Everington, S

Marshall, M

Roland, M

English

UCL Discovery

Perspective The NEW ENGLAND JOURNAL of MEDICINEJuly 9, 2020n engl j med 383;2 nejm.org July 9, 2020 97To many physicians who see patients with ill-nesses that are strongly influenced by social circumstances, socially oriented interventions make sense. The ideas behind such interventions are not new — community-ori-ented primary care in the United States has always had a strong fo-cus on social rather than medical interventions, and the Centers for Medicare and Medicaid Services’ Accountable Health Communities model addresses the health-related social needs of Medicare and Med-icaid beneficiaries with a goal of reducing health care costs and utilization. The United Kingdom is now aiming to make similar nonmedical interventions main-stream. As part of a National Health Service (NHS) program, all primary care physicians in Eng-land will have access to a “link worker” to support so-called so-cial prescribing, and an organiza-tion is being established to guide the training of such workers, mon-itor the availability of social-pre-scribing services on the ground, and ensure that these services are evaluated.1 The NHS plans to recruit 1000 social-prescribing link workers over the next 2 years and additional workers in subsequent years. The goal is for nearly 1 mil-lion patients to have been referred for social-prescribing interventions by 2024.Considerable claims have been made regarding the benefits of social prescribing, including that it reduces utilization of primary and secondary care, reduces rates of emergency department visits, and improves physical and mental health outcomes. Although more research is needed to substantiate these claims, we believe that so-cial prescribing has the potential to address the fixation by both physicians and patients on tests and prescriptions that may bear little relation to the cause of a patient’s problem.Many patients present to their primary care physician with a concern that is either nonmedi-cal or strongly related to the pa-tient’s socioeconomic circum-stances. Even when there is a clear diagnosis, the most effective in-terventions may not be medical ones. Nevertheless, physicians are drawn to medical interventions, including prescribing drugs rec-ommended by the plethora of dis-ease-specific guidelines that have been developed over the past 20 years. Doctors are increasingly being criticized, however, for “overmedicalizing” health prob-lems — a tendency that has led to a growing number of hospital admissions related to adverse ef-fects of medications. The opioid crisis is perhaps the most striking example of overmedicalization. Social Prescribing — Transforming the Relationship  between Physicians and Their PatientsMartin Roland, D.M., Sam Everington, M.B., B.S., and Martin Marshall, M.D. Social PrescribingThe New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on January 2, 2021. For personal use only. No other uses without permission.  Copyright © 2020 Massachusetts Medical Society. All rights reserved. PERSPECTIVE98Social Prescribingn engl j med 383;2 nejm.org July 9, 2020Such critiques lie at the heart of the Choosing Wisely and Too Much Medicine campaigns in the United States and United King-dom, respectively, which seek to promote conversations between patients and clinicians that will help reduce the number of un-necessary tests, procedures, and prescriptions.Alternative approaches recog-nize that lifestyle changes could help alleviate many problems and that there are frequently resourc-es available in the community, many of which will encourage changes in health behaviors that can help patients manage their conditions. Physicians are often unaware of these resources, how-ever, or don’t know how to con-nect patients with them. The con-cept of social prescribing entails educating physicians about social interventions, providing guidance on local resources, and permitting them to “prescribe” social inter-ventions for patients. Social inter-ventions in the United Kingdom may be funded by charities, private business, or, on occasion, by the NHS or local authorities. Social-prescribing programs have gen-erally focused on elderly people, people with mental health prob-lems, and those living in socioeco-nomically deprived communities.Some of these interventions have a clear biomedical intent — for example, exercise and weight-reduction programs to reduce de-pendence on medication among people with diabetes (see box). But social prescribing has a wid-er purpose. It’s also about cul-ture change — challenging the propensity to medicalize health and professionalize health care. And it’s about changing the ex-pectations of patients (and their physicians) that a drug will solve their problems by empowering patients to invest in their own health. Patients from poor com-munities and those with low health literacy may particularly benefit from improved access to community resources.There are many types of social interventions, and outcomes mea-sured in assessments of social prescribing range widely, from health care utilization and health-related quality of life to patient and physician satisfaction. Never-theless, published evaluations have identified some common out-comes of these interventions. Perhaps most striking are the strongly positive qualitative eval-uations given by patients and physicians. Claims of benefits in terms of quantitative outcomes (such as health care utilization) are harder to evaluate because many studies are small, lack con-trols, and are of poor quality. Al-though systematic reviews have found that many published stud-ies of social interventions report some positive outcomes, the poor quality of such studies led one group of reviewers to conclude that “current evidence fails to pro-vide sufficient detail to judge ei-ther success or value for money.”2,3We believe that the NHS should take advantage of its large-scale experiment in social prescribing to carry out research on which patients are most likely to bene-fit from social interventions and which interventions are most like-ly to be effective for both physi-cal and mental health problems. It will also be important to learn how best to avoid the risk of social prescribing’s becoming a “tick-box” exercise, rather than an ap-proach that genuinely engages with a patient’s needs, and to elu-cidate the role of social-prescrib-ing link workers in supporting these interventions.4 Payers will want to know the costs and ben-efits of such programs, and eval-uations also need to consider the possible adverse effects of social interventions that might divert pa-tients from more effective inter-ventions. Some programs may be ineffective simply because of lack of community resources. As one commentator put it, “Just as a doc-tor’s prescription can only improve health if the patient has access to a well stocked pharmacy, so social prescribing schemes depend on a well stocked community.”5Questions have been posed about whether social prescribing is an appropriate activity for phy-sicians, many of whom already have unmanageable workloads, and whether it runs the risk of fur-ther medicalizing problems whose solutions should be outside the sphere of medicine. Our view is that social prescribing is appropri-ate and important. All physicians should have learned about social determinants of health and bio-psychosocial models of illness during medical school. Such ed-ucation, however, seems to have had little effect on their propen-sity to reach for the prescription pad to address problems that are not fundamentally amenable to medical therapy.Patients will continue to pre-Examples of Social Interventions.Gym or exercise classes or groupsWeight-management and nutrition interventionsArt-based therapiesEmployment or volunteer opportuni-tiesSelf-help groups for specific condi-tionsParenting programsAdvice services (e.g., for welfare enti-tlements, housing, or debt)Community activities, including gar-dening, cooking, sports, and be-friendingThe New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on January 2, 2021. For personal use only. No other uses without permission.  Copyright © 2020 Massachusetts Medical Society. All rights reserved. PERSPECTIVE99Social Prescribingn engl j med 383;2 nejm.org July 9, 2020sent with problems that are pure-ly medical, purely social, or (for a large group in the middle) caused by a mixture of medical and so-cial factors. The aim of social pre-scribing is to give physicians ac-cess to interventions that should reduce unnecessary prescriptions and referrals and encourage pa-tients to take responsibility for their health by giv-ing them the capac-ity and opportunity to use their personal resources and those in their families and communities. Social interventions could also reduce disparities in health — particularly interven-tions that focus on socially dis-advantaged communities where patients’ medical problems are es-pecially likely to be compound-ed by social difficulties.Social prescribing has the po-tential to change the consultation in ways that have profound impli-cations for medical practice and medical education, but physicians need reliable information on what interventions work best and for whom and how social prescrip-tions can best be integrated into conventional medical practice.Disclosure forms provided by the au-thors are available at NEJM.org.From the University of Cambridge, Cam-bridge (M.R.), and the Bromley by Bow Health Centre (S.E.) and the Royal College of General Practitioners (M.M.), London — all in the United Kingdom. 1. NHS England. Social prescribing and community-based support: summary guide. January 31, 2019 (https://www .england .nhs .uk/ wp - content/ uploads/ 2019/ 01/ social - prescribing - community - based - support - summary - guide .pdf).2. Bickerdike L, Booth A, Wilson PM, Far-ley K, Wright K. Social prescribing: less rhetoric and more reality — a systematic review of the evidence. BMJ Open 2017; 7(4): e013384.3. Chatterjee HJ, Camic PM, Lockyer BL, Thomson LJM. Non-clinical community in-terventions: a systematised review of social prescribing schemes. Arts Health 2018; 10: 97-123.4. Moffatt S, Steer M, Lawson S, Penn L, O’Brien N. Link Worker social prescribing to improve health and well-being for people with long-term conditions: qualitative study of service user perceptions. BMJ Open 2017; 7(7): e015203.5. McNally L. Tackling loneliness with a well stocked community. BMJ 2018; 362: k2953.DOI: 10.1056/NEJMp1917060Copyright © 2020 Massachusetts Medical Society.Social PrescribingEnsuring Choice for People with Kidney FailureEnsuring Choice for People with Kidney Failure — Dialysis, Supportive Care, and HopeKamyar Kalantar-Zadeh, M.D., M.P.H., Ph.D., Aaron Wightman, M.D., and Solomon Liao, M.D. Each year in the United States, approximately 120,000 peo-ple with kidney failure choose to start dialysis therapy — an ardu-ous, life-sustaining treatment — and more than half a million pa-tients already receiving dialysis continue their treatment. More than 80% of these patients re-ceive hemodialysis therapy three times per week in an outpatient dialysis clinic, which involves fre-quent travel that can be particu-larly challenging for elderly peo-ple and frail patients with unstable conditions. Because of the lack of kidneys available for transplanta-tion, less than 5% of patients who have been receiving dialysis under-go transplantation each year.1In a July 2019 executive order, President Donald Trump called for increased utilization of home dialysis and kidney transplanta-tion; moreover, the Department of Health and Human Services hopes to achieve a 25% reduction in the incidence of end-stage kidney dis-ease by 2030. Many potentially beneficial changes could come out of this executive order, in-cluding the expansion of conser-vative and preservative manage-ment of chronic kidney disease (CKD) without dialysis and more effective symptom management (see diagram). There is also an emerging perception among phy-sicians and other experts that pal-liative and supportive care with-out renal replacement therapy may be increasingly leveraged for many current and prospective di-alysis recipients.Dialysis treatment prolongs life, but it can be burdensome for pa-tients and their care partners. It has physical, psychosocial, and financial impacts similar to those of chemotherapy for advanced can-cer, and patients starting dialysis will live an average of less than 5 years more. Given these bur-dens, palliative medicine special-ists may be engaged in providing guidance for current and prospec-tive dialysis recipients and their caregivers. Supportive care can address symptoms such as pain, fatigue, anxiety, and depression and can promote understanding of prognosis, discussions about goals of care, advance care plan-ning, and consideration of com-passionate, conservative care.However, involvement of pal-            An audio interview with Dr. Roland is available at NEJM.org The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on January 2, 2021. For personal use only. No other uses without permission.  Copyright © 2020 Massachusetts Medical Society. All rights reserved. 

Social Prescribing - Transforming the Relationship between Physicians and Their Patients

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