Growing the evidence base for social prescribing and considering how to embed it in the mental health claims process could offer a significant opportunity for insurers. Actuaries Digital Editor Melissa Yeoh reflects on this, sharing a recent article on social prescribing, by Professor Katherine Boydell from the Black Dog Institute.
The Actuaries Institute’s 2017 Green Paper on Mental Health and Insurance highlighted prevalence in the community: that one in five Australians aged over 15 will be affected with a mental health condition in any 12-month period.
One suggested area of improvement is to increase focus on early treatment and recovery. The paper quotes leading mental health advocacy group Beyond Blue who says:
“to maximise their ability to proactively manage their mental health, people need to be able to engage with socially inclusive networks and have access to social institutions which provide equitable access and a safe space for disclosure”.
This leads us to explore the concept of social prescribing, where GPs, nurses and other primary care professionals refer people to a range of local, non-clinical support. The concept of social prescribing recognises that people’s health is determined primarily by a range of social, economic and environmental factors and seeks to address people’s needs in a holistic way.
In the article below, Professor Katherine Boydell from the Black Dog Institute discusses social prescribing, including evidence of its benefits from various studies.
This is not an entirely new concept in Australia with many GPs already undertaking this in some ad-hoc form and some insurers already recognising the potential benefits e.g. iCare who ran an 18-month social prescribing trial in June 2017.
An opportunity remains for more insurers to consider and embed the concept of social prescribing in their early intervention and rehabilitation initiatives for mental health claims.
Social Prescribing: linking patient with non-medical support
Here are some recent headlines from the popular press:
- “Why your doctor may be prescribing art classes in the future”
- “How creativity on prescription can improve mental and physical health”
- “Combat loneliness with social prescribing”
- “Why social prescribing is the latest drug-free trend”
- “The arts are a shadow health service”.
These headlines indicate that our current health and wellbeing is reliant on far more than what medicine and psychology can provide.
Research indicates that we tend to underestimate the relevance of social factors such as loneliness and social isolation, and other social, economic and environmental determinants of health. For example, a recent meta-analysis showed that social isolation is associated with an overwhelming 29% increase in mortality, and there is evidence to suggest that 20% of all GP visits are for social issues primarily.
Social prescribing (sometimes referred to as non-medical prescribing or community referral) is a relatively new concept, developed as an innovative way to move beyond the medical model and to address the wider social determinants of health. Social prescribing enables GPs and allied health care professionals to refer patients, whose health or mental health is affected by non-medical factors such as housing, financial stress, health literacy, loneliness or social exclusion, to a range of community services that can deal with these issues.
Social determinants of health — the conditions into which we are born alongside the broader set of forces and systems shaping the conditions of our daily life — are the cause of many health inequalities. Non-medical factors have a widespread effect on our overall physical and mental health. For example, individuals who are less affluent and less educated have more health problems and die earlier than those who are more affluent and more educated.
Social prescribing involves the creation of referral pathways to the “third sector” (local non-clinical voluntary services and community groups) link worker in order to codesign a non-clinical social prescription to improve their health and wellbeing. Link workers (community development worker, wellbeing coordinator, social prescribing coordinator) holds detailed knowledge of local organisations, services and supports to ensure appropriate signposting for individuals and facilitate access.
Some examples of the groups and services used by social prescribing schemes include luncheon clubs; walking and reading groups; literacy classes; support with housing, employment, debt and legal advice; gardening groups; cooking classes; exercise programs; and arts and creative activities.
The social prescription should be an activity that is in keeping with the individual’s interests in order to enhance its benefits and individual adherence to it. These activities can then be combined with appropriate medical treatment (if required) to optimise chances of recovery wellbeing and quality of life.
A number of models of social prescribing have been described. While there is no commonly agreed upon best model, these models range from low to high intensity and from limited to full patient or client engagement. The low intensity model offers information only, such as a brochure in a GP office and no patient engagement. The next level of intensity involves direct referral with a GP or allied health professional referring a patient to a community activity or program. The most intense model is known as “referral social prescribing”, in which there is a link between the social prescriber role with mixed face-to-face and telephone interactions, an in-depth coaching service and a wide range of services offered.
What does the evidence tell us about the effectiveness of social prescribing?
There is emerging evidence that social prescribing has the potential to result in an array of positive health and wellbeing outcomes including increases in self-esteem and confidence, a sense of control and empowerment, improvements in psychological or mental wellbeing, and positive mood linked to decreases in symptoms of anxiety and depression. A recent systematic review of social prescribing schemes in the UK reported increased self-esteem and confidence, improved mental wellbeing and positive mood, improvement in physical health and lifestyle, increased social connectedness, reduced social isolation and loneliness, and reduced anxiety, depression and negative mood. Bickerdike and colleagues analysed 15 evaluations and reported that, although all studies showed improvements in health and wellbeing, there was a lack of evidence beyond six months.
There was only one randomised controlled trial reviewed, but it focused on four-month follow-up only and there was some lack of clarity regarding whether it represented social prescribing. Using a mixed methods analysis, Woodall and colleagues found improvements in wellbeing and perceived levels of health and social connectedness as well as reductions in anxiety. In many cases, the social prescribing service enabled individuals to have a more positive and optimistic view of their life.
In general, social prescribing schemes appear to result in high levels of satisfaction on the part of participants, primary care professionals and commissioners. In spite of this, systematic and rigorous evidence of effectiveness is fairly limited and more sophisticated designs are needed to provide further rigour. Many studies are small in scale and focus on process rather than outcome. Much evidence is based on self-reported outcomes and often lack comparative data. However, as Woodall and colleagues have noted, relying on the randomised controlled trial to assess social prescribing effectiveness is not only challenging, but has moral and ethical implications — primarily precluding clients from accessing voluntary and community services to improve their health.
There is now an imperative to develop research programs aligned with implementation of social prescribing that are longitudinal and that combine process and outcomes-focused mixed methods evaluations with embedded randomised controlled trials. This will produce empirical evidence regarding our understanding of who can benefit from which interventions in which contexts and enhance our understanding of patients’ unique interactions with referring service providers, link workers and community supports in the broad array of social interventions available.
Social prescribing represents an approach to public health that has the potential to address the health and social needs of individuals and communities. It offers a significant opportunity to focus on biopsychosocial and environmental models of illness that move beyond traditional biomedical models, to make efficient and effective use of the voluntary and community sectors.
Given the influx of funds to support social prescribing, particularly in the UK, we must ensure a concomitant evidence base. Such an evidence base can elucidate the potential of this scheme to move us beyond clinical options, enriching the capacity of the community to respond to the biopsychosocial and environmental aspects of our daily lives.
There is no denying that social health plays an important role in our overall health and wellbeing. Individuals who experience an injury or illness and are unable to work often also lose their social networks, and this isolation increases their risk of experiencing a mental health condition as a secondary condition. While many insurers now offer return to work and rehabilitation programs, not many would extend to social prescribing.
Emerging evidence would suggest that social prescribing may reduce the prevalence of mental health conditions and insurers should consider how this can be embedded as part of their claims management. Actuaries can play a role by demonstrating the value from various types of social interventions to help inform the development of a social prescribing program that creates the most value for insurer, claimant and the community.
 Actuaries Institute, Mental Health and Insurance Green Paper, October 2017
 The King’s Fund, What is social prescribing?, https://www.kingsfund.org.uk/publications/social-prescribing#what-is-it
 icare, From Isolated to Involved, https://www.icare.nsw.gov.au/news-and-stories/from-isolated-to-involved/#gref
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