“My youngest client is 18 and my oldest client is 93,” says social prescribing co-ordinator Fiona Laffan. “It’s absolutely wonderful; you never know what is going to come in the door.”
Clearly passionate about her job, Laffan’s comments reflect the diversity of social prescribing, which had been gathering momentum in Ireland before the Covid-19 pandemic and is now needed more than ever. It’s a process that involves identifying non-clinical services and activities in the community that are likely to benefit an individual’s wellbeing and health, and then supporting that person to connect with those organisations. It is mainly health professionals who refer people for social prescribing and a link worker will then sit down with the individual to explore what social outlets or services might be a “good fit” for them.
“It’s such a simple concept, but it is so very effective,” says Laffan, who has been doing this work in Co Waterford since 2017. She and a colleague, Nicola Spendlove, both based in the Sacred Heart Family Resource Centre in Waterford, cover the entire city and county between them.
“I have meeting spaces right across the county to make it accessible to as many people as possible,” says Laffan, who works in the primary care centre in Dungarvan three days a week, while Spendlove looks after the city and metropolitan area. They are both very busy and they have seen increased anxiety levels since the start of the pandemic.
“We are getting a lot of referrals from GPs, from mental health services, from WICOP [Waterford Integrated Care of the Older Person] and from various members of the primary care team: physiotherapists, speech and language therapists, dietitians.”
The local sports partnership, men’s and women’s sheds, choirs and art groups are examples of community activities that Laffan suggests to her clients. The “hands-on” nature of this signposting ranges from simply telling somebody what’s on where, to, if necessary, accompanying a person to an activity and staying there with them until they are comfortable.
The time that social prescribers can give people is vital. Laffan, who would always contact a new referral by phone within a week, allows an hour and a half for their first meeting. She expects to meet people six times, on average, before starting to support them to move on.
“GPs don’t have time to sit for an hour with that individual, whereas we do. Giving them time to talk through different things, I think that’s really important. Nine times out of 10 people will thank you for the time you have afforded them.” It is estimated a fifth of GP visits reflect social rather than medical problems, as Dr Aoife Kirk, a member of Irish Doctors for the Environment pointed out in these pages in May in the One Small Change column, when urging all GPs to introduce social prescribing into their practice.
The Palms GP Surgery in Gorey, Co Wexford, did that back in February 2021, when reception manager Jodi Lifely started to work on social prescribing two afternoons a week. She now has three to four new referrals a week from the nurses and doctors there. They may be patients struggling with, say, loneliness, mental health problems or isolation due to caring for a loved one or being new to the neighbourhood.
“They come in and we would have a chat about what’s going on in their life, areas they want to improve. I would ask questions like ‘what did you do years ago that you would have an interest in getting back to?’.” Then they research options together and she encourages them to take the next step, to make a call or send an email to sign up.
“People don’t realise how much is going on in the area, and they don’t know where to start.” After introducing them to an appropriate organisation or service, generally “they will fly when they have made the contact”, says Lifely, who follows up with phone calls to check how they’re faring.
When Laffan started in social prescribing, the majority of people referred to her initially were middle-aged women who had spent the previous two or three decades focusing on children’s needs. After their offspring have flown the nest, women can be left reflecting “what about me?”, she says. “They have forgotten how to socialise and they are not at the school gate any more.”
She saw this scenario so often, “it made me look at my own life — I have two teenagers, I had better start doing something for myself”.
Nowadays, post-pandemic, referrals are right across the age spectrum. Many older people have become socially disconnected and fearful of re-engaging with groups, while there has been a surge in younger people suffering from anxiety.
Elizabeth McGrath, now aged 25, was referred to her at the end of 2019, not long before the start of the pandemic. She was very anxious about her Criminal Justice Studies course at the Waterford Institute of Technology. “I was very down in myself and at the time I wasn’t too keen on therapy,” says McGrath. “I went to the doctor to see if there was any alternatives. He passed me on to social prescribing.”
She had never heard of it but soon found her interactions with Laffan extremely helpful. “I will never forget, she met me in college one day because I was so stressed. She sat down with me for half an hour and calmed me down. I was faced with my end-of-year project and I was freaking out.”
When Covid hit, she stayed in the student accommodation, rather than return home to Graiguenamanagh, Co Kilkenny. “I was mainly on my own down here. It was very difficult.”
But through telling Laffan that she was interested in getting fit, she was introduced to a personal trainer who ran small group sessions in Waterford’s People’s Park every Saturday.
“It was really good and that was the start of my fitness journey,” says Elizabeth, who saw that weightlifting was something she could take up as a hobby. Since then she has been doing workouts at home four times a week.
“You always need that kick-start, that extra motivation,” she says of the support she received from Laffan, who also helped her with her CV and linked her to employment services. Elizabeth graduated in 2021 with a 2:1 honours degree and is currently working on a start-up business with two friends.
“From talking to Fiona, she made me feel like anything is possible. If you can’t get what you want out of life, make it your own way.” After finishing with Laffan, she was ready to move into counselling. Looking back, she doesn’t know how things would have turned out without social prescribing at that crucial juncture in her life.
“I would recommend it to any young person — or older person — who is going through a tough time and needs guidance. You know how some services say they care about people and they never check up. Here they check up on your wellbeing: it was essentially about mental health and how to improve yourself as a person.”
Today, she says, “I am probably in the best shape I have ever been” — fitter and calmer. She feels she is starting a new chapter in her life and is excited about her future.
“I just wish I had known about it earlier. It would have really helped me in my first year of college when I was really struggling.”
Consultant geriatrician Dr David Robinson, who got funding from Sláintecare to set up Ireland’s first hospital-based social prescribing project at St James’s Hospital in Dublin, echoes Laffan’s point about the importance of time.
“I think the most valuable thing any healer, be they a medical healer or reiki practitioner, can give a person is their time. We doctors have been reduced to a point where we are not able to give people time. We can prescribe medicines but we can’t give them time, and that is what people really value.” His patients are all older people and of those he refers to the social prescribing link worker about 40 per cent have dementia.
“From a memory point of view, I want people to be more physically, socially and mentally active” — to reduce the progression of the dementia. “I want them to be engaged in novel activities and things that interest them,” says Robinson, a pioneering force in social prescribing here, after seeing it in action in Chicago and London. He is now co-chair of Social Prescribing Ireland, a 32-county organisation that hosted a conference in Derry last week to celebrate the growth of the practice and to look at how it can continue to expand. His fellow co-chair, Tony Doherty, represents the North and the community sector. At St James’s, older people are being referred to many different kinds of activities, such as guided walks, museums, choirs, musical events and biodiversity tours, says Robinson, who is also associate professor of medical gerontology at Trinity College Dublin. Mercer’s Institute of Successful Ageing at the hospital has its own creative life centre, while the social prescribing project has links to organisations such as ExWell and Siel Bleu, both exercise programmes, the nearby Irish Museum of Modern Art and the National College of Art and Design.
“Across the spectrum, from people who are very well to people who are quite disabled, I have seen people get worse because of the pandemic: physically, cognitively and from a mental health point of view.” A study on the impact of cocooning on the physical and mental health of older people, led by Dr Laura Bailey, a specialist registrar in geriatric medicine at St James’s and published in January 2021, found that almost 40 per cent reported that their mental health was “worse” or “much worse”, while more than 40 per cent reported a decline in their physical health.
While it is easy for a doctor to advise somebody that they need to meet more people or take more exercise, says Robinson, “a link worker will sit down with them and figure out what they are interested in and what’s available locally. They will follow up to make sure the person is engaged.” Social determinants of health, ie non-medical factors that influence health outcomes, are largely to do with a sense of control of your life, he suggests.
“If you haven’t got enough money to pay the rent and fear a landlord may throw you out, or you have got a disease that you fear is overtaking you, you have lost control and you become more stressed. Money is the answer to that for some people but actually going to somebody who has time to listen to you and help connect you with all the different resources makes a huge difference.”
In Waterford, Laffan aims to sign off on her social prescribing clients within three to four months, and they repeat the wellbeing assessments they did at the start to gauge their progress. Some like the “safety net” of knowing that her door is always open and she sums up her approach with a line from the film character Nanny McPhee: “When you need me, but do not want me then I must stay. But when you want me but no longer need me, I have to go.”
-----
Social prescribing in Ireland
Social prescribing has captured policymakers’ imagination, both abroad and here in Ireland, where the Health Service Executive (HSE) last year published a framework for expanding its use in partnership with voluntary and community organisations.
“It’s quite interesting because, in this case, the policy is well ahead of the research,” says Dr Bridget Kiely, a PhD scholar at the Royal College of Surgeons in Ireland who also works one day a week as a GP in Dublin’s north inner city. She is researching the effectiveness of social prescribing for people with multiple, ongoing health conditions.
There are currently 31 HSE-funded social prescribing services across the country, of which 19 are in Sláintecare Healthy Communities, based in areas of disadvantage. The vision is that there will be one social prescribing link worker for each of the 96 Community Healthcare Networks that are planned to deliver primary care, serving a population of 50,000 each.
Although link workers will be employed by community and voluntary organisations through HSE funding, “they should ideally have a physical presence for one to two days a week in a local primary care centre or GP practice”, according to the framework, the development of which was led by Anne Sheridan and Orla Walsh of the Mental Health and Wellbeing Programme. The framework cites research by the University of Westminster that showed average reductions following referrals to social prescribing of 28 per cent in GP services, 24 per cent in attendance at emergency departments and statistically significant drops in referrals to hospital.
Enthusiasm for social prescribing is “coming from a good place: people want to address the challenges with mental health, wellbeing and health inequalities”, says Kiely. However, she warns, they have to be realistic and not get carried away. It doesn’t negate the need for investment in GPs and primary care teams, and also in the wider social determinants of health and wellbeing, such as housing etc.
People living in deprived areas develop multiple chronic conditions at least ten years earlier than those in non-deprived areas. Yet, inevitably, healthcare is least available where it is most needed. North inner city Dublin, for example, has one GP for every 2,500 people, compared with the national average of one per 1,600. However, she believes social prescribing has a role to play, including being “a very effective way of getting GPs thinking more about the wider communities that they are working in and what resources are available out there.”
Kiely has reviewed existing evidence of the effectiveness of social prescribing and has also led the biggest clinical trial so far of its use in the Republic. Involving the recruitment of 240 patients from a number of GP practices in disadvantaged areas, the preliminary findings have shown improvements in wellbeing. They are also looking at patients’ quality of life.
“It does make sense that social prescribing would make more of an impact on general wellbeing than health specifically,” she says. “If we’re trying to work out does social prescribing work, then we have to decide what do we expect it to do, realistically, and how do we decide how we measure that, and who’s involved in deciding how we measure that?”
In the trial, 87 per cent of participants said they would not have connected with a social prescribing link worker without a GP referral. Clearly GPs will have a pivotal role in the expansion of social prescribing, so are they getting behind it?
“In theory — they know that social circumstances have a massive impact on people’s health,” says Kiely. But just as people trust their GPs, the doctors need to be able to trust the link workers they are making referrals to “particularly when it is outside their normal realm of experience, when it’s not an HSE clinical service that they know about.”
“GPs are very conscious of referring their patients into something that will be safe for them, where they will be looked after.” Therefore, building up relationships between GPs and link workers, and between link workers and community resources, is really important.
However, GP practices don’t have to be the only place for referrals, she adds. Social prescribing is about community and the help that’s out there in many different forms.
