How social prescribing works

In this episode we find out how our Smarter Choices, Smarter Places (SCSP) programme is supporting partnerships to deliver social prescribing projects.

SCSP Manager Graham McQueen chats to three guests who have used our funding to deliver interventions that are improving social, mental and physical health and wellbeing through active and sustainable travel and being outdoors.

Inverness GP Dr Katie Walter explains what social prescribing is, how it attempts to break down the barriers people face to improving their health and wellbeing, and how she prefers the term "patient empowerment". She also discusses her own project which has so far helped 400 patients to get active and improve their health.

Dr Viola Marx, from NHS Tayside, gives an overview of how her project reinvented the traditional medical prescription by turning it green and prescribing an activity rather than a drug.

Forth Environment Link's Emma Thomas talks about how social prescribing worked with a select group of cancer patients in the Forth Valley and what effect the introduction of an ebike had on their recovery and outlook.

All our guests discuss the many benefits of social prescribing including its role in the climate emergency.

For more information on SCSP and how to apply for a grant, visit www.pathsforall.org.uk/scspopenfund.

Transcript

GM Hello, my name is Graham McQueen. I’m the manager of Paths for All’s Smarter Choices, Smarter Places programme. And I’m delighted to be joined today by three distinguished guests of this Voices of the Walk podcast episode.

Today we have Dr Katie Walter, who’s an Inverness based GP, who also chairs Velocity Café, Inverness. 

Then we have Viola Marx, who is a green health partnership coordinator with NHS Tayside. 

And we have Emma Thomas, who is the senior project officer on the sustainable transport programme, Forth Environment Link runs in the Forth Valley.

All of our guests today have one thing in common, their projects are all funded through our Smarter Choices, Smarter Places' programme to deliver social prescribing initiative. I think it’d be really helpful for our listeners to hear from our experts on exactly what social prescribing is. So Kate, over to you.

KW Oh thank you very much, Graham. Um, so social prescribing, I guess it’s quite a complicated thing. But it’s also quite a simple thing. So, I guess it’s a term that we use very loosely to describe an intervention that health professionals can recommend that isn’t a medicine that aims to improve somebody’s health. And that’s kind of the common way that we can use it.

So, that’s a simple answer. But if you pick at it a little bit more closely, there are some things that are worth sort of highlighting with that definition. So, in a broad way, take somebody who’s got high blood pressure, or diabetes, or depression. and we know that in a very simple way, a social prescription in this situation might be for that person to walk more and to get them into a place where they are able to walk more. 

So, a bit like old fashioned prescribing of medicines, it’s actually a lot more complicated than saying walk more, and a bit like old fashioned prescribing, it actually all starts with the conversation and the content and the quality of that conversation will determine a lot about whether that pill, or that treatment, or that intervention stays in the cupboard, of the trainers stay in the box or whether actually, it happens. 

Social prescribing is an intervention in many senses that we can say is designed to address social determinants of health. So, somebody’s health is made up of loads of things, it’s made up of the environment that you live in, the genes that you’ve got, some chance factors; there’s lots of things that go into a melting pot of why somebody has the health that they have. 

And we do know that actually, the environment that somebody lives in makes up a huge bit of that health. And the example that’s often quoted around that and around these social determinants of health is that somebody’s life expectancy in one area of Glasgow might be 15 years lower than another part of Glasgow, and there’s lots of that, it can be attributed to what we call social determinants of health. So they’re the things like the housing that you have, the work that you do, the money that you’ve got, your education, what social networks you have, how active you are, whether you smoke or not. And the list goes on and on and on. 

The problem is that many people can’t really easily change those social determinants of health. So for everybody, they’ll have their own set of barriers to why they can’t change some of those circumstances. And I guess social prescribing is an intervention that’s looking at trying to start to unpick some of those barriers that people have. So it has to be person centred, because each individual has very different social circumstances, and very different barriers to things that can improve their health.

So for example, we know walking is a really great way to improve your health, your mental health, your physical health, diabetes, but every person will have different barriers to how, to why they can’t do that. So it might be that they’re looking after an elderly relative with dementia, and actually, their barrier to walking is getting some respite care. Another person, it might be that they can’t afford a pair of trainers, a third person might be that actually, they’ve got mobility issues, and they need some help. Or, for example, it might be around getting childcare. 

So really, every single social prescription comes from a place of needing to be really focused on that one person, what are their barriers? What are the things that they can change, one of the things that we can help them with? 

The second point is it’s got to be motivational. So, to get people to a place that they can change the things that they have agency over, we’ve got to be able to help them to do that. And it not being finger wagging, but really just helping them make those changes. So the term I really like is about patient empowerment. And this is about us helping to empower patients to make choices. That was a very long-winded answer, wasn’t that.

GM No, no, that’s brilliant. I’ve been talking about social prescribing for about three years now and that’s the best explanation I’ve heard of it. Thank you very much. And just to try and follow on from that, Viola, in your opinion, what are the key benefits of social prescribing then?

VM Katie’s covered a lot of these already, so I’ll try not to repeat anything because it was such a fantastic explanation. And I guess to summarise it, the main benefits that social prescribing has is it helps our physical, mental and social wellbeing and health, and then just as touched upon before, that can be broken into lots of different elements.

So, social prescribing helps address the needs people have from physical activity to diet and nutrition, housing, mental health, social support, and many, many more. So, it’s that approach, that’s more than medicine, and in a way that feeds into the sedentary lifestyle that many people have, or most of us have these days, because you know; we get up, we go to work, we sit down, we move a little bit, we sit down again, we go home and then we sit somewhere having dinner, and then in front of the television or, now home working, we might not even have the commute anymore. 

So, the sedentary lifestyle that many people have, is a massive contributor to ill health, and social prescribing, apart from the targeted interventions, whether that’s, you know, diet, nutrition, health and mental health, they get people outside and they get them active. And my programme Greenhealth prescribing, we have partnerships focused specifically on interventions that take place outside. So, it can be any of the activities that help us socially, but simply by changing the environment from an indoor setting to an outdoor setting, there’s even more benefits that people can get. 

GM It’s clear from our Smarter Choices and the Paths For All perspective, social prescribing can provide a unique link between health and transport. Projects such as those we support and those we’re discussing today can influence behaviour change for people that need to get more active for their health, but can also do so in a manner that encourages less car journeys and more sustainable travel. 

So, encouraging people to build activity in their day to day lives and journeys covers both the transport needs and their health needs. And I think it’s much more likely that people will continue with the changes if it becomes a habit, and it’s got purpose.

KW So, I think the really powerful thing for us, up in Inverness and the Highlands has been the coming together of the transport- sustainable travel- with health together. And I think that’s been powerful because actually it reframes a lot of the story for people, doing these changes within their lives around how they move around can be done from a standpoint of not just your own health, but actually your community’s health and health for the planet as well.

It’s amazing how much more of a motivator that’s now becoming, that we’re hearing about in the consulting room of people saying ‘Well, actually I want to do something for the planet, I want to do something for my grandkids. So I’ve got an e-bike, or I started walking around to the shops.’

And I think that that twin powerful model of Smarter Choices, Smarter Places being willing to bring  funding to a health setting has been really, really helpful. It’s been helpful to unlock funding from our side as well as from the health settings side. And I think it really helps 

transport and health come together on what I think is both a health and a transport agenda.

GM Well fantastic, that’s really encouraging to hear the examples there that people have given when they change their behaviours.

VM Yeah, so, Smarter Choices, Smarter Places have been absolutely essential in our Dundee model of social prescribing, or green prescribing as I like to call it, we developed a sort of formal pathway that’s open to self-referrals to allow NHS professionals, so anyone from the GPs, the nurses or consultants, the pharmacists, to identify people who will benefit from a green health activity. 

In order to deliver this service, we needed to make it person-centred, and in order to do person-centred, we needed a consultant in our team who is able to have consultations with people who received a prescription to find the activity that they will enjoy and want to engage in. We have a whole lot of activities and they’re delivered by our third sector in Dundee from, you know; walking groups, gardening groups, but one of the things that we found was missing initially was a cycling group that’s accessible. 

There are many people who can’t make use of a normal two-wheeled bicycle and then Dundee’s quite hilly, probably as many cities in Scotland, so we needed that electric element as well. So, we developed a group called Rediscover Dundee, which is an electric tricycle group, and our Greenhealth development worker also coordinates this group. So, we have a direct link in from Greenhealth prescribing to our Rediscover Dundee group.

 And that’s enabled so many more people to participate in active travel that haven’t been able to do that before because they might have mobility issues, or weight issues, or balance issues, or people have COPD, or we have some cancer patients as well. So, having these electric tricycles has been absolutely amazing because so many more people are now on bikes, and during the pandemic, and it’s still continuing, we’ve started to let people who are part of the programme use these in their own time.

 And there are a couple of people who still have a trike and they use it twice a day, instead of taking the taxi or the bus because they have a mobility walker, but an electric tricycle enables them to move about freely, and we see them cycling around town, and then they wave to us. And it’s actually really amazing. This project was really amazing. And we wouldn’t have been able to do that without support from Smarter Choices, Smarter Places.

GM It was always great to hear stories of that, that’s always good. Another positive thing for me, you mentioned there is the partnerships that developed through these projects. I mean, I know you guys are in the Forth Valley, Emma has got some fantastic partnerships with the project you do. 

ET For us, it helped us kind of bring together clinician teams from NHS Forth Valley. And also the academic side of it because we wanted to do a study, an evaluation study, so Edinburgh University. So without this, the Smarter Choices funding, we couldn’t have been able to make those links and bring all those people together.

Our project, so, it was a partnership between those three entities specifically, the surgical colorectal cancer team at Forth Valley, and Dr. Paul Kelly is a part of the physical activity for health and research centre. So collectively, we were really interested in the long term use of e-bikes with patients that were undergoing bowel cancer surgery, we wanted to explore both prehabilitation and what kind of effect that would have on their fitness levels, but also tried to kind of integrate cycling into their day to day lives to see if they would use the e-bikes, not just for leisure, but for making every day journeys. 

So basically, the NHS team kind of led on the recruiting section, FAL provided e-bikes and cycling support, Edinburgh university did the study. We’d aimed to work with between 20-30 patients, providing each other them with an e-bike for around three to four weeks before surgery. But unfortunately, COVID has a bit of an impact on that with the surgery times being delayed. 

We also wanted to provide some wraparound care in the form of kind of cycling conference sessions and one-to-one buddy rides and social rides with the patients, and we wanted to monitor the bike use as well. So, we had trackers on the bikes. So, we’d be able to collect that data and look at the kind of behaviour and how they were using the bikes- what distances they were going. Dr. Paul Kelly also conducted some interviews with the patients and staff just to get an idea of how they were using it and how they were feeling about it, just give you a wee snippet of, kind of, some key things that came out of it was that then we’ve managed to recruit thirteen patients all and all for the trial.

And that was kind of impacted because of the pandemic and there was less face to face time in the hospital with the patient. I think actually there were eighty-two patients that went through surgery, and I think there was maybe thirty-two that were actually online eligible. From the trackers we found that around 40% were using the e-bikes in a way that was consistent with health enhancing physical activity, patient’s experiences positive impacts in relation to their mental health and their outlook and physical health.

I think probably the most important one from a patient point of view was their mental health. We kind of described it in terms of giving them peace of mind and helping them with depressive feelings or give them that kind of sense of wellbeing with their outlook. They spoke about it in a general sense in life, but also with their cancer diagnosis saying things like it took them out of patient mode and into recovery mode. 

And I think one of the key things that we noticed as a benefit was it gave the patients a sense of ownership or control over their own treatment plan. And the clinicians also kind of spoke about the kind of offer of the e-bike being a kind of positive aspect or something positive to talk to the patient about, aside from giving them this terrible negative diagnosis and also help them, I think once they’d kind of realised that there was physical benefits and it helped with their recovery, they were more inclined to talk about their care in general and for our specific patients. They also talked about benefits related to their cancer, so they had improved bowel movements, there was reduced side effects from the chemotherapy, and they were just able to cope with it a little better so yeah, it’s good.

GM That’s a really good, sort of, overview of your project as well. Really, I should probably ask you other guys to give us a brief sort of overview of what your projects is specifically and how it works. Because I know we’ve got the three different projects which are all based on social prescribing, but they all work in a slightly different way. So, Emma, you kind of said yours was for a very specific target audience. And it was referrals from that specific target audience whereas the one in Dundee and the one in Inverness are slightly difference. So, Viola if you were to give us a sort of brief overview of how your project works.

VM Our project has, well used to have, just a paper-based prescription. So, we took the red medical prescription and we turned it green. We took away the slip where you prescribe medication and replaced that with lots of activities that people can choose from because we actually want the person to choose what they want to do rather than the prescriber to tell the person what they are to do; because if somebody doesn’t like walking then they will not go walking but maybe they like yoga or cycling or something else. 

We created this physical form that looks like a prescription that prescribers, so this can be GPs, nurses, anyone in primary or secondary care, everyone that have contact with patients and that patients talk to, enable them to issue this prescription. We now have a digital version as well. So, if there’s a near-me consultation or a telephone consultation, we can also issue a digital prescription instead. So, the prescriber gives a prescription to a suitable patient and a suitable patient for us is very general because we have so many different activities supporting so many different people and needs.

So it can be anyone who needs socially connected, we have a lot of people who suffer from social isolation or loneliness. We have many with mental health, that can be low mood to severe depression, it really depends. It’s a spectrum. We have people with cancer, and we’re linking to McMillan and Steps to Health. And then we have people with mobility issues, people with COPD, people who are getting physiotherapy already. So, just need to go out and kind of getting more active in general.

We’re also linked into the surgery teams. So for pre-surgery getting people active and fitter, so that the outcomes are better afterwards. But we’re also linked in directly to the vascular surgery team because they use walking as part of their treatment plan. So again, walking or any form of physical activity that we can offer is linked into that. So, for us, it’s really, really broad. We also have arts and crafts classes, again for those who want to be socially connected, or maybe are not able to join a walk because of their condition.

So, yes, we have a consultation and our brain health development worker, they then talk to the patient and find out which of all of these activities do they want to try. It really is about trying them and seeing what they enjoy. So, one shoe doesn’t fit all and after the activity we check in with them again and ask how did you get on? Did you like this? Do you want to go back? Do you want to try something else? We have some people who don’t enjoy the walking groups, they then join another class that they very much enjoy. 

We also have some people who start off at one thing, and they enjoy that so much they start participating in other activities. So, it’s about having that conversation and then sending them there. At the same time, all of this is open to self-referrals. During the pandemic, actually, we had a significant increase; 50% of our referrals came through self-referrals.

 So, people who heard about the service and just gave us a call or sent us an email or a text message and said Hi, do you have something I can do? And so, we got them linked up in that way. We now also offer online activities. Obviously, that was a necessary requirement during the pandemic when we weren’t allowed to meet. But actually, we learnt that this opened the doors for many more people who are usually unable to join us in person, because they might have caring responsibilities and they just don’t have the time to travel, or they have transport issues, so they don’t have the means to get from A to B, or they are working and many of the activities happen during working hours. 

But also people who are socially anxious, you know, getting them to a new activity, that’s hard enough in normal circumstances. But if somebody is really, really worried, actually allowing them to meet people online first, maybe with their camera off, can build that trust, and then eventually that into doing an activity outside with the people. So, our model has adapted a lot because we wanted to make sure that as many people as possible are reached and can be reached. 

And I guess the last group that really benefited from the online activities were people who are housebound in general and are unable to leave, for now at least we managed to get them active a little bit. And we’ve received fantastic feedback. So, we’ll continue working with prescribers and people to adapt and find ways that we can make it possible for them to become active. 

GM Fantastic. You know, as you say it’s very wide-ranging and covers a lot of people, which is great. Katie again, yours works slightly differently again in that it’s a pair of officers between GP surgeries I think isn’t it so could you give us a wee brief overview of how your project works.

KW I was very aware as a GP that I was having a lot of opportune moments with patients for discussions around behaviour change around potentially people taking up walking, cycling, wheeling more but that I was time pressured, and probably actually not very well skilled in having those conversations. I think there is a realisation that to have a really good motivational conversation with people that takes skill and unfortunately most health professionals are really bizarrely are not trained enough and not trained well in it. 

And I hope that’s something that’s changing now, but certainly my generation, I can’t remember having a single training experience throughout my entire medical training on actually how to have conversations with people around behaviour change. And that training is all stuff that I’ve sought out afterwards. So, I guess what we wanted to do was give space to patients to have a better, more in depth, more person-centred conversation, that would be motivational around physical activity uptake, with a focus on walking, wheeling, cycling. 

So, the model we took was of referral clinic, a bit like a smoking cessation clinic. So having some link workers who where there that we could refer to, or patients could self-refer to, for a one-to-one conversation, an in-depth one to one conversation, sometimes up to an hour long. So the first one, and then to be followed up over a three month period with the explicit aim of forming a goal of what their physical activity uptake plan was going to be. And then the link work has really helped people think about why being more active is important to them, and how it will benefit them. And exploring the barriers I was talking about what makes it difficult. Looking at ways that can be achievable. And all doing that assume to motivational interviewing, and a testament to that is that of our participants, and I think we’ve now topped 

I think four hundred, over four hundred participants, walking is, by far, the most commonly chosen activity. And of those people who choose an activity walking is the one most readily achieved, that has given me great confidence in terms of thinking back about their social determinants of health, that we’re not worsening health inequalities, because actually walking is available to everybody. And it’s achievable very easily. So, that’s been really empowering to see that. 

But it’s not just walking. So, some people will actively want to join a group. As Viola said, there’s a really important bit there about social connection. And there’s an important bit about fun as well, so some people are going to be joining a ping-pong group, or gardening, or volunteering or helping get cycling skills.

So, very much signposting on and referring on as Viola mentioned, to other local services and groups. And really the whole project came from the gap between knowing that these interventions help, actually how do we help people to make those changes and support them in that behaviour change. Again, a bit like Viola, we’ve had lovely feedback, you know, I’ve got a quote here:

 “Before taking part in this project, I did virtually no exercise, meeting up with the link workers has given me the necessary motivation to get moving and enjoying it. It came at the right time and gave me the kickstart I needed.” 

And I hear that time and again from patients, that actually this feels empowering is often in the context of say, a diabetes consultation, when people are coming in with the expectation that they’re going to be told off and told to take more tablets. And actually the outcome of the consultation is potentially a life changing step taken for them in a very different direction, to take control of their chronic disease. And I think that link with chronic conditions has been really powerful. And the evidence from our monitoring and evaluation, as I said, is really that walking is a win-win.

But there are lots of other activities as well, that were helpful. So a very simple model. We started with a few surgeries, we expanded out to more surgeries, and we’re now open to referrals in from all surgeries in the NHS Highland area from secondary care as well as from allied health professionals.

And I think one thing that’s really interesting is that the dieticians have become a really strong referring group because there’s obviously really strong links that go there with people wanting to get more control over their weight as well. So, it’s evolved, they were early adopters of Near Me before the pandemic, so I think we were actually a case study for Near Me nationally before the pandemic, because they were using it and that’s actually become the standard way now. 

GM Thank you very much, Katie. I think, you know, listening to everyone’s overview of the projects, there’s obviously big differences in projects and how you approach things, but there’s a lot of similarities as well. And I think that person centred, patient centred focus is incredible across a few projects and that’s really positive. Hopefully everyone agrees there’s some fantastic projects there as well. I mean, they’ve been a pleasure to support and we want to continue supporting them going forward.

I’d just like to kind of finish off with one final discussion point. So some of the main elements of the prescribing projects are mental health, physical health, and we also want to mention the climate emergency so, with those three topics, could each of you volunteer for one of them and just give us a brief kind of run through how social prescribing, how your project specifically can support either mental health, physical health or the climate emergency? Any volunteers for- 

KW I volunteer for any of those three? I’ll do whichever ones the other ones don’t want to do, because I’m happy to.

GM Okay, Emma, you had your hand up. So, which one would you like to start on Emma?

ET Oh, I’ll take climate change.

GM Forth Environment Link, of course you should.

ET Yeah. So integrating health and transport is key. And I think that some people are put off when they’re told, you know, the chief medical officer is trying to get your weekly dose of exercise, and you have to think maybe I have to do a class or maybe I have to do something out with what you normally do, kind of fit it into your schedule. And I think cycling and walking are just perfect for that. Because you can use them to get to places- go to your shop or go to work. And you get your exercise to do that. So, I think yeah, trying to campaign social prescribing with transport is, it’s just a win-win.

GM Fantastic. Thank you very much Emma. I wholeheartedly agree. Mental health and physical health, Viola you can choose.

VM Let’s go for the mental health one. Social prescribing is great for mental health because it connects us to others. And that spikes dopamine and all the happy hormones in us in the first place. It’s good for our mental health, specifically in our project because we get people outside. And that just gives you that headspace, that fresh air, that moment where you can calm down and you can listen to what’s around you. 

So, you don’t even need to be there with somebody else, you can do this on your own. And you still get lots of benefits. Now, if you start moving around, you also get the physical benefits. But I’m not going to go into that. 

There was this one study that I just really enjoyed. And it was published now during the pandemic, which showed how significantly acute stress, so when you’re stressed in the moment, and you just feel like everything’s getting too much- how that taking yourself outside reduces that stress and helps you calm down again and manage everything else that’s around you much better.

So those are the little things that will eventually, could potentially contribute to you being chronically depressed if we don’t take care of the little bits that happen in our day-to-day. So I think, for our mental health and resilience, and social prescribing activities are just absolutely fantastic. So hopefully that’s enough.

GM That’s brilliant. No, no we’ll finish this first. Kate, physical activity?

KW As I said earlier, we know that social determinants of health impacts on physical health, we know that obesity has been a factor of the way our society works. And I guess that social prescribing is a means of starting to engage people with ways that aren’t medical ways to address what, you know, in some cases, social factors. 

Now, I’m cautious about social prescribing, because I think it’s easy to say social prescribing is brilliant, and we should really go for social prescribing, which we should, because it sits with a big movement around realistic medicine and about not over medicalizing our world. But I think it has to come with a caution. This is focusing very much on an individual’s behaviour and behaviour change. But there are many, many interventions that would have a much more powerful effect across the society which are actually not within individuals’ remit, but within political remit. 

And I guess that is the bit where we’re coming to the crux of it at the moment in our society, I think in terms of the push and pull. So, we know that walking, wheeling, cycling is good for our health. We know it’s good for our society. We know it’s good for our communities. Now the problem is if you make it all about an individual’s choice, you’re missing a big part of the story. 

Because another big part of the story is actually about the environment that we live in that is determined by some of the political decisions that we make. I know this might be taking things a bit beyond the topic of conversation, but I think it’s worth pointing out that actually the biggest power of public health rests with politicians making decisions about the environment and the society that we live in. and that will have a much bigger impact than individual social prescriptions.

 So, if I was to wave a magic wand, I would say I’d love to live in a society where social prescribing yes is normal and is well done, where the health professionals doing it are well trained to do it. And have the skills to do it. But I’d really like to live in a society where the onus isn’t all put on the individual. But actually, the onus is actually on our society to build a society that makes it easy for people, easy to walk, easy to cycle, easy to wheel, easy to get around with visual impairments. 

And I think for me, that’s a bit of the narrative around social prescribing- we need to be really careful about it because it sometimes gets harnessed by the saying, well you know it’s all up to people getting out there and walking. It’s all up to individual responsibility. I think that’s what I love about these projects, is it allows us to sensitise a lot more people to the environment that we’re living in, and how important it is to get that environment right. 

GM No, amazing Kate. Thank you very much. Yeah, I think we can all agree it’s part of a bigger picture. So, again, thank you so much for coming along. We very much appreciate your time. And hopefully everyone has found it as interesting and as enlightening as I have to hear your opinions. Thank you very much.