unregulated social prescribing has the potential for creating harm with link workers being overwhelmed with inappropriate referrals and having little idea how to respond (Tyrer & Boardman, 2020).  There are studies of environmental interventions similar to social prescribing that have been shown to be cost-effective (Tyrer, 2019) and if social prescribing could be formalised more clearly it is quite possible that good data and effectiveness will follow. But the present verdict can only be that social prescribing is ‘an experimental intervention of uncertain efficacy that needs further study’.”

Tyrer P.  (2019). Nidotherapy:  a cost-effective systematic environmental treatment. World Psychiatry, 18, 144-145.

Tyrer P, Boardman J. (2020). Refining social prescribing in the UK. Lancet Psychiatry,7, 831-832.

Dr Rachel Sumner, Senior Research Fellow, Cardiff Metropolitan University, said:

“The findings of this robust review confirm some important and unfortunate gaps in the social prescribing evidence base. Up until recently, many social prescribing evaluations relied on the report of outcomes such as wellbeing, which whilst extremely important to patients and health services, are not “hard” measures of clinical health.

“The difficulty with evaluating social prescribing is that it very commonly relies on the self-reporting of the participants, and many participants understandably find the completion of psychological questionnaires in such scenarios to be inconvenient or intrusive, when they are taking part in activities that are being prescribed to them in order to improve their health. It is also very common for many social prescribing programmes to be evaluated without a comparison group, which was a key factor for literature to be included in the review, and so the review does exclude quite a few potential studies that report clinical measures of health because they do not include this comparative data.

“Social prescribing has accelerated a great deal in practice in the UK over the last decade, and continues to be looked to in order to help meet some of the challenges faced by our modern health landscape, where many of us are living longer in poorer health, and with fewer social connections. The evidence so far is pretty clear that social prescribing is something that patients gain a lot from, and is often something they greatly enjoy participating in. As the traction for this method of health support gains, it will be more and more important to establish robust methods to evaluate it to ensure that it is meeting those challenges effectively. This has been highlighted well by this recent review, which will hopefully help to steer some of those robust methods of evaluation in the future.”

Dr Rebecca Sheriff, Consultant Psychiatrist and Senior Clinical Research Fellow, University of Oxford, said:

“The press release is incorrect in saying that the review was for adults with multimorbidity and from deprivation, in fact the review included all studies of community-dwelling adults attending primary care and the main outcomes were health related quality of life and mental health outcomes.

“The review appears to be systematic and fairly well reported. It is a complex area and some decisions made by the reviewers aren’t fully explained, such as why studies of social prescribing delivered by telephone were excluded.

“Social prescribing links people to community assets. It therefore stands to reason that it would be effective if the community assets themselves are beneficial for the outcomes of interest (e.g. mental health). However, the evidence-base of the effectiveness of many of the community assets, how they work and who they work for is also scant with regard to mental health outcomes

“Due to the very nature of social prescribing, being for those who attend primary care, means that it misses some of the most deprived and marginalised people many of whom do not seek help from health services. In particular underrepresented people and reluctant help-seekers such as ethnic minorities and young people have high rates of mental health problems and might benefit significantly from community based approaches but many are missed by this review and by social prescribing.”

‘Effect of social prescribing link workers on health outcomes and costs for adults in primary care and community settings: a systematic review’ by Bridget Kiely et al. was published in BMJ Open at 23:30 UK time on Monday 17^th October.

DOI: 10.1136/bmjopen-2022-062951

Declared interests

Dr Rachel Sumner: No declarations of interest

Dr Rebecca Sheriff: No conflict of interest  For all other experts, no reply to our request for DOIs was received.