Abstract

Social prescribing is a current UK social policy phenomenon but to what extent does it represent a substantive change in the way policymakers think about services for people with multiple and complex needs? I draw on several local studies of social prescribing initiatives to argue that cautious optimism is merited: through the idea of social prescribing ‘plus’ key actors in a number of localities have embraced the principles of asset-based working and collaborative innovation to achieve real change in policy and practice. However, policy interest in social prescribing cannot be decoupled from the public sector austerity and transformation agenda, and the true testing ground will be how local policymakers develop services in future: will they draw on the asset-based collaborative principles of social prescribing ‘plus’; or will it lead to expectations that people and communities do more for themselves without the necessary investment in this alternate model of welfare.

Introduction

Social prescribing has become something of a social policy phenomenon in the UK in recent years. If your local area hasn’t ‘got it’ already then you can be certain that key players from the local voluntary and community sector will be lobbying health and social care policymakers to get it up and running sooner rather than later. But is it just the latest ‘shiny new policy thing’ that will come and go before too or long or does it represent a more substantive change in the way policymakers think about the design and delivery of services for people with multiple and complex needs? This policy commentary draws on more than four years’ experience of research and evaluation with social prescribing initiatives at an area level, and parallel engagement with accompanying policy debates,¹ to lay some groundwork for addressing this question. I do this by introducing the idea of social prescribing ‘plus’ and drawing together two emergent theoretical concepts – asset-based approaches to health and care; and collaborative innovation – to reframe social prescribing in the context of broader debates and competing paradigms of public administration. In the process, I hope to stimulate discussion and debate about social prescribing, its place in systems of health and social care service delivery, and the broader processes and principles of public service transformation.

What is social prescribing?

Social prescribing is a recent innovation in public health and social care services through which medical and care professionals – including General Practitioners (GPs), mental health practitioners, nurses and social workers – refer patients with complex health conditions to sources of social support provided by local voluntary and community organisations (South et al, 2008; Kimberlee, 2015; Dayson, 2017). The overarching aims of social prescribing are twofold: to reduce demand on primary, secondary and social care services; and to improve personal well-being and a wider range of social determinants of health such as isolation, self-esteem and social connectedness. In its early days social prescribing was typically delivered from the ‘bottom-up’ by local neighbourhood and  community organisations and through volunteers working with single GPs or small groups of practices to link patients with existing activities and opportunities in their community. This work sometimes received small amounts of public funding but was not considered part of mainstream statutory service delivery. However, the period since 2012 has seen the emergence of social prescribing as a ‘top down’ policy agenda, with large ‘services’ increasingly being commissioned as part of area level health and social care integration and transformation programmes (see Hughes, 2017, for a broader discussion of this policy discourse). Despite this mainstreaming of social prescribing there remains considerable difference in the ways in which it is being implemented across the UK with local variations according to level and source of funding, model of commissioning, the targeting and identification of service users, geographic coverage, referral sources, and the breadth of ‘prescribed’ activities. A more detailed overview of these variations is provided in table 1.

Table 1: Variations in social prescribing delivery models

Given the growing heterogeneity of social prescribing delivery models and the aims and assumptions that underpin them it is increasingly important to differentiate between approaches to social prescribing, in particular the breadth and depth of models developed in different localities and for different types of patient. An early attempt to  codify approaches to social prescribing by Kimberlee (2015) laid them out on a continuum, from ‘light’ at one end through to ‘holistic’ on the other. However, as social prescribing has become part of mainstream commissioned services most approaches could be described as ‘holistic’, and there is a need to distinguish yet further between the these ‘holistic’ approaches. In response, the idea of social prescribing ‘plus’ has emerged from practice as a means of identifying the most extensive and embedded models and setting them apart from other ‘holistic’ approaches.

Although social prescribing ‘plus’ is an emergent concept that has not been formally defined, there are a number of key features and practices that set it apart from other approaches.

• Broad geographic coverage: the service will cover a large geographic area that is contiguous with a local authority or NHS Clinical Commissioning Group (CCG) boundary.
• Multiple clearly delineated referral pathways from a variety of health settings: including from GPs and other practitioners at a practice level, statutory mental health services, and secondary care.
• A range of social prescribing specific services and activities are available: social prescribing service users are able to choose from a ‘menu’ of services that have been specifically developed for the service. These services will receive funding to ensure they can meet the demand from social prescribing service users. Where appropriate, service users will be supported to develop their own self-sustaining groups or activities.
• Significant long term investment of strategic funds across multiple service areas: local policymakers will view social prescribing as model for strategic commissioning with the voluntary sector and ensure funding is available over a long time period (three years or more) following a successful pilot phase.

Although an example of social prescribing ‘plus’ would not be expected to exhibit all of these characteristics, it should exhibit a number in combination, and include a commitment to resourcing financially both the referral processes through which service users are identified and directed to support, and the services and activities to which they are referred. In areas where social prescribing ‘plus’ has been implemented it has necessitated step change in local commissioning practices that involve the local voluntary and community sector, from ad hoc and piecemeal awarding of grants and short term contracts, to a more strategic approach. An overview of one prominent example of social prescribing ‘plus’ – the Rotherham Social Prescribing Service – is provided in table 2 for illustrative purposes.

Table 2: Social prescribing ‘plus’ in practice: a case study of the Rotherham Social Prescribing Service

Framing social prescribing ‘plus’ from a policy perspective

Social prescribing is variously described as an ‘asset-based approach’ and a ‘social innovation’, but with limited engagement with the theoretical underpinnings of these terms or the processes associated with them. The following sections aim to provide some theoretical substance to the idea of social prescribing ‘plus’, first as an asset-based approach and then as an example of collaborative innovation, before bringing them together in a re-framing of social prescribing ‘plus’ as a model of policy innovation that combines both sets of ideas.

The possibilities and pitfalls of asset-based approaches to health and care

Although social prescribing is an important social policy development in and of itself, its rise to prominence needs to be understood in the context of the wider propagation of ‘asset-based’ approaches to health and care which have emerged in the past 10-15 years as a way of increasing equity in health.  As a discourse it has permeated practice, policy and academia as a critical counterpoint to the (perceived) persistence of deficit-based approaches to health which focus on ‘problems’ that need to be ‘solved’ by health professionals and policymakers (Durie and Wyatt, 2013). The implicit assumption of deficit approaches is that individuals and communities do not have the necessary resources or expertise to address health problems themselves (Warr et al, 2013). In contrast asset-based approaches aim to promote and develop the capabilities and capacities that support good health and well-being whilst ameliorating the symptoms and consequences of poor health (Brooks and Kendall, 2013; Morgan and Zigilo, 2007).  Morgan and Ziglio (2007: 18) describe a health asset as:

“…any factor (or resource), which enhances the ability of individuals, groups, communities, populations, social systems and/or communities to maintain and sustain health and well-being and help to reduce health inequalities. These assets can operate at the level of the individual, group, community and/or population as protective (or promoting) factors to buffer against life’s stresses.”

In essence asset-based approaches seek to redress the balance between meeting the needs of people and communities and nurturing their strengths (assets) in support of better health and well-being (McLean, 2011).

Although the rise to prominence of asset based approaches is evident in international, national and local policy developments (see e.g. WHO, 2012a and 2012b; NHS England, 2014; Department of Health, 2014; NHS North West, 2010) their practical implementation is in its infancy. They have typically been delivered through small projects or pilots rather than large programmes or system wide approaches to implementation. As such, evidence of their efficacy in addressing health inequalities is limited (Hopkins and Rippon, 2015) and very little has been written about the characteristics of a successful asset based approach. An exception is Morgan (2014), who proposed a set of principles against which the practical implementation of asset-based approaches can be assessed. An overview is provided in table 3 along with discussion of the extent to which different approaches to social prescribing meet these criteria. It indicates that whilst much of social prescribing practice mirrors the criteria of effective asset-based working it is social prescribing ‘plus’ that is most closely aligned with the principles Morgan (ibid) proposes.

Table 3: An assessment of social prescribing as an asset-based approach

Source: Adapted from Morgan (2014)

Processes of collaborative innovation

Social prescribing can be described as a ‘social innovation’ in that it is a new idea that both addresses unmet social needs and works effectively to create social value (Mulgan, 2007; see also Dayson, 2017 for a broader discussion of social prescribing as a social innovation through which social value is created). However, to date, there has been little discussion of the processes of social innovation through which social prescribing has been adopted and diffused across the UK. The idea of collaborative innovation is helpful here because it highlights the importance of multi-actor collaboration during the development and implementation of a new policy (Hartley et al, 2013). In particular, it emphasises the involvement of ‘downstream’ actors, including voluntary and community organisations and service users, alongside ‘upstream’ policy stakeholders, in the creation and diffusion of novel and bold solutions to previously intractable and ‘wicked’ problems (Ansell et al, 2017). This requires a genuine commitment to multi-stakeholder involvement throughout the design and implementation of a policy: from understanding problems and challenges; to developing and testing new ideas; and implementing, adapting and diffusing successful approaches (see Sorensen and Torfing, 2015, for a broader discussion).

Proponents of collaborative innovation situate their arguments in a critique of the New Public Management approaches to public administration that have been predominant since the 1990s in many western democracies. Whereas New Public Management advocated quasi-markets through which public services were contracted out and imported other private sector mechanisms such as performance targets and performance related pay (see e.g. Hood, 1991; Osborne and Gaebler, 1992); collaborative innovation and associated New Public Governance approaches (see Osborne, 2006 and 2010 for a broader discussion) emphasise a more collaborative cross-disciplinary and inter-organisational approach focussed on complex (‘wicked’) problems and the development of bold new solutions to meeting them. Advocates of this type of approach argue that they are more likely to produce public innovations that lead to effective, efficient and higher quality services (Sorensen and Torfing, 2015).

Table 4 draws on the case study of the Rotherham Social Prescribing Service to demonstrate the extent to which the development and implementation of social prescribing ‘plus’ exhibited the characteristics of collaborative innovation. This example highlights the extent of the collaborative processes involved in developing and implementing a social prescribing ‘plus’ model. It demonstrates how key actors in the social prescribing service were able to form a coalition of ‘upstream’ and ‘downstream’ actors from the public, voluntary and community sectors to first understand problems and challenges associated with people multiple and complex long term conditions; then develop, test and implement series of new ideas for addressing their needs; before diffusing the approach to other areas of service delivery (mental health) and other parts of the country.

Table 4: Social prescribing ‘plus’ as a process of collaborative innovation: a case study of the Rotherham Social Prescribing Service