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ETHICS wood word on compressed board with human's finger at S letter © Shutterstock

Health problems often co-occur with social and personal factors (e.g. isolation, debt, insecure housing, unemployment, relationship breakdown and bereavement). Such factors can be particularly important in the context of non-communicable diseases (NCDs), where they might contribute causally to disease, or reduce that capacity of patients to self-manage their conditions (leading to worse outcomes). This results in the suffering of individuals and a greater burden being placed on healthcare resources.

A potential point of intervention is at the level of addressing these upstream contributors to poor health. A suggested tool – gaining momentum amongst those involved in health policy – is the use of ‘social prescribing’. Social Prescribing focuses on addressing people’s non-medical needs, which it is hoped will subsequently reduce their medical needs. In primary care, social prescribing can take a range of forms. For example, it may involve upskilling existing members of staff (e.g. receptionists) to signpost patients to relevant local assets (e.g. organisations, groups, charities) to address their non-medical needs. It is also becoming common for GPs to refer patients (or people may self-refer) to a link worker (sometimes called a care navigator) who can work with them to identify their broader social and personal needs. Together, they then develop a plan for how those needs could be met through engagement with activities, services or events in the local community. The resources that link workers direct people towards are often run by voluntary organisations and might include, among other things, sports groups, arts and crafts, drama, gardening, cookery, volunteering, housing advice, debt management, and welfare rights.

Supporting people to establish more stable and fulfilling social lives whilst at the same time reducing healthcare costs seems like a win-win. However, it is essential to evaluate the justifications for the introduction of social prescribing schemes, including their effectiveness. This raises a number of complicating factors, including some questions that require not just a consideration of empirical evidence, but a commitment to certain philosophical and ethical positions.

We won’t discuss the evidence for the effectiveness of social prescribing schemes here but note that, currently, it is sparse. There are considerable complexities in assessing such schemes, in part because of variability in what is on offer, to whom and how. Being clear about what the proposed benefits of such schemes are (for instance, improvements in mental well-being, fewer GP visits, improved management of long-term conditions, reduced social isolation) is important. However, it can be difficult to measure the benefits people receive from engagement with activities such as arts projects and volunteer schemes using traditional metrics from psychology and medicine. Furthermore, long term follow-up is required to capture diffuse benefits across different areas of a person’s life, including the potential to improve circumstances of those around them (e.g. family members being less concerned about a loved one who is going out and socialising more after engaging in social prescribing).

Aside from methodological difficulties and the need for more evidence regarding effectiveness, there are some ethical questions that must be addressed.

Is this an appropriate role for health services?

 On some measures, social prescribing is explicitly not healthcare as it might be viewed traditionally by members of the public (i.e. delivered in specific settings – hospitals, surgeries – by medical professionals). It is too restrictive to demand that the NHS only spend money on things that directly contribute to health (e.g. through the diagnosis and treatment of disease). However, we don’t typically expect healthcare funds to be spent on education, housing, or the arts. Yet the more we learn about the aetiology of NCDs, the more apparent it is that a range of factors can contribute to or detract from health. This makes the question of what, exactly, the scope of health services should be more acute. Health professionals advise us on our dietary habits, how we travel to work, how we spend our leisure time. The decision to practice social prescribing could encourage even more activities to be viewed in terms of their contribution to health, inviting further medicalisation. Alternatively, it may reduce medicalisation by taking a more holistic perspective to health and well-being, encouraging people with low mood or anxiety, for example, to try social activities or to engage in cultural events alongside, or in place of, medication.

If isolation, housing, employment, etc. have a clear effect on health, the NHS may be justified in intervening on these upstream factors as part of its role to protect and promote health. We might accept that definitions of health are (and ought to be) widening. The NHS need no longer focus on narrow health promotion and disease alleviation; it might legitimately act to promote broader well-being and related values, by facilitating people to lead a meaningful, purposeful life, in which important relationships are fostered.

Are patients being ‘fobbed off’?

One risk of directing people to social prescribing services is they feel that their health problems aren’t being taken seriously. Alternatively, people may find social prescribing intrusive, to the extent that it involves efforts to modify their lifestyle. This is speculative. Detailed empirical work will be needed to assess how, in fact, people respond to social prescribing. We should, however, acknowledge that some of the value people derive from being seen by healthcare professionals may be lost if social prescribing is used to cut down on GP appointments. For instance, receiving medical treatment and attention can be legitimising – indicating that one’s illness is sufficiently weighty to warrant specialist care. This legitimising effect might not only be of internal reassurance to the patient, but signal to others that their illness is valid. Referral to social prescribing could undermine this experience of being taken seriously.

Even if people do not resist being redirected towards non-medical services, there might yet be an objection to this practice. Doctors have a duty of care to their patients, one that is not easily or straightforwardly transferred to others. It seems that the role of the link worker here will be crucial to ensure that medical care, when necessary, is sought, and that those neither qualified nor capable of dealing with patients’ complex health problems are not left struggling to provide support and care. Guidance on the link worker role from NHS England should help alleviate such risk.

The emotional impact of social prescribing

The burden social prescribing could create for those delivering services warrants consideration. As with other caring professions, link workers are likely to undertake emotional labour. This term was first introduced by Hochschild in relation to the aviation field. She wrote about how flight attendants managed emotions in their job (e.g. when dealing with difficult customers). Emotional labour relates to strides individuals take within their work life to present an emotional persona that meets with an organisation’s expectations. When employees’ feelings do not fit with what is required socially, they may have to engage in emotional regulation, which has been depicted as a serious cause of workplace stress, due to the effort it entails; suppressing unpleasant emotions has been associated with poorer job satisfaction and increased intention to quit. This has implications for sustainability of link worker schemes. Therefore, it is important that link workers have outlets and support to express and manage difficult emotional responses, after working with potentially vulnerable patients, who lead challenging lives. This has been flagged as an area for attention within the guidance on link workers from NHS England. How far and the format this support will take as link workers become established within primary care networks is not clear.

A band-aid on a bullet wound?

Social prescribing emerges from a recognition that, often, health problems arise in the context of challenging personal and social circumstances. Serious efforts to combat NCDs may necessitate significant structural changes to current social practices and structures. Work on the social determinants of health has established the links between social deprivation and poor health outcomes, and suggests that the pervasive effects of social inequality on health, beginning at birth and persisting throughout someone’s life, are unlikely to be addressed simply through social prescribing. It should be noted that social prescribing requires a vibrant voluntary and community sector to flourish; more disadvantaged areas may have fewer community assets, thereby potentially contributing to Tudor Hart’s inverse care law.

The worry is that key social determinants of health are not tackled through broader social reform; instead, social prescribing is used as a smoke screen for change without addressing some of the more fundamental issues contributing to health inequalities within society. This might be an ungenerous interpretation of the motivation behind social prescribing, but it places an onus on those tasked with implementing social prescribing services to ensure such interventions are properly evaluated and not used to deflect attention from remaining problems, and from undertaking other (potentially politically unpopular) solutions. More optimistically, it is plausible that social prescribing could form a basis for political willingness to begin to tackle the engrained problems of social deprivation and health inequality.

Where does responsibility lie?

Interventions to improve health, particularly in the context of slowing the development and improving management of NCDs, often require effort on the part of the individual: making changes to their diet, physical activity, smoking, alcohol consumption, medication adherence, and so on. Political rhetoric and media reporting emphasise the importance of individual responsibility in tackling health problems. This is countered, however, by claims that individuals are often not in a position to ‘exercise responsibility’ over their lifestyle in the ways necessary for notable health improvement. Social prescribing shows a sensitivity to the latter viewpoint, by seeking to provide social networks and structured support to individuals to make changes that may promote their health. The question remains whether this is an appropriate shift in the locus of responsibility. As noted above, it seems to move responsibility from the NHS and GPs to link workers and voluntary organisations who, along with patients themselves, are now expected to address contributing factors to poor health and well-being.   

The recognition that, since social factors contribute to health, some of the responsibility for addressing health problems should also rest with society, has been lauded. Yet others might find the dependence on volunteers and community groups troubling, and maintain that the State is obligated to ensure social conditions are amenable to people living healthy and fulfilling lives. More consideration is required of how responsibility can and should be distributed amongst the different stakeholder groups involved here.

Disclaimer: The views expressed in this commentary are those of the authors and not necessarily those of  the National Institute for Health Research or the Department of Health and Social Care.