Can data-driven social prescribing reduce demand?

On National Social Prescribing Day, Charlotte Osborn-Forde, chief executive of the National Academy for Social Prescribing, joins Pulse PCN’s bank of expert columnists and shares her thoughts on the role they can play in population health. Social prescribing link workers are the third most popular profession hired via ARRS with more than 2,700 employed by PCNs

Social prescribing has rapidly evolved since 2019, when funding was first made available via the ARRS for Social Prescribing Link Workers. It was originally developed as a responsive service, reliant on referrals from GPs and other practice staff for patients with ‘non-medical’ needs – often related to problems with finances, debt or housing, loneliness and isolation, and other complex social factors.

In the last few years, however, many PCNs have explored how social prescribing can be utilised intelligently to address particular population health concerns or focus on specific patient groups. This was encouraged by NHS England in 2022, with the introduction of a requirement in the Network Contract Directed Enhanced Service (DES) on Proactive Social Prescribing, which asked PCNs to identify and support specific cohorts.

PCNs have done this in different ways, and we have seen excellent examples of how population health management can be to identify and support patients. There is also now a growing body of evidence and good practice demonstrating how social prescribing can support people with long-term conditions.

Recognising the social and economic impact of long-term sickness on working age adults, some PCNs have used data from sick notes to identify people who could most benefit from social prescribing to support a return to work.

We worked with the National Association of Primary Care to analyse data from a PCN with more than 40,000 patients. This revealed that 24% of patients had received at least one sick note (MED3), 6% in the previous year, and that 2% had received 15 or more.

People who had frequently received sick notes clearly had significantly higher physical and mental health needs than the general population. The data from the PCN we analysed also showed the interconnection between a range of social and physical factors and the likelihood of absence from work.

Frequent sick note users were twice as likely to live in deprived areas, had twice the level of social need, and tended to have worse diets. They were seven times more likely to experience chronic pain, and had reported back, neck or chest pain to their GP four times more often than the general population.

They were more than twice as likely to smoke, and far more likely to have asthma or COPD, with asthma control 10% worse than the general population. On average, they had a BMI 16% higher than the population average, were significantly more likely to have diabetes and hypertension.

These patients were five times more likely to have depression and six times more likely to experience anxiety than the general population. As you would expect, they had high levels of clinical demand, requiring four times as many repeat prescriptions, four times more GP appointments, three times more referrals, and four times more hospital admissions.

This data suggested that the reasons people were absent from work were complex and multifaceted. Most people cited a single reason, but there were often multiple, interconnected physical, mental and social factors at play. A medical response that focuses on specific presenting symptoms could easily miss the wider context.

Social prescribing is a promising response because it can directly address the two key causes of absence from work – chronic pain and mental health – but also because it encourages a holistic, whole-person approach.

Results from Gladstone Medical Centre in North London – a practice with 9,753 patients – show the potential impact. The 630 people who were supported by Social Prescribing Link Workers saw 29% fewer sick notes, 50% less chronic pain, and 82% fewer cases of anxiety or depression, while a control group saw increases of 30%, 82%, and 58% respectively. Some improvements may have happened naturally, but the large differences suggest social prescribing is making a real impact.

Our previous research has shown how social prescribing can reduce demand on health services and save costs. Using data to target specific cohorts through social prescribing – alongside group-based and digital approaches – can be particularly effective. A growing evidence base suggests that is an impactful and cost-effective way for PCNs to achieve better patient and population health.

For more information, visit www.socialprescribingacademy.org.uk