R.E. presents to her family physician with several concerns. She has high blood pressure and illness suggestive of generalized anxiety disorder with depressed mood. R.E.’s family physician understands that R.E. is a sole parent for 3 young children: “I wish I could get out of the house or book an hour for talk therapy, but it is just not feasible for me.” In addition to trying medication, they decide to connect R.E. to a local link worker. The link worker is able to help R.E. organize municipally subsidized child care and provide a social prescription to a parent exercise group co-located with the child care centre, thereby also finding time for talk therapy. Through a social prescription that addresses R.E.’s social needs, R.E. is able to take part in a care plan that allows for a comprehensive approach to her multiple medical issues.
The social determinants of health represent a paradox in family practice. On one hand, family doctors have the ability to understand how a person’s social context affects that person’s health.1 R.E.’s family doctor, for instance, identified lack of child care as an obstacle to R.E.’s treatment for hypertension and anxiety. However, despite awareness and appreciation of social context, there are barriers to addressing the social determinants of health and relevant social needs in primary care. Medical training and guidelines are often reductionist and disease specific.2 In both prevention and treatment, the biomedical model is focused on proximal causes, such as comorbidity and lifestyle, rather than fundamental causes, which are often social.1 Many in our professional communities feel underprepared and unsupported in addressing social needs,3 while others argue that social determinants of health are beyond the scope of primary care.4
Social care for social needs
Nonetheless, a routine day in primary care is enough to intuitively understand the importance of social context in the treatment of medical illness.5 The social determinants of health are not a new concept—in fact, we understand that they contribute to 80% of health and well-being.6-8 On a population level, modest increases in spending on social services in Canada have been associated with decreased mortality.9 On an individual level, social conditions are fundamental causes for medical illnesses that present in primary care, and social needs are the downstream manifestations of these social conditions.1 By connecting people with social care, social prescriptions are a culture shift away from the medicalization of social needs.10 This realization has influenced the United Kingdom’s National Health Service, for example. It plans to make available a thousand new social prescribing link workers to family practices by 2021, with the goal to connect at least 900 000 people with a social prescription by 2024.10,11 Limiting primary care to medical needs for medical illnesses, therefore, represents a missed opportunity for addressing the fundamental causes of illness.1
In the article that follows, we promote social prescribing as an optimistic way forward. Associate Scientific Editor of Canadian Family Physician Dr Roger Ladouceur recently wrote about an aspirational state in family medicine, where family doctors might “prescribe happiness” as easily as they could prescribe a medication.12 Unlike diabetes or asthma, concepts like happiness, early childhood development, and social inclusion might seem difficult to address in a clinical setting. However, current models of social prescribing are both practical and effective.13,14 Screening, referrals, and supports for social needs approach clinical aspirations around the social determinants of health at the individual level.
Social prescribing empowers clinicians to connect people to community supports that have been shown to improve health and well-being.14 Under the umbrella of social prescribing is a group of interventions that are person centred and evidence based.15 In our age of complexity and chronicity, social prescribing has the potential to transform the way we practise family medicine. Social prescribing allows nonmedical treatment options for the myriad primary care illnesses influenced by social context. We suggest 3 fundamental values that facilitate clinical discussions pertaining to social prescribing.
Fundamental values
Social prescriptions should emerge from the foundational relationships family doctors develop with people and communities
People: Social prescriptions can be natural consequences of the mutual trust, understanding, and respect family physicians already build in recurrent clinical encounters. These relationships can influence beliefs, receptivity, and expectations around a social prescription—all factors that affect the success of social prescribing programs.16
Communities: Family physicians often have strong links with their communities and local health systems.17 These relationships vary depending on context. Physicians in team-based models might have more intrinsic supports available (in Ontario, these models include community health centres, family health organizations, and family health teams; in Alberta, examples of these models include the Crowfoot Village Family Practice and the Taber Clinic). Virtual, telephone-based, or off-site supports might also serve as a high-value gateway toward social prescription regardless of practice setting.18 In other communities, supports might include municipalities, public health departments, local hospitals, the Royal Canadian Legion, or Canada 211 (accessible by dialing 211 or online at 211.ca).
Social prescriptions should build on the strengths of the recipient and the clinician
Individual strengths: The biomedical model focuses on disease and deficiency.2 Social prescriptions, on the other hand, can focus on strengths and build on what matters to patients.11 In fact, they are often an opportunity for individuals to contribute to their community. For example, a social prescription for a meaningful volunteer program in a newly retired older adult might add purpose, benefit the community, and prevent social isolation. Table 1 provides examples of such programs. Such programs might also stave off depression, preserve cognition, and reduce chronic pain.19 Therefore, a single strengths-based social prescription has the potential to benefit the recipient in several ways and to benefit many others.
Examples of social prescriptions in Canadian communities
Clinician strengths: Family doctors are specialists in person-centred primary care. A family doctor’s understanding of an individual can direct him or her in introducing a social prescription. In many contexts, physicians might explore and introduce social prescriptions themselves. In other contexts, physicians could refer to a local professional or organization that is better equipped or has more time to explore and support a social prescription. When supported by a team (eg, with the referrals in Table 2), a family doctor’s strength in the context of a social prescription might be in screening for this need and in expanding the circle of care to a system navigator or a link worker, whose role is to co-design a social prescription with the recipient.11 However they happen, social prescriptions can connect recipients with social care in their communities. In creating a pathway for family physicians to integrate with community assets, a social prescription allows for a shift toward demedicalization of social needs.
Examples of possible referrals to initiate an appropriate social prescription
Social prescriptions should involve tracking and follow-through
Tracking: Social prescriptions should continue to be tracked, measured, and evaluated. Social resources have existed for decades, but current programs incorporate nuance in evaluating uptake, health improvements, and effects on systems.9,13,14
Follow-through: Unfortunately, not all social prescriptions or referral programs are universally available to clinicians. In light of these discrepancies, a referral to a telephone number or website with no clear follow-through can worsen distress in people seeking our help. Family physicians should therefore be knowledgeable of the social prescribing referrals available in their communities and should ensure short-term follow-up to evaluate whether the referral was effective.
Social prescriptions are interventions that seek to address social needs. They have the potential to bring happiness and purpose, but also community connection, good nutrition, sustainable exercise, and benefits in other domains of health and well-being. Policy makers and systems advocates should support family doctors in expanding access to in-person or virtual teams, dedicated community navigators or link workers, and other high-quality referrals to social and community services. In turn, family physicians can be informed by their relationships with people and communities to introduce strengths-based social prescriptions. In light of the potential effects of addressing social needs, we challenge family physicians nationwide to more formally and systematically incorporate social prescribing into their daily work (Table 3).20-23 We welcome local examples, anecdotes, and discussion—to comment on this article, open it at www.cfp.ca and click on the eLetters tab.
ALF (assess, link, follow-up) social prescribing challenge
Conclusion
There is a need for new and effective interventions that address social needs in primary care and, in doing so, reduce the effect of social context on health. Social prescribing is dependent on healthy public policy, investment in community and social services, and high-quality clinical care.10 Social prescriptions can bridge these disparate systems14 and change the lives of people in our practices for whom social context influences their health. For further details, we encourage readers to view the frameworks shared by the United Kingdom’s National Health Service or Ontario’s Alliance for Healthier Communities.11,24 Social prescriptions can realize our aspirations to address social needs, achieve health equity, and transform how we practise person-centred primary care. Family physicians are ideally placed to model high-quality social prescribing and thus lead the way for a healthier Canada.
Acknowledgment
We thank the reviewers who helped strengthen our article with their feedback, including Sonia Hsiung for sharing example social prescriptions, and Dr Pauline Pariser and Natasha Sheikhan for their thoughtful comments.
Footnotes
Competing interests
Dr Nowak has no competing interests to declare. Dr Mulligan works with the Alliance for Healthier Communities, an organization that received funding from the Ontario Ministry of Health to conduct a social prescribing pilot project.
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
Cet article se trouve aussi en français la page 96.
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