1. Social Precribing
Developing effective interventions in the Primary Care
environment based on health and socioeconomic need.
A Therapeutic Model

2. What is Social Prescribing?
Social prescribing has been quite widely used for people with
mild to moderate mental health problems, and has shown a
range of positive outcomes, including emotional, cognitive and
social benefits. Social prescribing may also be a route to
reducing social exclusion, both for disadvantaged, isolated and
vulnerable populations in general, and for people with
enduring mental health problems (Bates 2002; Gask et al.
2000).

3. What are the advantages?
Reduction in need for clinical or secondary care
Reduced need for prescriptive intervention
Develops patient autonomy
Increases awareness of alternative care pathways using
non-clinical approaches
Acknowledges patients socioeconomic and comorbid
health needs

4. When to prescribe?
We all use assessment material to measure an individuals
mental well being, PHQ 9 for example. But what other
information lies beyond the numbers that are generated?
Are we taking into account other factors that are
impacting on their lives? Do we have the time? Do we
have the skills to address these other factors, provide
relevant information or know where to sign post them?
Social Prescribing finds the issues that are underpinning
and reinforcing these problems and finds non clinical
pathways to address them.

5. Based on a US model of delivery
Health Leads is part of the clinic team.
With Health Leads, doctors, nurses, and social workers can focus
on the complex clinical issues that they are uniquely trained to
address. By providing an alternative workforce to connect
patients with basic resources, Health Leads enables providers to
deliver comprehensive patient care. In the States the model
combines a paid worker who serves as the Social Prescribing
Coordinator with a team of volunteers who are able to buddy
with clients to guide them through alternative service pathways
and support their individual or family needs.

6. Health Leads – ‘The Health Leads model had a positive impact on reducing
unmet social needs for low-income families. This innovative multidisciplinary teambased model was able to connect the medical home with community-based resources,
often a daunting task within the current primary care model’
Legal
Utilities
Food
Employment
Education
Housing
Benefits

7. Delivery
Model
Patient
presents in
primary care
setting
Provider
screens for
needs using
PHQ 9
Post service
review and
primary care
update
Patient
presents to
Health Leads
Desk
Follow up by
Social
Prescriber or
Advocate or
Administrator
Information
moved to
central
administration
Social
Prescriber
provides
education and
information

8. One to one
therapy
PHQ 9 increase
–potential
referral into
secondary
services i.e.IAPT
Triage to
address
socioeconomic
problems
Social
Prescription
Home IT
Anxiety
Program
Motivation
Group Therapy
Reassessed for
Family
Therapy
Condition
Specific
Group

9. Future of Social Prescribing Service
Client
Diary
Therapy
Tools to
access in
the home
Psychoeducation
Tools to
download
iCloud
Central
System
Access to
assessment
material
Email
exchange
& contact
facility
Client
Notes
Central
Booking
System

10. What do US Physicians think?
4 out 5 of 1000 surveyed (690 from primary care 310 pediatricians)
agreed with the following statements with regard to social prescribing;
Unmet resource needs lead to worse health outcomes
Are not confident in their capacity to address their patients needs
Say that patients social needs are as important as their medical
conditions. This is especially true for physicians (95%) serving
patients in low-income urban communities
Does the US model reflect UK need and the experience of clinicians
working in the primary and secondary sector?

11. What would Social Prescription look like in the primary
care setting?
If the practice is committed to enabling social prescription throughout the
patients primary care experience then this has to permeate through each tier
of the primary care model. Dissemination of information and training of
staff is key to enable sign posting of patients prior to referral to a clinician.
The voluntary sector model of the use of volunteers to provide much of the
service will be key; not only economically but this will enable individuals
and families to navigate an often confusing system of health and
socioeconomic care system without the intervention of traditional costly
secondary services.

12. Conclusion
It is clear that there is a growing need to provide a service which
addresses the issues that are not evident within the clinical
diagnostic environment yet are having a profound impact on
individuals and families lives. It is also clear that clinicians time
can be used more effectively if these non-clinical issues are met
within primary care and support physicians to meet the complex
demands that they are faced with.
Social Prescribing can provide the evidence based effective
service that meets the growing socioeconomic burden people are
faced with each day of their lives. It is not a vehicle to relinquish
personal responsibility when met with hardship; it recognizes
that people need to be able to connect with services that improve
well being and compliment clinical delivery and this burden of
need has to be shouldered by all of those throughout the public,
private and voluntary sector tasked with the provision of care.