When patients shuffle through Natalie Viaux’s medical clinic in Brandenburg, a German city west of Berlin, she has no clue what their health problems are – and that’s by design.
Rather than checking patients’ blood pressure or reviewing their medical charts, Viaux asks about their lives, challenges, and resources.
Her clinic is experimenting with social prescribing, which aims to boost patients’ health by “prescribing” things far outside the medical realm, such as museum visits, sports clubs, and time spent in nature. Social connection and community support are a priority.
“It's valuable, all the modern medicine and what it does, yet with humans, some things can be rather simple,” Viaux, who is also a trained therapist, told Euronews Health.
Here’s how it works: Doctors flag patients grappling with social problems that may be hurting their wellbeing – loneliness, grief, relationship issues, finances, housing, employment, or anything else – and send them to “link workers” like Viaux.
Rather than treating a medical diagnosis, link workers partner with patients to create personalised plans that address the issues holding them back from good health.
The idea is that by helping people get back on their feet – mentally, financially, or physically – they’ll be empowered to take charge of their health, in turn reducing the burden on overstretched medical systems.
“We described it many years ago as focusing on what matters to people, rather than what the matter is with them,” said Dr Sam Everington, a UK-based physician and an early pioneer of the social prescribing movement, which has now spread to more than 30 countries worldwide.
Research indicates social prescribing can help improve people’s mental and physical health, reduce their visits to general practitioners, and boost their motivation and sense of meaning in life.
Now, 22 health centres in eight European countries – Belgium, Croatia, Denmark, Germany, Poland, Portugal, Slovenia, and Spain – are trying social prescribing as part of a research project to identify how well this approach works to improve health for refugees and immigrants, older adults who live alone, and LGBTQ people.
“It's not about privileged persons who would like to have a yoga class,” Dr Wolfram Herrmann, who is leading the five-year project at Charité University Hospital in Berlin, told Euronews Health.
“It's really about people who have social problems, and usually also have mental problems and somatic problems,” he said.
Social services v. social prescriptions
Many programmes already address the so-called social determinants of health, even if they aren’t labeled social prescribing. This includes everything from doctors’ referrals to social or legal services, to “food as medicine” initiatives or unconditional cash transfers for new mothers.
But social prescribing introduces new ideas, like prescription pottery classes or community gardening, that go beyond traditional support services.
Julia Hotz, a US journalist who chronicled social prescribing efforts across the globe for her book, “The Connection Cure,” says the material and social aspects are two sides of the same coin. She views social prescribing as an umbrella term for any initiative to address the non-medical factors that affect our health.
“I think you need them both together,” Hotz told Euronews Health. “A nature prescription or culture prescription is not going to do somebody much good if they're unemployed, struggling to make ends meet, or not eating healthy food”.
“If you think about Maslow's hierarchy of needs, you need those things in order to achieve these sorts of higher delights,” she added. “But on the other hand, ethically, who are we to say” what matters most to an individual person’s wellbeing.
“The most advanced social prescribing communities recognise all of that,” Hotz said.
Link workers are key
In some cases, link workers have helped physicians rethink what might improve patients’ health. When Viaux joined the Brandenburg clinic, doctors initially gave her a list of services, including the Red Cross, a church, and migration support.
But Viaux had some ideas of her own.
“She had a new brochure [that included] many more ideas we didn't even consider,” Dr Benjamin Senst told Euronews Health, such as local clubs, sports leagues, nature, and art.
“This was so eye-opening,” Senst said. It “went beyond the well-established, basic structures of social support, to something broader [that] also addresses certain problems with disease and social diagnosis”.
Having strong link workers, who are sometimes called bridge-builders or community health nurses, appears to be the key to making social prescribing programmes work.
Everington ticked off a list of qualities they should have: emotionally intelligent, creative problem-solvers who go the extra mile to support and motivate people.
“A sign-poster might just say, ‘the swimming pool is there,” Everington told Euronews Health. “A social prescriber will say, ‘well, actually, there's all female sessions.’ Or, ‘by the way, there's lots of people who are very overweight, so don't feel body-shy about going swimming.’ Or, ‘this time of day, the pools are actually empty’”.
“It's actually [about] how you get somebody to go through the door, not just pointing them to the door,” he added.
Viaux worked with one older woman, for example, who had mental health issues and obesity and used a wheelchair. While a doctor might have advised her to work out more, Viaux found her a water exercise programme after she said she wasn’t comfortable attending a tai chi class due to her weight.
She also helped the woman overcome bureaucratic hurdles to get a new wheelchair. Soon after, the woman began leaving her house more often and joined a local card-playing group.
“Once the ball was rolling, she took over,” said Viaux, who works with 40 to 50 patients at a time for a maximum of three months each.
“The beauty of social prescribing, for me, is that we connect [patients] to something existing,” she added. “We use the resources that are already there, which makes it a very cost-effective approach to health”.
Building the evidence base
Yet while advocates say the benefits of social prescribing are clear, they cite a common challenge: proving, conclusively, that it works. It’s also been hard to home in on exactly which programmes are the most effective.
“Oftentimes, people will look at that data and they'll say, ‘Well, this was a small sample size, how do you demonstrate that it was the social prescription, specifically?’” Hotz said.
“I get that from a research perspective,” she added. “But a social prescription will often have all these intangible benefits, like giving us more confidence, getting us out of the house more, [and] helping us to adopt other healthy behaviours”.
Social prescribing also isn’t a silver bullet solution to all of society's ills. As one research team put it, these programmes are “not a quick fix to address problems of inequality and social exclusion in disadvantaged areas”.
That’s exactly what the new research project aims to explore, with nearly nearly €7 million in funding from the European Union. It will run a randomised trial that splits patients into two groups: one that gets social prescribing and one that receives standard care, so researchers can determine what impact the approach has on vulnerable groups.
“There are things which seem to make total sense and [be] very good, but in the end, they do not show positive effects,” Herrmann said. “We would like to see if there are really positive effects,” with the goal of influencing health policy decisions across Europe.
In the meantime, Everington is continuing to push for social prescribing – which the UK government committed to rolling out in primary care clinics nationwide in 2019 – to enter the global mainstream.
He said his London clinic, which runs more than 100 social prescribing projects, hosts thousands of visitors per year, including national health ministers interested in replicating his model.
“We learned very early on that you cannot describe it and get people to understand it by a document,” Everington said. “You actually have to come and taste it, smell it, feel it, and talk to people who are actually doing it”.
His personal enthusiasm may be another selling point.
“We have a cure for a hell of a lot of disease and illness, and it's called social prescribing,” Everington said. “This is the magic medicine that we've been looking for”.
