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Welcome to this Padlet of resources for social prescribing and drivers for change.
This will help with Learning Outcomes:

2  Show evidence of reasoned discussion and analysis through critical appraisal of appropriate evidence.

3  Critically discuss application to innovation and/or research in contemporary nursing practice within chosen field.

NMC Platform :

Promoting health and preventing ill health

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Well-being exists in two dimensions, subjective and objective. It comprises an individual’s experience of their life as well as a comparison of life circumstances with social norms and values

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•Medical Model (Biomedical Model)

•Social Model

•Psychological Models

•Biopsychosocial Model

•Personalised Care

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https://youtu.be/4K5fbQ1-zps

This highlights inequalities and life chances even before people have begun.

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Social Inequalities Explained in a $100 Race - Please Watch to the End. Thanks.

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https://fingertips.phe.org.uk/profile/health-profiles/data#page/1/gid/1938132701/pat/6/ati/202/are/E06000009/iid/90366/age/1/sex/1/cat/-1/ctp/-1/yrr/3/cid/4/tbm/1

https://fingertips.phe.org.uk/static-reports/health-profiles/2019/E06000009.html?area-name=Blackpool

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Office for Health Improvement and Disparities (OHID)

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Local Authority Health Profiles - Data - OHID

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An overview of health for each local authority in England.

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https://fingertips.phe.org.uk/profile/health-profiles/data#page/1/gid/1938132701/pat/6/ati/202/are/E08000010/iid/90366/age/1/sex/1/cat/-1/ctp/-1/yrr/3/cid/4/tbm/1

https://fingertips.phe.org.uk/static-reports/health-profiles/2019/E08000010.html?area-name=Wigan

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Office for Health Improvement and Disparities (OHID)

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Local Authority Health Profiles - Data - OHID

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An overview of health for each local authority in England.

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https://fingertips.phe.org.uk/static-reports/health-profiles/2019/E07000119.html?area-name=Fylde

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Office for Health Improvement and Disparities (OHID)

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Local Authority Health Profiles - Data - OHID

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An overview of health for each local authority in England.

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https://www.youtube.com/watch?v=Zr1yKowQlcg

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Zoe Williams: The future for general practice using social prescribing

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https://www.youtube.com/watch?v=0lVnN_eZk8k&t=147s

Jennifer describing SP in action

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Social Prescribing and the Power of Change | Jennifer Neff | TEDxStormontSalon

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https://www.youtube.com/watch?v=RmgkN-FNPEg&list=TLPQMTUwODIwMjKpcGW2xOKWKQ&index=2

quick explanation

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Transformation Partners in Health and Care

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How to provide social prescribing services

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Sure Start - Sure Start | Department of Education (education-ni.gov.uk)

Big Society - PM's speech on Big Society - GOV.UK (www.gov.uk) this has now been shelved with rather a lot of criticism about mishandling of money and subsequent cuts in funding.

Building Community Capacity - iHV_BCC-Toolkit.pdf
a major part of the 0-19 teams work was around this initiative.
https://youtu.be/oNr9_riy5XU

Levelling up-  Levelling Up the United Kingdom: Executive Summary (publishing.service.gov.uk)

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Read the speech and Q&A:

Prime Minister:

Let me just say a couple of things. I mean, normally in politics the difficulty is getting people to talk about your ideas. You make a speech, you come up with something, and actually it falls stillborn onto the floor and no one refers to it again. That is not the problem we have with this, so that's a good start.

People have got very many questions about it, and I'm going to try and answer some of those even before taking yours. Is it too vague? Is it going to be made impossible by cuts? Is it a cover for cuts? And all of those questions. I want to take on some of those questions, but first of all, I just want to say why this is so important to me. I know full well that the first task that my government has got to carry out is sorting out the deficit and the debt and an economic recovery. That is - if you like, our duty. I really believe in duty in politics. I find myself as Prime Minister at a time when we have this appalling budget deficit, bigger than almost anywhere else in Europe - we have to sort it out. I know that is the major task facing the government, and we've got to do it.

That is our duty, but if you like, what is my mission? What is it I am really passionate about? It is actually social recovery as well as economic recovery. I think we need a social recovery, because as I have said lots of times in the past, there are too many parts of our society that are broken, whether it is broken families or whether it is some communities breaking down; whether it is the level of crime, the level of gang membership; whether it's problems of people stuck on welfare, unable to work; whether it's the sense that some of our public services don't work for us - we do need a social recovery to mend the broken society. To me, that's what the Big Society is all about.

To me, there's one word at the heart of all this, and that is responsibility. We need people to take more responsibility. We need people to act more responsibly, because if you take any problem in our country and you just think: 'Well, what can the government do to sort it out?', that is only ever going to be half of the answer. Take crime: yes, government's got a huge role. We've got to put the police on the streets, we've got to make sure the sentences are there, and we've got to make sure that prison places are available - that is our job. But actually, we will never crack crime unless parents bring up their children properly, unless businesses stop selling alcohol to underage people, unless we all decide that these are our streets and our communities, and we have a role to help make sure they are safe.

So, responsibility is the absolute key. If you ask yourself the question, 'Can I take more responsibility, can I do more?', very often, the answer is no. How easy is it, if you are not satisfied with education, to club together and start up a new school? It's incredibly difficult. How easy is it to try and take over the closing down pub in your village to keep it running? It's incredibly difficult. How easy is it to volunteer if you want to take part and do more, with all the rules in the past about vetting and barring and criminal records? It's extremely difficult. So, what this is all about is giving people more power and control to improve their lives and their communities. That, in a nutshell, is what it is all about.

Now, what about those key criticisms? Some people say it is too vague. Well, if they mean by that there isn't one single policy that is being sort of rolled out across the country, then yes, I accept that, because actually what we are talking about here is a whole stream of things that need to be done. First of all, we have got to devolve more power to local government, and beyond local government, so people can actually do more and take more power. Secondly, we have got to open up public services, make them less monolithic, say to people: if you want to start up new schools, you can; if you want to set up a co-op or a mutual within the health service, if you're part of the health service, you can; say to organisations like the Big Issue: if you want to expand and replicate yourself across the country, we want you to.

The third part, but it is only a part, is yes, I think it would be good if we had more philanthropic giving, more charitable giving and more volunteering in our country, so that all of those three things need to happen. But then people will say: 'Okay, maybe it's not so vague - I can see you've got the three parts to it - but this is just a cover for cuts, isn't it?

It is not a cover for anything. It is a good thing to try and build a bigger and stronger society, whatever is happening to public spending. But I would make this argument: whoever was standing here right now as Prime Minister would be having to make cuts in public spending, and isn't it better if we are having to make cuts in public spending, to try and encourage a bigger and stronger society at the same time? If there are facilities that the state can't afford to keep open, shouldn't we be trying to encourage communities who want to come forward and help them and run them?

Then there are the people who say, 'Maybe it is not a cover for cuts, but the cuts will make building a bigger society much more difficult.' What I would say to that is: of course, there is no area that can be really immune from the public spending problems that we face, but if you actually look at what central government is doing, you look at the part that I am responsible for, we are actually doing things to try and make a bigger society more possible. We are setting up a Big Society Bank, and we are putting £200 million into it from the banks this week. We are setting up a transitional fund so we can actually help organisations that need funding in this difficult environment. We are going to be announcing this week how we train another 5,000 community organisers to help build the Big Society, because there is no naïveté here. I don't believe that you just sort of roll back the state and the Big Society springs up miraculously. There are amazing people in our country, who are establishing great community organisations and social enterprises, but we, the government, should also be catalysing and agitating and trying to help build the Big Society.

I think the last question I want to answer before opening it all up is those people who say, 'Okay, it's not a cover for cuts. You're trying to make cuts in a way that doesn't damage the Big Society, and I accept it's not vague, but there are lots of different bits to it.' Some people say, 'This is nothing new. This is what happens already. You're just trying to take credit for the very good work that people already do.' Now, to that I would say: yes, this is not entirely new. The idea of communities taking more control, of more volunteerism, more charitable giving, of social enterprises taking on a bigger role, of people establishing public services themselves - all of these things are happening in our country. All of these things have happened in our country for years. My question is: should we try and do more of it? How do we encourage more of it? How do we replicate it across the country? How do we make this country a really brilliant place for setting up a new charity, a new social enterprise, for opening up the provision of public services? So, yes, this is not entirely new - of course it isn't - but it is a new approach in government to say: instead of thinking we in Whitehall have got all the answers, what are the things we can do to help you to do more to build a stronger society.

As I say, this is my absolute passion. I think it is a different way of governing, a different way of going about trying to change our country for the better, and it's going to get every bit of my passion and attention over the five years of this government. But above all, it's going to depend on many of the people in this room, because it's actually enterprise, it's entrepreneurship that is going to make this agenda work. So with that, let's go to the first question. Who wants to kick off?

Question:

Good morning, Prime Minister. I'm involved with various charities and uniformed services. I'll give you one example: the Scout movement - Girl Scouts, Boy Scouts, and Girl Guides. There's a 50,000-person waiting list for people to join this organisation. The big issue for us is getting adult volunteers, and the issue there is bureaucracy. It scares people away when they have to do multiple CRB checks, for no reason other than it's costly. The Scouts pays for that. So, one of the issues I think is to encourage more adult volunteers by breaking down bureaucracy.

Prime Minister:

I think you are absolutely right. The fact there is such a big waiting list to join these sorts of organisations shows the enthusiasm there is for this agenda. In terms of volunteering, I think under the last government it just became much more difficult, for very good reasons sometimes because you've got to have Criminal Record Bureau checks, and it does make sense to ask some questions about who is looking after our children. But for instance, the vetting and barring procedure just became hideously complicated. At one stage, I think 11 million adults were having to be vetted. You were having to be vetted if you were doing something only a few times, like for instance driving a neighbour's children to sports practice or taking a crèche in a Sunday school, as I occasionally, very badly, have managed to do. So we are changing that. We are radically reducing the number of people who will be subject to vetting. We are simplifying Criminal Record Bureau checks. This is just one example of something positive a government can do to help deliver a bigger, stronger society and we are certainly going to fulfil that agenda.

Question:

Thank you, Prime Minister. I found myself on BBC Radio Humberside this morning.

Prime Minister:

I sometimes find myself there too.

Question:

And I was described as a fan of Big Society which slightly took me aback because I have been a vehement and vocal critic about cuts to our sector, but actually in some ways, parts of what you're talking about are incredibly important and I want to welcome the emphasis you are putting on more service delivery through charities and social enterprises. I want to warmly welcome the Big Society. I think that is a very important initiative, something that will grow and provide loans and social finance for our sector which will support our increasing role. This is good, but I have to say what is bad, is what is happening to our charities and our voluntary organisations. You have a passion for Big Society; I have a passion for charities and when I see them cut, that is bad. And I think you need to think about the cuts they are making. They are hurting disadvantaged communities and perhaps you should be talking to us about how you reshape public services so that actually we could work together and do things better.

Prime Minister:

Thank you. I think this is the absolutely key question. Because look, the truth is, everyone is having to make cuts - central government, local government and it's incredibly difficult. And it's not possible to make those cuts without cutting some things that are important. It really is that difficult, and that is the situation we are in as a country.

Now, I will make a couple of points about voluntary bodies and charities. As I've said, first of all, central government is actually going about the spending reductions while trying to protect those things that are valuable to the Big Society. That is point one. Point two - of course 75% of charities and voluntary organisations get no government money at all. It's worth bearing that in mind. Point three, and this goes exactly to what you said. While difficult decisions are being made, the bigger picture is we are massively opening up public services to charities, to voluntary enterprises, to social enterprises. Hundreds of millions of pounds of potential funding - let me just give you a couple of examples. Welfare to work providers - we're opening that up. That is worth about £700 million to social enterprises and voluntary bodies who want to get into that sector. In the health service - because we are giving people the right to hold their own budgets and purchase their own care if they're in need of that at home - that is going to be worth well over £1 billion. So we shouldn't belittle those opportunities.

But let me go straight to your point about local authorities. We have asked local authorities to reduce their budgets. We have no choice about that. We have to do that. But the local authorities do have a choice about how they reduce their budgets and we are saying to them as vigorously as we can, please will you make sure you cut your own bureaucracies, you cut your pay, you cut your bureaucracy before you cut voluntary bodies and charities. Now some local authorities are responding extremely well to this - for example in leafy old West Oxfordshire they are working as hard as they can to make sure the Citizens' Advice Bureau - an absolutely vital part of the Big Society - doesn't get a cut.

Now, not all local authorities are behaving in the same way. Now this is a democracy; it's not a dictatorship. I cannot order every local authority what to do with their budget but what I can do is actually give local people a tool that they have never had before, and that is transparency. We are now getting every local authority to publish every item of spending over £500 and the reason you are reading in the pages of the Daily Mail and the Sun and the Times and the Telegraph and elsewhere, the salaries of the chief executives, it's not because they've got armies of brilliant journalists going out and finding this information, it's because we've got local authorities to publish it. This is great pressure and I want to see that pressure exerted on local authorities so they make the right decisions, not the wrong ones. But as I say, this is not a dictatorship - I cannot order those local authorities what to do. Now I hope they will make the right decisions, and I am giving local people the tools, the transparency to help encourage them to do just that.

Question:

My question, Prime Minster, relates to your last point about the importance of democracy and we've engaged over a million young people in our election programme over the last year to ensure that young people - particularly disadvantaged young people - have a seat at the table and at important times so that their voice is heard. What more can be done to strengthen the role of youth voice in societies at a time when the Big Society needs to ensure that young people are at the heart of it?

Prime Minister:

I think the Youth Parliament is an excellent idea for doing just that and I think it's right for instance that we've opened up parliament for young people to come and take part and actually have their debates in parliament. I think one of the things that we will find - and Peter Cruddas was talking about it just a minute ago - is that young people do have a passion for volunteering, for taking part, for getting involved and I think this agenda of opening up social enterprises and charities and encouraging them to do more will massively benefit young people.

But again, I am not naïve; I don't think that Big Society just grows as you have to make difficult decisions about public spending. A number of things we are doing to help make it grow - I have mentioned the Big Society Bank, I've mentioned the Transition Fund; another one is National Citizen Service. This is a very simple idea that every 16-year-old when they finish their GCSEs should have the opportunity to take part in volunteering in community service and in also something that's stretching and exciting like training with the army on Dartmoor or climbing the three peaks, or climbing a rock face in the Lake District. National Citizen Service is something that this year about 30,000 young people are going to start on pilot schemes. I didn't just talk about this in opposition, I set up a charitable organisation to run pilots to get the right sort of programme to make it work, to mix children from across the country and I hope that by the end of this Parliament we will give the opportunity to every single 16-year-old there is. So this is a massive way in which the government is taking a step to help build a bigger, stronger society, particularly involving the young people that you are talking about.

Question:

Good morning, Prime Minister. I am a student at university and I just want to raise just a tiny point. A lot of what you say about the Big Society - totally agree in terms of handing more and giving more responsibility to students such as myself. Now, the thing that I tend to find with a lot of the students I communicate to is not necessarily a point of opening up - which I think is a great thing - opening up these opportunities. But it's a question of once you open up these opportunities, a lot of especially students - young, entrepreneurial students with a passion to really get in and get involved in society - they need that education, they need that bit of a push. So I would just like to ask for a little bit of clarity on how we are going to educate this, our society today to be able to step into the new society.

Prime Minister:

That's a good point. I mean I would say that National Citizen Service is probably the best way to do that. At the moment what happens is lots of children get incredible opportunities through the Duke of Edinburgh Award scheme or the Prince of Wales Trust, but we don't actually do something as a country that brings everybody together and gives everybody that opportunity. And the reason I called it National Citizen Service is, when you listen to people who did National Service - don't worry, I'm not just about to introduce National Service in case you're worrying - but the point is, when you talk to people who did National Service, a lot of them say the thing was we did it together. It didn't matter whether you were rich or poor or what god you worshipped or where you came from in the country, we all did it together and I think that's the idea behind National Citizen Service.

That we encourage people from across the country to do this. We mix people together; they are taken out of their home environment; out of their community environment; they go off and do something and then they go back and learn about community service and volunteering and taking a bigger part in their community. And when we've tried this, mixing kids together from Warrington and Southwark I think it was, taking them off the Lake District, then back into their communities. It was a massive success. And that I think will engender in people the sense of 'we're all in it together. We're part of something bigger than ourselves. We have obligations to not just ourselves and our families but our neighbourhoods, our communities'. That's what it's all about.

Question:

Very impressive to hear your robust defence of the Big Society and we needed it right now. In fact I was writing a blog about it on Saturday; you answered all of the questions in The Observer on Sunday. But the one thing I think we really need now is a bit more detail on the short term. I mean the aspirations for the medium term are impressive and the long term - incredible if we get there. But we do know that in our communities, in our local councils, there is a sense of devastation. I think the rhetoric of broken Britain can feed into that sense of loss, so I think we do need a bit of detail on that.

Prime Minister:

Let's just deal with the devastation, and what we're talking about in terms of local government grants from central government is that they're going to go back to the level that they were in - who wants to fill in the gap? What do you think? From reading the papers - 1985 from reading the papers? 2007? In the case of Liverpool, the case I quoted in the House of Commons the other day, the level of grant they're getting, by 2013 it would have gone all the way back to 2009, so we've got to get this into perspective.

Yes, we are having to make some painful decisions. Yes, some of these cuts are difficult, but I think sometimes we're getting out of perspective the sort of level of spending and the level of grants that local authorities are going to get - I think that's a really important point to make. People ask about libraries - libraries are vital but if you're going back to 2007 grants, there was a good network of libraries in 2007, there should be a good network of libraries in 2011. There are a lot of people, in a lot of different organisations, including some charities, including the government, who are making a very persuasive case for more spending, and we have to hear that and it's actually right that they do, but let's keep this in perspective.

In terms of the short term and the medium term - one of the reasons I set up the Transition Fund of £100 million is recognising that some organisations will get cut because not all local authorities will make good decisions - that's why the Transition Fund is there. But the really big opportunity for charities and voluntary bodies is, instead of getting a sort of drip feed of handout money, is as we open up public services and say we will pay you by the results you achieve, they have a massive opportunity to get involved in rehabilitating criminals, in terms of getting people off drugs, in terms of running services in health and education - that's what the payment by results idea is all about. The Big Society Bank is there to lend money to these organisations so they can actually scale up, they can get bigger, they can replicate themselves across the country so they can take advantage of this new, more open way of delivering public services - so it is short, medium and long.

Question:

Thank you very much. I am the founder Family Beehive, which is a network of the ultra-high net worth society and business leaders. Business leaders have said on the website that they want to engage business in philanthropy - for example, retailers want to be able to invest in a programme to stop shoplifters re-offending. They also want charities to be accountable to their funders, and these are the sorts of things that the business leaders want, what they see is the Big Society.

Prime Minister:

Business has a huge role in this. If you ask yourself who is actually the best organisation at, for instance, getting people with mental-health problems into work, it's actually Marks & Spencer - so there are lots of businesses doing incredible work at building a stronger society. And that's not just because businesses are philanthropic; it's actually good for their image, it's good for their business, it's good for their brand.

Actually, if you go to any school now and you look at what children are learning about with business, and the websites they're going on, they're asking a lot of questions about is this an ethical business? How does it do business? So it's going to be even more important for business in the future. I know that sometimes businesses can feel a bit cut off from this agenda - I don't want them to feel like that all. This whole agenda, I think, is wide open to business to come and join in and play a part, and I'm looking forward to a lot of interesting announcements on that front.

Question:

I run an organisation called Food Cycle which is one of the recent award winners in the Big Society awards, and my question is about immigration. I really believe that the Big Society is great and I also think that you need a lot of international talent for this work here in the UK. My question is, with the current immigration changes, how this will reflect the Big Society, because potentially, as you can tell, I'm not British; I'm Canadian. Running Food Cycle, I will be potentially out of this country in a year's time because I do not meet the strict new immigration laws.

Prime Minister:

First of all, actually in the immigration rules we're putting in a new category of entrepreneurs so we can attract some of the best and the brightest to come to our country. But what I would say, having looked at the figures and looked at what we're proposing, I think there is an enormous amount of room to deal with the abuses that there are of the immigration system, which will enable us to make sure that we can still attract the brightest students and entrepreneurs and others to come to our country.

I was looking, for instance, at education - about 90,000 students who came last year, who were coming not to universities or even highly regarded colleges, but were coming to colleges or other recently established colleges that have a not-trusted status. So if you think about that, if you think about the huge amount of abuse there is, if we deal with that there will be plenty of headroom to allow in people who can make a real contribution while not breaching the strict immigration limits that we're going to put in place.

Question:

At a time when everybody is worried about falling living standards, even keeping their job, public-service cutbacks, do you think there is really an appetite for people out there to get involved in the voluntary sector? Aren't their energies more taken up with just worrying about themselves at this time, in particular?

Prime Minister:

I don't think the British people are like that; I think there's an enormous appetite. Every time you ask people 'would you like the opportunity to step forward' they actually say yes. Free schools is a good example: everyone said to us no one wants to run their own school, they're all far too busy, everyone is very happy with what they've got. We've already had hundreds of applications for free schools.

We came up with the idea that people within the health service might want to turn that part of the health service they work in into a mutual, into a cooperative. People said everyone's happy with the National Health Service; they don't want to change the National Health Service. Again, hundreds of organisations are coming forward saying, yes, actually we would like to run a mutual, I'd like to take control of this part of the health service and run a better service.

The community right-to-buy: 'Oh, people haven't got time to bother with that'. Again, loads of interest and applications, including ones I know about from my own constituency, even my own village, where people are very keen to step forward, particularly when they see the last - if it's the last post office or the last shop, or the last pub, or a bit of land in the community that's been left fallow for so long. There is an appetite for this. So, I think that the proof is always there. Whenever you give people an opportunity to step forward and play a greater role, in my experience they almost always take it. I believe that they will with all these opportunities that will be coming forward.

Question:

However good the values that underlie the Big Society might be, do you accept that a lot of people find the idea quite irritating in these rather austere times, and do you accept at the very least that it perhaps hasn't been sold as well as it might have been, and that there are plenty of people in your party who would quite like you to stop talking about it now?

Prime Minister:

The reason I talk about it is not because it's popular or I think I am going to win an election with it. The reason I talk about it is because it's what I care about. You know, the idea that actually you might put into a manifesto something you are passionate about and believe in, rather than just because it makes a great headline on the 10 o'clock news - that may be novel, but that happens to be what I think. I think the evidence is - and I think you see it round the room, you've got a lot of organisations represented here today - the evidence is that people are enthusiastic if they are given the opportunity. It tends to be, when you ask people: how do you feel about this idea of playing a greater role, of communities having greater control over their lives? People say, 'Well, I like the idea, but I don't believe it's possible.' I think we have to show that it is possible, that actually there is a way of making the police force accountable to you with local beat meetings; there is a way for communities that aren't satisfied with what they've got to establish a new school; there is a way, if you're depressed with the way the health service is run, you can run a mutual within the NHS. There is a way of actually opening up the provision of public services to voluntary bodies; there is a way of encouraging young people to volunteer and get involved.

Now, as I have said, the duty of this government is to deal with the economic mess. We've got to deal with that deficit. We have to make these cuts. We have to put up those taxes. It will not make us popular; in fact, it will make us unpopular. It will make me unpopular. I recognise that; it is my duty. We have to do this for the good of our country. But I don't believe it's impossible to do your duty at the same time as having a sense of mission and purpose about what would make this country a stronger, better, nicer place to live and make our communities more healthy. I think there's an enormous appetite for that. People do believe that we need a sort of social recovery as well as an economic recovery, and I think, as I say, this would be the right thing to do whether we were increasing public spending or cutting it, whether the economy was growing or not growing. This is a really good agenda that I think people when they hear about it say, 'Yes, I do think this is a good thing, because in the end, a stronger society is a nicer country to live in.'

Question:

Can I make a suggestion for a quick win? With regards to the National Citizen Service, it's welcomed by the majority of young people and by youth organisations themselves, and a very quick win would be if you were to create a framework which would allow existing organisations like the Duke of Edinburgh Award and the Prince's Trust, that you've mentioned before, to start helping to deliver the citizenship along the lines of the programmes they do already, because the aims are really quite the same as the ones that you suggest, and we could all come together under the banner of this new idea, rather than creating a separate scheme.

Prime Minister:

That may well be the answer. Last year, we ran a small number of pilot schemes to try and get the concept right, and this year we are running more, again with the same idea. When it then expands, can we do more to involve other organisations? I absolutely hope we can. When I go back and think of when I had this idea and wanted to get it going, I didn't just sort of write out a blueprint and make a speech about it. I got all those organisations - Fairbridge, Prince of Wales Trust, Duke of Edinburgh Award scheme, all the others I can think of - I got them all together I think in a television studio somewhere in North London and heard their views and talked to them about it, so we could try and shape the programme and get it right. So, yes, I'm sure we will be able to do that, but at the moment what we are trying to do is just see if we can do it at scale, and if it works and if it is the right sort of six-week programme.

Question:

I am confused standing here actually. You're talking about social enterprises taking the lead, and people using their own initiative for their own community. I've been doing that for four years with an ex-offender led project, ex-offender run. We have a 15% re-offending rate, and I am sure you can do the maths on that, and all the way through we have got to a certain point, and I am getting blocked, constantly blocked. We cannot compete against the big boys, but we are having a great social impact.

Prime Minister:

Please don't be confused, because you're exactly the sort of organisation that I think we should be looking to work out how we try and expand. If you take rehabilitation of prisoners, it's a classic example of where we need a Big Society approach rather than a big state approach. The big state approach, our big prisons, are failing. In fact, actually if you asked the governor of a prison what is the re-offending rate of the people in their prison, they can't tell you. That's not because they are bad people; it's because they are not actually set up to do that. They are just set up to house prisoners, to keep them inside, to give them a bit of training, and then to release them, whereas your organisation is absolutely focused on what really matters to everybody in this country, which is how do we turn them round? How do we rehabilitate them?

Prime Minister:

Now, you keep getting stuck for all sorts of reasons, one of which is that the state has certain areas of criminal justice it won't open up to the voluntary sector. Well, I say: why not? These prisons are costing us a fortune and they are not doing a very good job. Each prisoner costs £40,000 a year to keep. Wouldn't it be better to try and spend some of that money with organisations like yours and pay them by results? Indeed, why shouldn't we be paying prisons by results? If they are good at rehabilitating prisoners, they get paid more; if they are not, they get paid less. So, not only have we got the ambition to enable your organisation to do more, we have also thought of some of the ways in which we could help make that happen: opening up these big contracts; putting them all online; making sure they are all transparent, so you can see how much money the state is wasting and how much money you could save. Then the Big Society bank should help you to raise money to build up your organisation so you can do more.

So look, this is the start of a very long process. The media will be frustrated because there won't be a result tomorrow, but we are asking the right question, which is: how do you enable entrepreneurial organisations like yours to do more, to change the country, and to improve public services? And it isn't a simple switch that you flick; it's a whole series of things that we have to do to help your organisation.

Question:

I gave a talk at the National School of Government a fortnight ago about the challenges facing the Big Society.

Prime Minister:

How did you get on?

Question:

It took a while. I posed a question to the room, largely full of senior civil servants, grade 7 and above: who here knows what a social enterprise is? Ten percent of the room had even heard of social enterprise. What do you think we need to do to make the state, the civil service more permeable to innovation, to partnership working? What conditions do you think we need to create in order for this innovation to occur?

Prime Minister:

I think that's a very, very good point. As well as changing laws - for example, creating a community right-to-buy, so communities can buy something, as well as changing the rules about the health service, so they can set up mutuals if they want to. Some of this is about a change of culture, because the government, the state, the civil service, just hasn't done things like this before, and so it's a big change. When they've had a big contract to let in the past, too often it's just gone to the big organisation and it's all been kept very secret, and no one's been able to see the figures. So, the culture change is partly from leadership and the people at the top saying, 'This is how things are going to be. We are going to open up. We are going to do things differently. This is what social enterprises are. This is what they do. Could you engage with them?'

But also, this transparency agenda is hugely important. By putting every contract over £25,000 online, by making all the details public, by making sure as a small social enterprise you've only got to register once to bid for any government work - these are technical changes, but they will make quite a big difference. On Friday, I launched an initiative to make sure that we give 25% of procurement contracts to smaller and medium-size enterprises, including voluntary bodies, charities and social enterprises, who were in there at the birth, designing this policy. But there's a culture change.

The civil service is, I think, a great organisation. I have come into government. I have got an absolute Rolls-Royce in terms of people who work for me. They are brilliant: hard working, dedicated, impartial, professional. I couldn't fault them. I think I've kept Gordon Brown's entire private office. But is there a culture change needed in the civil service to understand this agenda? Of course there is, and there's a danger that because they are good, hard-working, impartial, professional people, they tend to take an idea like the Big Society and think it must be one idea that is an initiative that has to be rolled out across government. You're in danger sometimes of turning the Big Society into the big state (society), and we need to be very careful that doesn't happen. We've got to open things up to allow the entrepreneurialism of this sector to prove itself.

Question:

My question for you is given that is a kind of philosophy, and a mission and a vision, how will you know whether it has been successful? So, in five years' time, how will you measure your success?

Prime Minister:

I think there will be lots of things you will be able to look at. You can look sector by sector; you can look at education. Are there more free schools being set up by communities? Is the academies programme expanding and is business still investing in it? Are organisations like yours thriving? Look across at the health service. What's the involvement of social enterprises and charities? I think you'll be able to look at communities and say: have they actually taken advantage of these things that we're putting in place, like the community right-to-buy? I think you'll be able to look at the Big Society Bank and say: right, how big is it now? How much lending is it doing? What is the health of this charitable social enterprise sector? I don't want to produce a sort of top-down target, you know: eighteen weeks to set up a social enterprise, tick that box, okay, move on, let's go on to the next thing. I don't want to do that, but we can find some ways of showing and saying: well look, these are the things we were talking about; these are the things that have now happened.

What we have done in government is instead of setting targets like the one I just mentioned, we have these things called structural reform plans, where we just set out what the department promised to do, the date by which they were going to do it, and then you have to check off whether they have done it. So, have we introduced the community right-to-buy? Have we trained the 5,000 community organisers? Is the Big Society Bank up and running? Those things - you know, like a business, we should definitely be ticking them off as we do them, and on some of them we are ahead, and some of them we are a bit behind, but it's all transparent, so you can go on the internet and have a good look.

Question:

We are a national charity supporting community groups. Prime Minister, yourself and other ministers have talked about the extraction of £200 million from the banks to support the Big Society Bank, but can you explain to me how that actually helps, when it's a commercial loan? Does that make cheaper money available - cheaper capital available to the sector?

Prime Minister:

I think two things: (a) it should be cheaper money, but (b), perhaps more importantly, it is understanding. I was at a social enterprise this morning, the People's Supermarket, which is a basically a new cooperative. They have set up, and you pay £25 a year to join, and you have to volunteer to be part of it, and as a result, you get cheaper food at your local supermarket in Camden. They were saying to me, 'Right, we think we've cracked this. It really does work. We've got enough people volunteering. We've got enough money coming in. We are delivering prices that are 10% below the local supermarket. We have got the model. Now, we'd love to be able to set this up in other parts of London and in other parts of the country, but the banks aren't interested, because banks - a bit like the civil service - don't necessarily understand social enterprises.' But if you have a Big Society Bank that is absolutely versed in that whole sector and understands that sector, and is mandated to lend to that sector, I think you'll get more understanding, more money and hopefully at a better price.

Question:

To the sceptics about the Big Society, I suggest that they go and look at what has happened in social housing over the last 20 years. 20 years ago, housing associations were formed. They were very small; they were run by volunteers. Today, they are the dominant producers - developers of housing for those who need low-cost accommodation. There's a precedent for the Big Society too: the Housing Finance Corporation was established at the same time to provide a means to the debt markets for these housing associations. Having established the credit, the banks now are in, and we raise at the moment £2.5 billion for housing associations at rates cheaper than the government of Japan can borrow. So, the precedents are there for this. Let me suggest one idea perhaps for the lady in the corner. Prisons are a rather specialised form of housing. Housing associations already provide housing for assisted care; they do training especially in IT skills for their residents so that they can access the web. Perhaps housing associations should take over some of the prisons.

Prime Minister:

Very interesting idea. I mean I think you're right. You know 20 years ago you just had monolithic council owned housing stock, often very badly run, very badly looked after, and the growth of housing associations - the competition, the choice, the new money they brought into the sector - has been a great success. But I would almost turn the challenge back to you. I would say you would come across say farmers, who would love to build and let houses at social rents because they want to try and provide an income stream and keep people on the farm but they can't because they are not registered social landlords. Housing associations also need a bit of Big Society work as it were, to open up and say 'right, let's make this sector a bit more bigger, a bit more entrepreneurial' and allow other people to come into it to provide that innovation because that's often what's needed in housing to meet people's needs.

Question:

I'm the founder of a social enterprise called People Who Share which is dedicated to growing a global market place for sharing. Now what we are talking about though is a very big cultural change. I mean many people in this country don't know who their own neighbours are, so if we are talking about this notion of harnessing the power of sharing and people actually taking responsibility, how do you see that cultural change happening?

Prime Minister:

Part of it is what an American politician would call the bully pulpit. Part of it is talking about it; talking about social issues and social change and society and responsibilities in a way that fires people up and gets people going and gets people asking those questions and one of the reasons I've never had any doubt that the agenda of the Big Society is going well and will go on and will grow is that people talk about it the whole time. I was at my constituency at the weekend; people endlessly come up and say 'well, you know, we've just taken over the open-air swimming pool because the council closed it. We're running it. That's very much Big Society, isn't it? And we are getting local schools involved and we are encouraging people.' And this weekend I probably had about four examples of people who came up and said that's exactly what we're doing. And the questions I posed at the beginning is 'this isn't all new, is it?' I mean it isn't new - this has been going on for centuries in our country. It's just about trying to take it to the next stage and I think politicians do have a role by discussing these things, trying to get people to think about how to be better citizens, more active citizens and to do more things along the lines you suggest.

Question:

Top marks for sticking your neck out on culture change which is difficult - and I think it's great for schools to be able to innovate or have permission to innovate because as I say, those that have done well or have done it in the past because we have broken the rules of the government or at least not been limited by them. But, what concerns me about this in relation to education is that there's an unintended consequence of an increase in centralisation because every innovation has to go somewhere in order to be moderated particularly if it's a state-wide thing.

Prime Minister:

Give me a for instance on that because I'm conscious of this - if we come up with something new and we then try and force it - we're not trying to do that - but give me a for instance on that.

Question:

Okay, well, to set up a free school for example, as soon as I saw the White Paper, eager to start one, get the paper work in but actually it all has to go the top of now quite a fine pyramid in order to get that through and actually the more people who wanted to do that, the more that constriction would be there. Or a different example - actually having got the local authority on side about one such project, the local authority are worried about the Big Society kyboshing the free school because a different bit of the Big Society wouldn't like to have a new school on their doorstep.

Prime Minister:

It's a good point. I think though what we've got to be about is trying to clear the obstacles out of the way. So when it comes to free schools or new academies, there are - I think - almost too many ways in which trade unions or local authorities or whatever, can sort of frustrate the creation of these things. And one of the reasons for announcing pathfinder schemes in Liverpool and in Cumbria and Windsor and Maidenhead was that these were not pilot schemes, because you don't roll out the Big Society; it's all of these things we've been talking about. The idea behind the Pathfinders was to say to these communities - you sort of volunteer for it - tell us what it is that's stopping you from doing more things like handing over work to enterprises and charities, enabling communities. Tell us the national rules, the regulations, the laws that get in your way and we will then get government to act with you to get them out of the way. And we're finding lots of examples where actually local authorities would like to step in and help out and find a community solution to this problem or that problem. So I hope that we can do this in a way that is genuinely enabling rather than smothering. That would be the worst - it would be a disaster if this agenda ended up actually stopping the sort of social change that we want to militate on behalf of.

Question:

Prime Minister, very glad that you mentioned welfare to work - a very important area - but there are serious concerns here that you're creating a new sort of Byzantine bureaucracy to replace the old one. We are presently involved - as I think probably some of the people in this room also are - in putting in expressions of interest to the big service companies that have won or are preferred biller in the new single work programme. And I think there is a serious concern here that - or there's a warning that I'd like to make - that the big service companies could strangle the Big Society at birth. How do you stop these wonderful companies that we will end up working with, from doing this?

Prime Minister:

It's a really good question. I was looking at it on Friday when we were opening up government procurement to the private sector and the point was made - it's all very well to say the lead contract has got to be a SME or this sort of company, what happens if all the people they contract with are actually the big organisations? So I accept, this is very difficult and we want to work with you to make sure that we are genuinely opening up to the small, the innovative, the enterprising. Some of the big organisations will say 'well you'll never save money if you do that because only we have the scale to deliver these programmes at low cost.' I don't accept that. I think that when you're looking at things like welfare to work, where often the hardest cases need the most personal attention. If you think of someone who hasn't worked for say five or ten years, who has got mental-health problems, that person - if you can get them into work - is saving you probably £40,000 because of the likely time they would spend on benefits if you don't help them. But the organisation that is likely to get them back to work is probably very specialised, very personal, very sensitive, very innovative. So I completely agree with you; if this ends up with a few big companies running big government projects that is not what we're looking for.

Question:

I run a social enterprise called Start Here which is all about making information accessible and what we've discovered is that what people need most is local information. And what concerns me is how people really navigate through the system. And I think that if voluntary organisations collaborate together because a lot of charities do have local information, we can actually build a consistent social services type directory which I would have thought - and I'd love to hear your comments - should be one of the planks of the Big Society. And we've made some progress building that so we're not starting from scratch; I just don't want to see duplication of effort and us pooling resources.

Prime Minister:

I think one of the absolute building blocks is transparency of information. There is a bit of bossiness in the Big Society - you have got to boss local authorities to make them make available all of their information and this is an absolute plank of the Big Society because once all of that information is available - what services they run; who they pay; how much they pay - once all that information is available, it creates a lot of wealth and opportunities because organisations can take that data; they can mash it up; they can create new businesses. There is a very good one called 'They Work For You' which is about your MP and how hard they work and this is based on the transparent data about how much we all vote. This is exactly the same with local authorities; by making all this data available, we are actually enabling social enterprises and charities to come forward and run new services, compare different councils and actually start running services themselves. This is a very big part of the agenda.

Can I thank you all very much for coming. I'm sorry I didn't get to answer all your questions. I think we should probably do this again but thank you very much for coming today, and above all thank you for what you do. Thank you.

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Prime Minister David Cameron delivered a speech on Big Society on Monday 14th February 2011.

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social_prescribing_2_pager_infographic_final_17may2022.pdf (allianceon.org)

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Our strategy - NHS Resolution

Healthier Families - Home - NHS (www.nhs.uk)

change-model-guide-v5.pdf (england.nhs.uk)

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https://www.youtube.com/watch?v=tsnG0ogHAjw&t=132s

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Historical - not particularly academic but highlights communities and health 

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Historical - not particularly academic but highlights communities and health 

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Cadbury Foundation

Port Sunlight Village - VisitLiverpool

The Impact of War on Public Health in the 20th Century Facts & Worksheets (schoolhistory.co.uk)

Public figures and public health - Placing the Public in Public Health: Public Health in Britain, 1948-2010 (lshtm.ac.uk)

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https://www.healthierfleetwood.co.uk/try-something-new

https://www.longtermplan.nhs.uk/case-studies/healthier-fleetwood/

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Try Something New

Fleetwood has an extensive, vibrant network of events, groups and activities connecting residents to each other and to the wider community, all led by caring, compassionate individuals and organisations. Healthier Fleetwood is honoured to be a point of contact for this network and to support it's continuing development.

Use the links here to find out more about the opportunities in and around Fleetwood and who to contact.

We'll keep the page regularly updated - please to add something to the listings.

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Get involved in the local groups and activities led by residents and for residents.

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Health inequalities: Children | Local Government Association

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Explore case studies from councils looking at the impact of the pandemic and the cost of living crisis on children.

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Quantifying health inequalities in England

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Unfortunately, your browser is too old to work on this website. Please upgrade your browser

Key points

Health inequalities are complex and growing, yet firm evidence on their extent and trajectory is few and far between. There is a vital need to quantify health inequalities in order to better focus policies designed to address them.

This analysis uses a novel approach to explore the extent of diagnosed health inequalities across different population groups in England. We use the Cambridge Multimorbidity Score, developed by clinicians and academics, to assess the relative impact of different patterns of illness on people and their health care needs. Our access to patient data linking primary care and hospital records allows us to provide a more detailed picture of variations in diagnosed illness by age, socioeconomic status, ethnicity and region in England.

We know from previous research that, on average, people living in more deprived areas have shorter lives and spend more time living with diagnosed long-term illness. Our analysis shows, on average, a 60-year-old woman in the poorest area of England has diagnosed illness equivalent to that of a 76-year-old woman in the wealthiest area. She will spend more than half (43.6 years) of her life in ill health compared with 46% (41 years) for a woman in the wealthiest areas.

People living in poorer areas also have greater levels of multiple diagnosed illness (multimorbidity). Large inequalities in the burden of disease are concentrated within a few diagnosed conditions, including chronic pain, diabetes, COPD, anxiety and depression, alcohol problems and cardiovascular disease.

Inequalities in health start at an early age, with higher rates of diagnosed mental health conditions, chronic pain and alcohol problems starting to develop as early as the late teens and early twenties. These health inequalities then continue to grow and change across the life cycle, through working age and into old age.

Once we standardise for different age distributions across ethnicities, we find higher levels of diagnosed ill health among people of Pakistani, Bangladeshi and black Caribbean ethnic backgrounds than for people from white ethnic backgrounds.

We also add to previous research on the north-south health divide: people living in the north of England have the highest health care needs due to diagnosed morbidity once adjusted for age. Four conditions - chronic pain, alcohol problems, COPD and cardiovascular disease - account for 83% of the inequality in diagnosed illness between the North East (region with the highest levels of illness) and the East of England (region with the lowest levels of illness).

Introduction

Non-communicable illness is responsible for 88% of the burden of disease in England, with the majority falling most heavily on the poorest in society. The COVID-19 pandemic has highlighted pervasive socioeconomic, ethnic and geographical health inequalities in our society. But quantifying health inequalities can be difficult due to the complexities of comparing people with multiple different long-term conditions (multimorbidity) and assessing the implications for their health care needs.

In this analysis we use a novel tool known as the Cambridge Multimorbidity Score (see Box 1) to assess the relative impact of different patterns of diagnosed illness on people and their use of the health care system. This score has been developed by doctors, academics and primary care experts, and depends on administrative patient-level data linking primary care and hospital records. Given that our analysis relies on health care data, we are observing diagnosed health inequalities, as opposed to underlying health needs. Inequalities in access to care imply that there may be greater undiagnosed health problems in different population groups - it is not possible to take this into account in this analysis. We briefly outline more about the data and the Cambridge Multimorbidity Score in Box 1 below. More detail on data cleaning and disease definitions can be found in the appendix.

Diagnosed health inequalities by deprivation of local area

We analyse socioeconomic health inequalities by dividing local areas in England into 10 groups, or deciles, according to the Index of Multiple Deprivation (IMD). We then calculate the average Cambridge Multimorbidity Score (CMS) for people living in local areas within each decile. Decile 1 is those living in the most deprived 10% of local areas, while decile 10 is those living in the least deprived 10% of local areas.

Figure 1 shows the average comorbidity score (CMS-weighted prevalence) for diagnosed illness in each decile, broken down by contributing condition. Higher levels of local area deprivation are associated with a higher average comorbidity score. The gradient is steepest for the most deprived deciles, with greater disparities in diagnosed illness for those living in more deprived areas than for people living in the wealthiest half of the country.
Figure 1

Chronic pain, COPD, alcohol problems, anxiety and depression, cardiovascular disease and diabetes contribute to 64% of the burden of disease in the most deprived decile, compared with 49% in the least deprived decile. All of these conditions are at least 50% more prevalent in the most deprived areas of England than the least, and COPD is over three times more common once we standardise for age.

In contrast, cancer is one condition for which the diagnosed prevalence is higher in richer areas. This is a surprising result, as we know from other research that there are higher levels of diagnosed incidence of cancer in more deprived areas. Inequalities in cancer are complex and multifaceted: we see higher levels of cancer incidence by age in poorer areas, but there are further differences in terms of tumour locations, stage at diagnosis and survival rates. People in less deprived areas are more likely to live for longer with a cancer diagnosis, therefore the share of people living with the disease is greater.

People in poorer areas become ill earlier in life

Looking at diagnosed long-term conditions by age, gender and deprivation we can see how much earlier the people living in poorer areas reach a given level of ill health.
Figure 2

Figure 2a plots the average comorbidity score by age group and local area IMD decile. Inequalities in diagnosed long-term conditions are widest in absolute terms for people in their 70s, although in relative terms people living in the poorest areas have an average CMS of more than double those in the least deprived areas in their 50s and 60s.

We can compare how the diagnosed illness (average CMS) of those in the most deprived decile stand in relation to the older people living in wealthier areas. The analysis shows how the inequalities observed in Figure 1 are the result of diagnosed disease emerging earlier in more deprived areas. For example, people aged 30-49 living in the most deprived 10% of local areas have the same average comorbidity score as those aged 50-59 living in the least deprived local areas.

If we compare the extremes, those in the most and least deprived areas, we can see just how different lived experience of health is across the country. Figure 2b shows the levels of diagnosed illness (average CMS) by age and gender for the most and least deprived deciles: on average 60-year-old women in the most deprived decile have around the same level of diagnosed morbidity as 76-year-old women in the least deprived areas. Men have lower levels of socioeconomic inequality in diagnosed ill health at the same age, with a 10-year disparity in diagnosed illness compared with 16 years for women.

For diagnosed illness, there is a clear transition across the life cycle

Figure 3 disaggregates the gap in diagnosed long-term illness between the most and the least deprived areas, showing which conditions contribute to the inequalities in each age group. It is striking that over 50% of inequality in diagnosed illness for all age groups older than 30 years is caused by only three conditions: chronic pain, COPD and diabetes. These conditions, along with alcohol problems, heart failure and dementia, account for at least three-quarters of the absolute inequality and most of the burden of disease that exists within the population aged 50 years and older.
Figure 3

In Figure 3, we show the contribution of each condition to health disparities by age group. Absolute levels of inequality are very small for younger people, but this analysis shows that there is a clear transition of inequality across the life cycle. Children in more deprived areas are much more likely to be living with asthma, epilepsy and to experience alcohol problems and are less likely to be diagnosed with anxiety or depression. From the age of 20 we see greater differences in chronic pain, alcohol problems and anxiety and depression. From the age of 30 we begin to see health inequalities manifesting in different kinds of health conditions. Disparities in diabetes, COPD and cardiovascular disease rates grow and overtake anxiety and depression, although we still observe growing inequality in chronic pain and alcohol problems. Among people aged 50 and older, inequality in morbidity is dominated by chronic pain, COPD, diabetes and dementia. Contrary to other diseases, we see a higher prevalence of diagnosed cancer in the least deprived areas among older patients.

These findings suggest that health inequalities start at an early age and accumulate over time. Chronic stress and adverse conditions have been shown to contribute directly and indirectly to poorer health outcomes through their cumulative impact. This phenomenon, known as allostatic load, is linked to earlier death and is greater for those from poorer backgrounds. The stages of inequality in ill health shown here strengthens the case for a life course approach to public health policy.

The disparity in diagnosed ill health then reduces for people aged 80 or older. People living to this age have time to develop long-term illness even if they live in the least deprived areas. This is a study of people living with diagnosed illness and so does not reflect the stark inequalities in mortality rates. It is therefore worth thinking about the amount of time spent in ill health in the context of life expectancy.

Life expectancy and living with illness

Differences in the prevalence of diagnosed long-term conditions can be explained by inequalities in the wider determinants of health. Here, we explore the age at which we see disparities in health starting to develop.

We have produced alternate estimates of life expectancy to national statistics using our primary care data linked to mortality records, along with an additional measure of disease-free life expectancy (see Table 1). Disease-free life expectancy provides an estimate of the average number of years a person would live without being diagnosed with any of the illnesses included in the CMS.

Table 1: Life expectancy and disease-free life expectancy estimates, most and least deprived deciles, 2019/20
Men Women

Most deprived

83.6

39.9

43.6 (52%)

78.7

Note: Life expectancy estimates drawn from CPRD data are higher than those produced by ONS. This reflects that our data are a sample of 2 million people registered at a primary care practice and therefore do not include deaths among people not registered at a practice, who may have higher mortality rates. Our life expectancy estimates may also be higher for the following reasons: CPRD does not always observe when patients emigrate and do not de-register themselves; our data sample may not pick up infants and infant mortality as our dataset does not make use of the CPRD Mother Baby Link; the national statistics also include a 3-year average, covering a slightly different time period.

Inequalities in life expectancy are wider for men, but women spend longer in ill health

Our estimates reinforce the large inequalities in life expectancy indicated by official national estimates (Table 1). Both sets of estimates show that inequalities in life expectancy are greater for men than for women. They also both estimate that on average men living in the poorest areas live 9 fewer years than their counterparts in the wealthiest areas of England. The socioeconomic inequality in life expectancy for men is such that, despite spending a greater share of their lives with diagnosed illness (46% compared with 44%, Table 1), men in the most deprived areas spend less time living with diagnosed illness (35.7 years compared with 37.9 years in the least deprived areas).

But women overall face more time spent living with illness. Women in the poorest areas are expected to be diagnosed with a long-term illness at 40 years of age and are expected to spend over half their lives in ill health (52%). Women in the least deprived areas, on the other hand, on average develop their first illness 8 years later. They are expected to live an additional 5 years than those in the most deprived areas according to our estimates (the equivalent figure is an additional 8 years from official national estimates).

There are inequalities by region and by ethnic background

This novel method of analysis clearly shows inequalities in diagnosed illness both by the patient's ethnicity and where in England they live. We observe more diagnosed ill health in some people from minority ethnic backgrounds (Figure 4) and in the north of England (Figure 5). As evidenced in previous research, health inequalities are heavily linked to ethnic and geographic socioeconomic inequalities. For example, a recent study showed that once you consider the differences in socioeconomics and other important factors between ethnic groups, the differences in rates of obesity between ethnic groups are either severely diminished or removed entirely. There is much we still do not know about the interactions between ethnicity, region, the wider determinants of health, and how these impact access and need for health care.

To directly compare average rates of illness for people across ethnicities is to ignore their demographic differences. The average age of the white population is higher than those from other ethnic backgrounds. The white population in this analysis includes those from minority white backgrounds. As shown in Figure 4, once we standardise for different age distributions across ethnicities, we find higher levels of diagnosed ill health in Pakistani, Bangladeshi, and black Caribbean people than among the white population in England.
Figure 4

People from Pakistani and Bangladeshi ethnic backgrounds in England have the highest age-standardised rates of chronic pain, diabetes, dementia and cardiovascular disease. Despite not having the highest prevalence in other cardiovascular disease, the white population has the highest rate of diagnosed atrial fibrillation, an important risk factor for cardiovascular disease that can lead to preventive intervention in primary care. The white population also have the lowest rate of diabetes but are more likely to be living with diagnosed anxiety or depression, alcohol problems and cancer.

As previously discussed, these data reflect disparities in diagnosed health conditions and therefore they only show inequalities in needs that are identified by the health system. Evidence suggests that access and engagement with care is limited for some population groups, often on the basis of ethnicity. For instance this year, a review from NHS Race and Health Observatory and the Race Evidence Review found evidence to suggest that there are 'clear barriers' for people from minority ethnic backgrounds to seeking help for mental health problems. Other research has also found lower access to cancer screening and lower levels of patient satisfaction. The results presented here should therefore be considered in this context and further research is required to accurately represent underlying health inequalities.

Figure 5 shows the age-standardised average morbidity score by region, adding to the evidence of a north-south health divide. People living in the North East and North West regions of England have the highest health care needs, in part due to higher levels of chronic pain, alcohol problems, COPD and cardiovascular disease. These four conditions account for 83% of the inequality in diagnosed illness between the North East (highest) and the East of England (lowest). The north-south divide seen here is reflected in regional disparities in average incomes, wealth, economic opportunity and educational attainment, and speaks to the strong relationship between inequalities in the wider determinants of health and inequalities in diagnosed ill health.
Figure 5

Conclusions

There is a vital need to quantify health inequalities to better focus health and wider policy to address them. Equality is at the centre of NHS England's strategy, but insights on the extent of health inequalities like those presented here are few and far between. Our analysis adds to a growing body of evidence that health outcomes for disadvantaged groups are dramatically worse across a number of measures, with poorer people living shorter lives in greater discomfort due to ill health. These socioeconomic inequalities are borne out in greater levels of diagnosed ill health among minority ethnic populations and in different regions of England.

Our results show health inequalities starting at a very early age and continuing to develop through adulthood. The early ages and changing structure of health inequalities reinforces the notion that nothing short of a joined-up policy approach can address the wide and complex health inequalities we see in England. We believe this new presentation of health inequalities shows powerfully that investing in the circumstances in which people live will help people stay healthier for longer.
These are some of the first results from analysis conducted by the Health Foundation's REAL Centre in the development of a health and care funding projections model, in partnership with the University of Liverpool's Institute of Population Health. The analysis was conducted using the Clinical Practice Research Datalink (CPRD). The data are provided by patients and collected by the NHS as part of their care and support. Regulatory approvals to use CPRD data for this analysis were granted by the CPRD Independent Scientific Advisory Committee (ISAC protocol number 20-000096).

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Quantifying health inequalities in England

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Quantifying health inequalities is vital to better focus policies designed to address them. This analysis uses a novel approach to explore the extent of diagnosed health inequalities across different population groups in England.

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North-West Active Partnership Social Prescribing Forum - Provider Report 2022 V1

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https://www.bbbc.org.uk/social-prescribing/

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Social prescribing was developed in recognition that the majority of factors affecting mental and physical ill health are social and economic - people need friends and a feeling of belonging, a sense of purpose, financial security, a safe home and hope for their future.

Social Prescribing at the Bromley by Bow Centre

The Social Prescribing service at the Bromley by Bow Centre was developed to respond to the high levels of health inequality and deprivation in the local community. Now we have over twenty years' experience developing and delivering social prescribing, and over five years' experience delivering training on social prescribing.

Social Prescribing approaches have been central to the BBBC model since the organisation built and opened the first Health Living Centre (delivering primary care) in 1997. In 2014, the BBBC attracted a small amount of CCG funding and is now part of the Tower Hamlets borough wide service, commissioned by Tower Hamlets CCG via the GP Care Group (GPCG CIC). The service received additional funding from Tudor Trust. We have also worked with Macmillan to pioneer a social prescribing approach that works across secondary care, primary care and community services to support people living with and beyond cancer (Link to Macmillan report). This approach is now being scaled up across the UK.

June 2019 - June 2020 in numbers:

1,321 clients were supported by social prescribing link workers

848 proactive calls were made to vulnerable clients during Covid-19 lockdown

9-90 years old was the age range of people supported by social prescribing outreach during lockdown

Development and training

Over the past decade the Bromley by Bow Centre has worked extensively to support the development and growth of social prescribing nationally and internationally. We are founding members of the National Social Prescribing Network and are Social Prescribing Regional Facilitators for London for NHS England.

Our social prescribing schemes have grown and developed substantially over the last decade allowing us to develop significant experience and insight which we share with others. A key element of our training involves practitioner led knowledge sharing of both Social Prescribing as a service and as Social Prescribing Link Workers (SPLW) role. The Bromley by Bow Social Prescribing scheme consists of a general practice based social prescribing scheme serving, since 2012, a primary care network (PCN) of six GP practices with 53,000 registered patients.
Register your interest in training now

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Social Prescribing at the Bromley By Bow Centre

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Social Prescribing is a unique approach to health pioneered at the Bromley By Bow Centre.

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https://www.kingsfund.org.uk/publications/social-prescribing

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How does social prescribing fit in with wider health and care policy?

Social prescribing and similar approaches have been practised in the NHS for many years, with schemes dating back to the 1990s, and some even earlier (the Bromley by Bow Centre was established in 1984). For a long time, though, social prescribing was practised in pockets and largely unnoticed by national NHS bodies.

The past few years have seen an important change: national NHS bodies have embraced social prescribing and committed resource to rolling it out across England. The NHS five year forward view (2014) opened the door with its focus on prevention, its emphasis on the role of the voluntary and community sector, and by citing examples of social prescribing schemes having a positive impact. Subsequently, the General practice forward view (2016) noted the role voluntary and community sector organisations, and particularly social prescribing, can play alongside GP services in offering people community-based support.

The NHS long-term plan (2019) marked a step change in ambition by incorporating social prescribing into its comprehensive model of personalised care. Composed of six programmes including personalised care planning and personal health budgets, the model aims to enable people, particularly those with more complex needs, to take greater control of their health and care.

Rather than seeking to directly fund the groups that deliver social interventions, the Long-Term Plan commits funding to the link workers who connect people to the range of support and engagement opportunities - largely run by charity and voluntary organisations - in their local area. The Long-Term Plan set a target that by 2023/24 every GP practice in England will have access to a social prescribing link worker and 900,000 people will be referred by then.

Primary care networks (PCNs), groupings of GP surgeries serving populations of around 30-50,000 patients, are the channel for this resource and in many cases will host the link-worker service. In 2019, a new five-year contract framework for general practices came into effect, which allows every PCN with a population of 30,000 or more to be reimbursed the costs of employing a link worker (one full-time equivalent and more for PCNs with populations of more than 100,000). By autumn 2020 national NHS bodies were reporting that more than 1,200 link workers were in post.

Alongside funding link workers, national NHS bodies are seeking to grow the infrastructure that supports social prescribing. In 2019, the Department of Health and Social Care made £5 million available to establish a National Academy of Social Prescribing. The academy was officially formed as an independent charity in 2020, with support from a number of partner organisations, such as NHS England and NHS Improvement and Sport England; it plans to focus on raising the profile of social prescribing, building the evidence base and sharing promising practice. It also seeks to support voluntary organisations involved in social prescribing and explore funding partnerships.

Other government departments have shown a growing interest in the potential of non-clinical interventions in recent years. In 2018, the government's strategy to tackle loneliness backed the roll-out of social prescribing, and in 2020 the Department for Environment, Food and Rural Affairs announced funding for a two-year trial of 'green social prescribing' - initiatives intended to help people engage with the natural world.

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What Is Social Prescribing? | The King's Fund

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Social prescribing enables GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services to support their health and wellbeing. But does it work? And how does it fit in with wider health and care policy?

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https://collegeofmedicine.org.uk/social-prescribing-is-as-old-as-the-hills-dr-michael-dixon-gives-a-potted-history-of-integrative-medicine/

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College of Medicine and Integrated Health - Changing the conversation about health

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It may now be national policy and championed by both the NHS and the Government... but social prescribing still isn't on the radar of many practitioners, both in the UK and globally.

In our short video interview with Dr Michael Dixon, the College of Medicine's Chair, he explains exactly what he thinks social prescribing is, and touches upon its journey from being championed by a group of enthusiastic GPs to becoming national policy...

Here, College of Medicine Chair, Dr Michael Dixon, offers a guide to exactly what social prescribing is, how he discovered it as a disillusioned young GP and its earliest origins in the Peckham Experiment more than 70 years ago...
Watch our short video with him, offering a potted history of all things social prescribing, below:

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'Social prescribing is as old as the hills...' Dr Michael Dixon gives a potted history of integrated medicine - College of Medicine and Integrated Health

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It may now be national policy and championed by both the NHS and the Government... but social prescribing still isn't on the radar of many practitioners, both in the UK and globally.

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https://www.rsecovidcommission.org.uk/wp-content/uploads/2021/04/A-Desk-Review-of-Social-Prescribing-from-origins-to-opportunities.pdf

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https://www.linkedin.com/pulse/evolution-social-prescribing-gemma-griffiths/

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Social prescribing and the role for PCNs Enabling the development of social prescribing models to cope with the rising demand for community support coupled with capitalising on emerging new roles to support primary care are going to be key to Primary Care in helping cope with the additional demand t

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https://www.england.nhs.uk/personalisedcare/social-prescribing/case-studies/a-gp-perspective-on-social-prescribing-and-the-response-to-covid-19/

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Mohan Sekeram, is GP Principal at Wideway Medical Practice in Merton, RCGP Regional Clinical Lead London (Person Centred Care) and Clinical Lead for Social Prescribing in Wandsworth and Merton Borough.
We asked him about his experience of social prescribing in lockdown, and why he is convinced the PCNs should be including social prescribing link workers in their COVID-19 recovery plans.

What was social prescribing like locally before COVID-19 struck?

In Merton we have six primary care networks (PCNs) and nine social prescribing link workers across the borough. Within my practice we currently have two link workers who each work one day a week. Prior to COVID they would see up to seven patients in a day and contact patients initially over the phone. During COVID times they have been working remotely.

Link workers have really been the glue in bringing care together across the community. Patients can receive support for their 'non-medical' needs by speaking to a link worker who is able to connect them into the appropriate service. This is integral to personalised care and to identifying what really matters to an individual.

Family GPs are trusted by patients, and primary care being seen to endorse social prescribing link workers improves engagement with the people who need support most. They provide support that addresses the social and environmental issues that have such a big impact on people's physical and mental wellbeing. It's easy for us, and for the patients themselves, to be blinded to this need, as together we tend to 'medicalise' their symptoms.

What benefits have you seen from social prescribing generally - and also in response to COVID-19?

There have been huge benefits to community integration. The link workers have a fantastic relationship with the voluntary, community and social enterprise (VCSE) sector and know what services and assets exists to support our community. This has been fed back to primary care and allows utilisation of resources which previously we wouldn't have known about.

Embedding in primary care has been the real success. Link workers attend practice clinical meetings, staff meeting and multidisciplinary meetings - as well as social events. They have integrated wonderfully and adapted to the environment in general practice. This has allowed the service to grow and develop to fit in well with the overall care we provide in the practice and our PCN.

To start with, GPs were the only ones referring patients to the link workers but now the service has evolved, with nurses, healthcare assistants and receptionists all referring patients, as they often know things about a patient which the GP may not be aware off.

How are your SPLWs contributing to the coronavirus response?

The link workers have been contributing in a number of ways during the COVID response.

Practices have continued to refer patients who have an underlying social problem. The majority of referrals have been made via the Elemental software tool which allows the link workers to pick up referrals remotely from practices. The other way has been using manual forms and emailing lists of patients to link workers who have a secure NHS email account. The link workers have also competed data protection and GDPR training.

Other referrals have included giving link workers lists of vulnerable patients which have consisted of shielded patient list, vulnerable adults, mental health patients, carers and other groups which we have felt needed extra support. The majority of cases have centred around welfare checks, emotional support, domestic violence support, housing and employment issues, problems related to homelessness and many other reasons.

Link workers in Merton have also linked with pharmacy prescriptions and have been co-ordinating medication drop offs for vulnerable patients by using the NHS Volunteers and GoodSam app.

Many patients/clients have been very anxious during the current pandemic and worried about a number of things. Speaking to a link worker has provided reassurance and helped them to manage their anxiety.

Why should PCNs recruit social prescribing link workers?

In Merton we carried out a local evaluation with a group of our patients. It showed that 'pre COVID' times social prescribing reduced these patients' GP appointments by 33% and their A+E attendances by 50%. Their wellbeing scores improved by 77 %.

The link workers allow clinicians to concentrate on medical problems. We have seen the health and wellbeing of clinicians themselves improve as social prescribing has provided real solutions for patients with complex social needs. Previously these social needs would be side-lined as clinicians can feel ill-equipped to support these problems.

Problems often originate in deprived populations where health inequalities are at their greatest. Social prescribing helps tackle these issues and contributes to closing the inequality gap. Marmot (2020) talked about a widening gap in health inequalities where some areas had a reduction in life expectancy. We need to support our populations.

Link workers provide true integration into community assets which we need to build upon. They are expert at integration and are a vital component of population health management.

During COVID times, the link workers have been exceptional, adapting to the needs of the practice and the PCN. It has allowed our vulnerable and isolated patients to get the support the require. They have supported those in a crisis and will also be integral to our recovery offer.

If you could give one piece of advice to PCN leadership about social prescribing, what would it be?

My advice would be to support your link worker and provide clinical supervision to ensure they embed into your network and practice. They will find some fantastic resources which are in your own community and provide sustainable and real solutions for your patients.

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A GP perspective on social prescribing and the response to COVID-19 in Merton

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Mohan Sekeram, is GP Principal at Wideway Medical Practice in Merton, RCGP Regional Clinical Lead London (Person Centred Care) and Clinical Lead for Social Prescribing in Wandsworth and Merton Borough. We asked him about his experience of social prescribing in lockdown, and why he is convinced the PCNs should be including social prescribing link workers in their COVID-19 recovery plans.

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What is social prescribing? - YouTube

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Transformation Partners in Health and Care

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Carol's Going Local Story | Adur & Worthing Councils - YouTube

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Carol's Going Local Story | Adur & Worthing Councils

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Comprehensive Model of Personalised Care (short verison) - YouTube

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Comprehensive Model of Personalised Care (short verison)

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RSPH | Driving forward social prescribing: A framework for Allied Health Professionals

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Driving forward social prescribing: A framework for Allied Health Professionals

Social prescribing, sometimes referred to as community referral, is a means of enabling people to be referred to a range of local, non-clinical services.

Recognising that people's health is determined by economic and environmental factors, social prescribing seeks to address people's needs in a holistic way. It also aims to support people to take greater control of their own health.

Social prescribing can meet a wide range of needs, with many schemes aiming to improve mental health and physical wellbeing. It can be used to support adults, young people and children as well as people with learning disabilities or mental health problems. It can be used in primary and secondary care. Social prescribing can also help to address social issues such as debt, unemployment, gambling and loneliness.

Examples of schemes include volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports.

The extent to which we have control over our lives, have good social connections and live in healthy, safe neighbourhoods are all important influences on health. These community-level determinants are protective of good mental and physical health and can buffer against stressors across the life course.

Community-centred ways of working can be more effective than more traditional services in improving the health and wellbeing of marginalised groups and vulnerable individuals. For this reason, they are an essential way of reducing health inequalities within a local area or community.

Social prescribing and community-based support is part of the NHS Long-Term Plan's commitment to make personalised care business as usual across the health and care system. Social prescribing is one of the six components of Universal Personalised Care. The NHS Long Term Plan published in January 2019 has a commitment to personalised care and increasing access to social prescribing for the whole population.

Social prescribing should also be used by Allied Health Professionals working outside of the NHS. Social prescribing improves outcomes for people by giving more choice and control over their lives. It is effective at targeting the causes of health inequalities and is particularly useful for people who need more support with their mental health, have one or more long-term conditions, are lonely or isolated, and/or have complex social needs that affect their wellbeing.

There is a growing body of evidence that social prescribing reduces pressure on the NHS by directing people to more appropriate services and groups - an evidence summary published by the University of Westminster suggests that where a person has support through social prescribing, their GP consultations reduce by an average of 28% and A&E attendances by 24%.

More information and background to social prescribing is available in the All Our Health guidance on social prescribing.

There are 14 types of allied health professional:

Art Therapists

Dramatherapists

Music Therapists

Chiropodists/Podiatrists

Dietitians

Occupational Therapists

Operating Department Practitioners

Orthoptists

Osteopaths

Prosthetists and Orthotists

Paramedics

Physiotherapists

Diagnostic and Therapeutic Radiographers

Speech and Language Therapists

The ways in which AHPs will use social prescribing will vary according to their role. All AHPs however, have the skills and knowledge to use social prescribing to address both the presenting needs of the person and those which become apparent later on.

AHPs can engage with social prescribing in four main ways. These can be viewed as a spectrum from low AHP input (active signposting) to high input (AHP as prescriber). You may find that some of your social prescribing activities sit between the categories on this spectrum.

Click on the titles on the image below to visit the four sections of the framework.

With thanks to the following organisations who supported the development of the framework.

The NHS organisations involved are NHS England and NHS Improvement.

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Driving forward social prescribing: A framework for Allied Health Professionals

# data[].attributes.attachment_link.description
Social prescribing, sometimes referred to as community referral, is a means of enabling people to be referred to a range of local, non-clinical services. Recognising that people's health is determined by economic and environmental factors, social prescribing seeks to address people's needs in a holistic way.

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HEE elfh Hub (e-lfh.org.uk)

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This is a bite-sized session to give health and care professionals an overview of social prescribing - including key evidence, data and signposts to trusted resources to help prevent illness, protect health and promote wellbeing

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Health Equity in England: The Marmot Review 10 Years On - The Health Foundation

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We have commissioned the IHE to work on an analysis of health inequalities in England and update of the Marmot Review to be published in February 2020, on the 10-year anniversary of the Marmot Review.

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Health Equity in England: The Marmot Review 10 Years On

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Commissioned by the Health Foundation, the Institute of Health Equity is working on an analysis of health inequalities in England and update of the Marmot Review to be published in February 2020, on the 10-year anniversary of the Marmot Review.

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Microsoft Word - DTRT Summary of learning about outcomes measurement for social prescribing.docx (richmondgroupofcharities.org.uk)

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social-prescribing-around-the-world.pdf

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Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation | BMC Medicine | Full Text (biomedcentral.com)

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Show authors

BMC Medicine 21, Article number: 91 (2023) Cite this article

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Abstract

Background

Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D).

Methods

Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods.

Results

People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17-4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27-1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients' wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness.

Conclusions

Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.

Peer Review reports

Background

Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector (VCS) [ 1]. Activities are typically non-medicalised, provided locally and have a wide remit (from lifestyle programmes to welfare advice and/or community engagement initiatives, depending on patients' needs and local availability) [ 2, 3]. In the UK, the link between primary care and the VCS is facilitated by a link worker (also referred to as a social prescriber), whose role ranges from signposting to patients' needs assessment, ongoing support or the development of new VCS activities where gaps exist [ 4]. As part of the NHS Long-Term Plan, NHS England set to recruiting enough link workers to make the service available in every GP practice by 2023/2024 [ 5, 6].

SP is expected to advance the prevention and management of long-term conditions, such as type 2 diabetes (T2D) [ 7, 8], by encouraging a healthier lifestyle, self-management and personalised care [ 9, 10, 11]. However, the current evidence base for SP and its role in specific areas of health need, such as T2D, is scarce. This study focused on T2D prevention and investigated the role of primary care-based SP in people at high risk of the condition based on the following considerations. First, T2D is a major public health concern; it is common (and increasingly so) and is associated with reduced quality of life, life expectancy and considerable socio-economic consequences [ 12, 13, 14]. Both individual behavioural risk factors and socio-economic determinants appear to be major driving forces behind escalating T2D epidemics and health inequalities [ 15, 16]. Second, many community-based activities accessed through SP focus on healthy lifestyle, including weight management, dietary recommendations and physical activity [ 1, 17, 18, 19], which also underpin existing T2D prevention behavioural programmes, such as the NHS Diabetes Prevention Programme (NDPP) [ 20]. However, by also acknowledging people's underlying social constraints, SP may offer a means of providing contextually sensitive and holistic health promotion [ 21], in line with best practice recommendations for individual-level T2D prevention [ 22]. Third, NDPP focuses purely on the promotion of behaviour change in patients at high risk of developing diabetes. Delivered at scale through (mostly private) independent providers, NDPP has shown low uptake and high attrition rates, especially amongst socio-economically deprived and diverse ethnic groups [ 23, 24, 25]. There is thus a need for T2D prevention strategies to increase attention to patients' wider social context and improve their reach to those in greatest need.

This study aimed to investigate the possible role of SP in T2D prevention and evaluate the extent to which it may complement and inform existing preventative approaches (NDPP). We hypothesised that the reach and equity of access of SP and NDPP across high-risk patients within a multi-ethnic, socio-economically deprived population could differ and sought to understand why (and how) possible differences could occur. Using a realist mixed-methods design, we investigated, first, whether (and the extent to which) SP might reach high-risk patients in greatest health and social need; second, what "good" practice in SP relevant to people at high risk of T2D might look like; and third, key ingredients of SP that might contribute (or not) to T2D prevention.

Methods

Overview of study data sources and analysis. Legend: SP Social Prescribing; NDPP NHS Diabetes Prevention Programme; T2D Type 2 Diabetes; VCS Voluntary and Community Sector

Theoretical approach: realist evaluation

This study used mixed-methods realist evaluation [ 28], informed by a previous realist synthesis undertaken by this team [ 21]. Realist evaluation is a theory-driven methodology that seeks to facilitate a deep understanding of how complex interventions, such as SP, work and in what circumstances [ 29]. Causal narratives are central to realist evaluation but have a wider conception that goes beyond the criterion of observability to also account for the non-physical and unobservable-for example, the conscious or unconscious reasoning which drives individuals' decisions and actions [ 30]. In order to explore these underlying causal explanations, realist methodology is designed to tease out what are known as context-mechanism-outcome configurations (CMOCs) [ 31]. A CMOC is a hypothesis that the programme works (or does not work) (O) because of the action of some underlying mechanisms (M), which come into operation only in particular contexts (C) [ 32]. These causal explanations (also referred to as programme theories [ 33]) are made explicit and tested, confronted and refined iteratively throughout the research using a range of empirical data [ 27].

Study setting and intervention

Tower Hamlets was also one of the 27 areas across the country chosen to be part of the first wave roll-out of NDPP in 2016. The programme targets individuals at high risk of T2D, demonstrated by a diagnosis of non-diabetic hyperglycaemia or previous gestational diabetes. It is delivered by a private provider and commissioned by NHS England, with referral volume used as the main metric of site activity. General practice involvement is limited to the identification and referral of patients, enhanced through various incentives and support strategies. The core NDPP intervention consists of group-based sessions offering behavioural change content intended to achieve improvements in diet, physical activity levels and weight. The course consists of a minimum of 16 h of contact time over at least 9 months [ 20]. During the pandemic, sessions were held online or over the phone, depending on patients' preference.

Quantitative data

The study population was all adults (18+ years) without diabetes, registered with a GP in any of 35 practices in Tower Hamlets, east London, between 1 December 2016 and 14 February 2022. Electronic health record data were accessed from these GP practices via the Clinical Effectiveness Group, Queen Mary University of London, and pseudo anonymised at source under NHS and local information governance and data security policies. Detailed inclusion and exclusion criteria and study variables are presented in Additional file 1: Table S1.

Qualitative data

We collected different types of qualitative data to evaluate the actual delivery of SP, including key ingredients that could explain its potential in reaching high-risk patients with greatest health and social need. Qualitative data sources and sample characteristics are shown in detail in Additional file 2: Tables S1-S5. Briefly, we drew on [1] semi-structured interviews with 8 SP users at high risk of T2D, 11 primary care clinicians (GPs, nurses, a physiotherapist and health care assistant), 11 link workers and 13 local VCS organisations accessed through SP; [2] 36 hours of ethnographic observations of community-based SP activities (including holistic weight management and physical activity programmes), privately delivered NDPP sessions and VCS meetings; and [3] documents about the local SP scheme, NDPP programme and VCS organisations (including descriptions of activities on offer, target population, eligibility criteria and evaluation reports). Interviews and observations were initially conducted remotely (online or over the phone) and later shifted to face to face in compliance with COVID-19 safety measures. The sample size was determined iteratively guided by data saturation. Interview transcripts, fieldnotes and documents were initially analysed thematically. We combined a broadly deductive analytic approach (to test and refine previous realist review findings) with a more inductive analysis (to explore new, unexpected findings related to the specific intervention and local contexts) [ 43]. Data were analysed in six iterative stages (repeated reading, development of initial codes, generation, review and naming of themes, and writing), guided by the framework proposed by Braun and Clarke [ 44]. We sought negative cases (including contradictory findings and inconsistencies across and within data) and triangulated within the research team to enhance validity and rigour [ 45]. Data management was supported by NVivo V.10 software.

Integration of quantitative and qualitative findings

Data were integrated using visual means (also referred to as joint display integration [ 26]), which enabled drawing new insights beyond the information gained from the separate quantitative and qualitative results [ 46]. Referral patterns and practices were further contextualised in light of rich qualitative data to develop explanations of how and why they occurred and their meaning for people at high risk of T2D. At this point, a realist logic of analysis was applied, which involved making inferences about whether different components of the data were functioning primarily as context, mechanism or outcome (and the relationships between them) [ 32]. CMOCs were further reviewed, refined and tested against empirical data, our previous realist review [ 21] and through discussion with the research team and stakeholders.

Results

The extent to which SP succeeded in reaching high-risk people (quantitative findings) and the mechanisms by (and contexts in) which this was achieved (qualitative findings) are explained below.

Referral and non-referral to social prescribing in a population at high risk of type 2 diabetes: quantitative findings

Table 1 Distribution of socio-demographic characteristics within the total study population and their association with referral into SP, cohort study 1

Distribution of clinical features and their association with referral into SP among the total study population, cohort study 1. Legend: T2D Type 2 Diabetes. Cardiovascular disease includes Ischemic Heart Disease, Peripheral Arterial Disease, and/or Stroke and Transient Ischemic Attack. Respiratory condition includes Asthma and/or COPD. See Additional File 1: Table S2 for information on the variables included in each adjusted model

Of the total population eligible for SP, 9.2% (41,378) were identified as high risk of T2D and were, therefore, included in cohort study 2. The median follow-up period for these high T2D risk individuals was 5.2 years, which resulted in 5226 referrals into SP (164,614 person-years). The pattern of findings for high-risk patients was similar to the general population. As shown in Table 2, those referred into SP were more likely to be female (RR 1.54 (95% CI 1.46-1.64)), socio-economically deprived (RR 1.83 (95% CI 1.53-2.19)) and South Asian (RR 1.16 (95% CI 1.08-1.25)). Similarly, living with cardiovascular disease (RR 1.43 (95% CI 1.31-1.55)), obesity (RR 1.30 (95% CI 1.23-1.37)), mental health conditions (RR 2.31 (95% CI 2.18-2.45)) or multimorbidity (RR 1.98 (95% CI 1.88-2.10)) significantly increased the risk of being referred into SP. Adjustment for confounders, however, resulted in a lower attenuation, suggesting greater homogeneity in terms of socio-demographic features across this high-risk sample (see Fig. 3 and Additional file 1: Table S3). In all cases, the referral rate was higher at older ages and during the first year of service roll-out (December 2016-December 2017) (Additional file 1: Tables S4 and S5).

Distribution of clinical features and their association with referral into SP among people at high risk of T2D, cohort study 2. Legend: See Additional File 1: Table S3 for information on the variables included in each adjusted model

Table 2 Distribution of socio-demographic characteristics within the study population at high risk of T2D and their association with referral into SP, cohort study 2

Distribution of clinical features and their association with referral into SP amongst people eligible for NDPP, cross-sectional study. Legend: See Additional File 1: Table S6 for information on the variables included in each adjusted model

Table 3 Distribution of socio-demographic characteristics amongst patients eligible for NDPP and their association with referral into SP compared to NDPP, cross-sectional study

How did social prescribing contribute to meeting the complex health and social needs of people at high risk of type 2 diabetes? Qualitative findings

We identified the following four mechanisms through which SP operated to reach high-risk patients with greatest health and social need.

Accessible social prescribing: type 2 diabetes prevention as an inclusive and proactive care process

Unlike NDPP, SP had broad eligibility criteria (any patient 18+ and registered with a local GP could be invited). Lack of requirements for tests or medical assessments prior to a referral made the service easier to consider by referrers during routine consultations: "there's no restrictions. We don't have like; your blood pressure has to be this. Your weight has to be this. We can just refer" [Nurse 01.8]. Although patients were not necessarily referred based on their T2D risk, they often ended up accessing services relevant to its prevention: "[...] he was pre-diabetic and he was very, very overweight, which wouldn't surprise me because often these conditions go together. Through [name of physical activity programme] and the support he got, he lost a lot of weight. His sugar levels were much more normal, things like that. I think that's a good example of where he wasn't actually there for the diabetes side but actually it really helped him more generally" [VCS 03.9].

Our study also revealed that patients often lacked confidence and felt guilty or helpless to reach out and access the services they required. As expressed by a patient referred into SP: "I know how to contact her [the link worker] but you know, [...] I don't want to feel that you know - I feel a bit guilty really that I didn't follow up on a lot of the information that she gave me" [SPU 04.1]. Additional support was often needed to help them navigate (and reach) SP. Strategies included scheduling regular follow-ups with link workers, filling in referral forms in primary care (instead of signposting or encouraging self-referrals) or creating friendly and welcoming environments in the VCS with the help of volunteers, buddy systems and/or information packages, amongst others. However, the relationship between the provision of support and patients' access or engagement was non-linear and hence unpredictable. Patients often failed to respond, did not turn up to sessions or refused to carry on despite these supportive environments. Making services accessible in such situations often relied on providers' capacity (and willingness) to be tenacious and attentive: "She persevered, even though there would have been times when I did not pick up that phone and I did not want to talk to [name of link worker] or anyone. Yet again she would try and she would always inform me that 'I could not get hold of you today, I will try in another five or six days' time' and she always kept her promise" [SPU 04.3]. Accessibility was no longer a static service attribute, but rather a proactive ( creative and ongoing) process through which providers tried to overcome existing barriers and find ways to bring services closer to the patient.

Holistic social prescribing: type 2 diabetes prevention as a dynamic and personalised practice

Providers throughout the SP referral pathway proactively explored patients' wider socio-economic circumstances in search of concerns influencing their wellbeing and clinical presentations. Open conversations led to diverse courses of action, depending on the identified priorities. This broadened the scope and understanding of T2D prevention beyond lifestyle recommendations to also include services related to employment, housing or welfare advice, amongst others: "It's not just about 'I want to change my diet', it will be looking at the barriers to them changing the diet. We might refer for the diet and exercise classes, but we'll also refer to English classes and things like that" [Nurse 01.8]. Providers tried to widen and diversify their service remit to better accommodate patients' multiple, intertwined needs (e.g. by providing in-house legal advice alongside physical activity programmes, up-skilling link workers on relevant domains (such as health coaching, welfare advice) or even bringing welfare advisors and lifestyle programmes into GP practices): "for example on a Thursday it'd be the advisor here and the receptionist would say, come and see the advisor in the surgery at that time. They'd make an appointment with them in the same way you'd make an appointment with the nurse. That's excellent service" [VCS 03.9].

Instead of adhering to established, pre-defined ways of working, we identified joint attempts to work around patients' complex life circumstances and adapt services accordingly. This involved prioritising patients' context and the provision of support over the specific content and consistency of lifestyle recommendations: "It's not specifically saying, this is what you must do for cholesterol. This is what you must do for diabetes. Very often the advice is the same anyway. [...] the issue is not about the actual specific condition, it's more about getting that peer support to help that person manage whatever's going on for them in their life" [VCS 03.9]. Some patients needed "taking" ("I took patients on walking groups [...], just so that they go. [...] I've taken a patient to an ESOL class because she didn't want to go alone. So, I just took her to the first one" [LW 02.5]), while others needed to be listened to ("Sometimes also we receive referrals where they do not want any help; all they want is someone to listen to them" [LW 02.8]) or somebody to whom they could feel accountable ("I just needed somebody in a way to whom I could be answerable, if that sounds strange" [SPU 04.4]). Some patients preferred medicalised preventative approaches (where information about disease risk and anthropometric measurements were considered), while others responded better to "subtle" (opportunistic) lifestyle recommendations or regular follow-ups by health care assistants in primary care (instead of being referred into community-based lifestyle programmes).

Sustained social prescribing: type 2 diabetes prevention as an ongoing and unpredictable struggle

Patients reported that their capacity to follow a "healthy" lifestyle fluctuated over time, highly conditioned by the amount and consistency of support they received. Many patients had tried different weight management or physical activity programmes, managed to lose weight while being supported and then relapsed as the intensity of interventions decreased. Critically, the lack of a long-lasting response was interpreted by patients as a personal failure rather than a deficiency of the services in place or a consequence of underlying structural constraints (e.g. poverty, food insecurity, obesogenic environments, etc.): "when I did the [name of weight management programme] I'd gone down to 97kgs and that's the best I ever did in my entire life. In the entire 35 years of my life that was the best I'd done and I felt great and I was a good size 18 and I was so happy. Then within stopping that programme because it's again, for me, I think I lack and I don't think it's the services, for me I start something but [...] I never sustain that, I never maintain anything. So, [...] within a year I put all that back on plus more. So, it's been very difficult" [SPU 04.3].

Regular services, conversely, allowed for the provision of ongoing support. Patients could build on previous work and share the burden of (and, hence, better cope with) critical social and health constraints: "I just felt a little bit better that I'm not dealing with this on my own" [SPU 04.3]. Continuity of care allowed providers to monitor patients' progress (or lack thereof) and adapt their approach and next steps accordingly. "Testing and trying" involved making the erratic nature of prevention, as well as the limitations of existing interventions explicit beforehand. Knowing that interventions could fail, be insufficient or inappropriate prevented unrealistic expectations and shifted the responsibility of any potential failure from the individual to the intervention: "So, I think what the prescriber was saying was 'my resources are limited and you could go to this walk-in therapy and hate it and that's okay, you'd come back and tell me'. But I think so often people are referred to a social prescriber and they take up one offer and that doesn't work and so they think nothing will work" [SPU 04.4].

Ongoing services allowed for the development of meaningful ("therapeutic", "trustful") relationships with patients, across sectors and amongst attendees in group sessions: "a lot of people have been coming for 10 plus years, so they've built up these really good bonds with each other. So, not only are we looking out for them but they're looking out for each other" [R1 VCS 03.2]. Patients were made aware that "there [was] somebody there for them" [LW 02.5], which proved reassuring and had therapeutic effects by itself: "just knowing that there's people available for us" [SPU 04.2]. It counteracted feelings of helplessness and mistrust towards a system that had previously let them down ("if [the service] stops it's like, 'oh they're the same as everyone'." [VCS 03.8]) and provided some stability within a context of great service and staff turnover (both within the health sector and the VCS): "with many services in the community coming and going, [...] even in the NHS as well, programmes with different names each year, I think there's real benefit in having someone stable, by having a known person in a GP surgery that they can come to whenever there is a change in their life situation because that often provides that window of opportunity to really change something" [LW 02.2].

Integrated social prescribing: type 2 diabetes prevention as a locally embedded and joint endeavour

Bidirectional communication across sectors and among professionals allowed providers to develop greater knowledge on patients' needs, "build on other's work" and deliver consistent care. Clinicians became increasingly aware of patients' "underlying story" and able to adapt care practices accordingly because of the information that link workers had shared: "I quickly realised how much the GPs are really struggling to know what the story is behind the medical record and [...] just by sharing a few lines, [...] 'well actually this person had an accident last year or lost their job', just very simple things that make us able to humanise people and their choices" [LW 02.2]. Patients' medical notes provided link workers with "a two-sided approach" and relevant "context" ("background information") over which they could build their assessment and recommendations. Similarly, VCS organisations often received key information with or prior to a referral on how best to support a patient by avoiding specific "triggers" that had already been disclosed. Communication channels across and within sectors were also used to flag those patients requiring closer, urgent attention ("Usually, they give us one- or two-lines feedback [...] There's also something on the records [...] and, for very specific people that I'm maybe a bit more worried about, I may just ask them to let me know what has happened" [GP 01.1]) and/or reach out if they had not been contacted. Service providers became effective advocates by ensuring patients were not left behind and received the support they required: "When I felt depressed about my weight and not getting any contact from the weight management programme, [name of link worker] was right on it sending emails and making telephone calls, whilst I was on the phone by the way, and getting in touch with them and saying 'look, I've got a patient here named... she's waited for that number of weeks, why has nothing come through?' So, I felt like the support was first-hand" [SPU 04.1].

Integration (and embeddedness) within the local community and primary care system also enhanced the scope and responsiveness of services. Patients at risk of T2D ended up accessing physical activity programmes that would have been difficult to locate had it not been for the SP network ("any kind of exercise programmes that we have running or any health sessions we try and send out to the GPs and that's where a lot of our referrals came from" [VCS 03.2]). Link workers informed the design of VCS activities (e.g. lifestyle programmes, physical activity sessions) by sharing relevant information on identified needs and facilitated their development in local GP practices: "we would often run services at GP surgeries to increase accessibility. For example, [name of GP practice] has a room, we'd meet in there" [VCS 03.9]. Clinicians and link workers often worked together (and learnt from each other) to support patients with complex needs: "if you're having any difficult patients, challenging, you can bounce off or you can say, 'How are you dealing with that patient?' Maybe in a different way and you see whether you can make sense of it or not" [LW 02.4]. This not only led to greater service appropriateness but also strengthened the local community by creating new partnerships and opportunities: "there's an opportunity here for us to develop physical and social activities together. So it's about doing things together and one of the - we use local residents who've become qualified instructors, we try to keep everything local" [VCS 03.8].

Synthesis: primary care-based social prescribing as a means for successful individual-level type 2 diabetes prevention

Synthesis of study findings. How SP operates to deliver T2D prevention

Highly supportive ( proactive, welcoming) environments and broad ( inclusive) referral criteria made SP easier to access than NDPP by high T2D risk individuals in greatest health and social need (CMOC1). Holistic practices involved gaining understanding of these underlying health and social constraints (including what they meant for people at high risk) and providing tailored care and services accordingly. This was often achieved by holding broad conversations with patients and widening the scope and remit of available services (CMOC2). Following a "healthy" lifestyle proved highly demanding for patients at high risk (especially insofar as underlying drivers persisted) and hence benefitted from sustained (ongoing and open-ended) support by known and trustful service providers (CMOC3). Our quantitative data also clearly showed that people at risk of T2D with multiple physical and mental health morbidities were more likely to be referred to SP than NDPP and our qualitative data suggests that this likely reflects the integrated delivery of SP including cross-referrals, connected and seamless care within primary care and across sectors (CMOC4).

The identified mechanisms were interconnected and mutually dependent, meaning that they only became possible (and led to significant outcomes) as the rest of the dimensions co-existed. Holistic practices, for instance, were more than a set of questions asked in one consultation prior to a referral. They came about only over time (through sustained practice) as providers got acquainted with (and gained understanding of) the local population, their community and the specific patient involved. Similarly, providers were able to deliver proactive care and make sure services were accessed only through regular follow-ups and timely feedback from other practitioners ("I know she started because the [name of VCS organisation] updated me, so she has started" [LW 02.11]). Integrated SP facilitated a greater understanding of patients' circumstances, enhanced service responsiveness and allowed to address their needs holistically. Yet, far from representing a static structural dimension, it relied on trustful interpersonal relations across providers and hence required time ( sustained encounters) to be developed: "I've built such a good relationship with [VCS organisations], and it's because you've been doing it for so long, you get to know people on the team as well because you're backwards and forwards with emails" [LW 02.5].

Discussion

This mixed-method study, in a multi-ethnic, inner-city locality with high levels of deprivation, systematically illustrated how accessible, holistic, sustained and integrated SP practices in primary care appeared to support the delivery of individual-level T2D preventative approaches relevant (and available) to those in greatest health and social need.

The qualitative study showed that lack of disease (or diabetes)-specific eligibility criteria simplified the referral of patients to SP during routine, busy primary care consultations, which resulted in increased access of high T2D risk individuals to health promotion and wellbeing activities (all relevant to T2D prevention). This inclusive approach to T2D prevention seems particularly relevant given the low accuracy (and inconsistencies) of current pre-diabetes screening strategies (whereby patients may receive an incorrect diagnosis while others be falsely reassured and not offered any intervention [ 47]) and the generalised merit of healthier diet and exercise (which are likely to benefit most patients in multiple aspects of health, not just their risk of developing diabetes [ 48]). Our research suggests that accessibility in T2D prevention (and SP) can be best understood as a twin process of identifying patients' needs and conditions (instead of risk levels) while finding ways to make services readily available to them, which often entailed ensuring highly supportive environments.

We showed how patients' health-related behaviours (and consequent T2D risk) are contingent and socially patterned [ 49, 50], and therefore amenable to change insofar as interventions are within patients' material reach, familiar to their existing social world and relevant to their life circumstances [ 51]. The literature has shown mixed responses to similar T2D preventative strategies. For example, while some studies found that regular feedback regarding risk level prompted attendance to lifestyle interventions and successful behavioural change [ 52], others reported the opposite reaction, whereby obtaining new knowledge specific to patients' own risk elicited negative feeling and prevented further attendance [ 53, 54]. These inconsistencies confirm that different strategies work for different people and suggest (in line with our study findings) that a personalised ( holistic) approach which takes into consideration patients' specific (and changing) characteristics, priorities, expectations and circumstances might be better suited to deliver effective individual-level T2D prevention [ 22, 55].

The benefit of sustained approaches in T2D prevention has been widely acknowledged in the literature [ 22, 55]. Participating in interventions often acts as a relevant motivator for change and may provide "relief" (and sense of fulfilment) for being committed (and striving) towards betterment, regardless of the outcome [ 56]. Following healthy lifestyle recommendations may also be lived as an ongoing "struggle" (given underlying, persistent constraints) and hence benefit from continuous support [ 56]. Trustful relationships with service providers (enabled through and within ongoing interventions) have also been found to help patients make informed decisions about their health and contribute to healthy lifestyle maintenance. Critically, short-term interventions may lead to feelings of "frustration", "failure" or "guilt" amongst participants for not achieving the intended (though arguably unrealistic) outcomes [ 48, 51].

Our study, in line with published literature, revealed that high-risk patients often suffered from co-morbidities and multimorbidity, which made them require (and access regularly) primary health care. Integrating SP and T2D prevention into routine primary care allowed for opportunistic health promotion advice to those who might have contacted the GP regarding a different (yet, coexistent) concern [ 55, 57]. It also encouraged to think of and practice the promotion of a healthy lifestyle as an ongoing and incremental process, instead of a one-off intervention [ 58]. Lastly, relying on community-based, local organisations (as opposed to external private providers, as was the case in NDPP) contributed to strengthening the local community [ 53, 59]. Services became "more than a place" in which patients were seen (or referred into) to be also conceived as "community spaces" where meaningful social connection and community action could engender (whose benefits may transcend T2D prevention) [ 60].

Our study suggests that SP may offer an opportunity for individual-level T2D prevention to become more inclusive, personalised and long-term. Interestingly, this was achieved through the very same interlinked mechanisms that define the strength and essence of primary care (namely, comprehensiveness, continuity of care, contact accessibility and coordination, as defined by Starfield [ 61]). This parallelism reminds us that SP relevant to T2D prevention both requires and results in a strengthened primary care system. Such practices, however, did not happen in a cultural or historical vacuum. They were enacted within (and shaped by) an environment characterised by a long (and proud) history of partnership between the health sector and local voluntary, community and faith groups. In adapting and accommodating practices together (over time), SP became recognisable and relevant to all concerned.

Strength and limitations

The study has limitations. It was confined to a single locality with a particular history and ethos of social engagement and provider innovation. Findings might not, therefore, be applicable elsewhere-in particular the close and productive working relationships between public and third-sector organisations in our study site cannot be expected to occur everywhere. Quantitative data were restricted to referrals into SP (and/or NDPP) and did not, therefore, capture the extent to which patients actually engaged with SP or NDPP, the type and duration of activities accessed, subsequent actions or clinical outcomes. Qualitative findings, however, helped to mitigate these constraints by providing rich context and in-depth explanations, including the key ingredients for potentially successful individual-level T2D prevention and detailed accounts of how (and why) programmes may (or may not) work. Our quantitative dataset also showed 24% of missing ethnicity data, which although may have altered the real ethnic distribution of our cohort, is in line with the proportion of missingness described in published electronic health records studies [ 63]. Lastly, pandemic restrictions involved adaptations of both the intervention(s) (e.g. remote SP and NDPP sessions) and data collection strategies (e.g. holding some of the ethnographic observations and qualitative interviews remotely). This might have biased our sample towards less deprived and digitally literate participants. We sought to mitigate this by offering phone as well as video interviews, adapting interview schedules to meet individual circumstances and undertaking face-to-face interviews as soon as it was permissible and safe to do so.

Implications for practice and policy

This realist evaluation generates a framework (Fig. 5) that could contribute to guiding the development, implementation and evaluation of SP programmes relevant to the prevention of T2D in communities at high risk. Building on rich, empirical data we defined "best practice(s)" in SP relevant to T2D prevention and identified the conditions ("key ingredients") that need to be in place to facilitate this (and why).

Our study revealed the potential of accessible, holistic, sustained and integrated SP practices in T2D prevention. Critically, such approaches are not acknowledged by (and even seem to contradict) overarching SP health policy discourses and arrangements, which emphasise and prioritise the commissioning of short-term, motivational interventions [ 9]. Our study supports a revision of exiting SP health policy and commissioning strategies, so that they facilitate (and encourage) personalised, inclusive and long-term preventative approaches in primary care and the VCS. Study findings may also provide valuable insights into how to enhance the reach and equity of access of existing NHS T2D preventative strategies, such as NDPP (especially where a social gradient exists in those accessing and gaining benefit from the service) or develop adapted interventions that combine or integrate elements from SP and NDPP.

Conclusions

Our research revealed the need (and merit) of an alternative framing of individual-level T2D prevention: as personalised, long-term and inclusive practices rather than standardised, short-term and targeted interventions (such as NDPP). SP proved ideally placed to deliver this where practitioners, providers and commissioners worked collectively to achieve holistic, sustained, accessible and integrated services. The wider contexts in which these practices developed proved, however, far from neutral. Existing organisational arrangements, priorities and routines shaped providers' capacity (and willingness) to deliver SP relevant to patients at high risk. Additional research is being undertaken by the researchers involved in this study to investigate existing barriers and enablers for the delivery of accessible, holistic, sustained and/or integrated SP practices in primary care. Further research will also be critical to ascertain whether (and if so, to what extent) such practices contribute to reducing patients' overall risk of developing T2D and to support appropriate delivery and roll-out in different settings.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

NDPP:

NHS Diabetes Prevention Programme

SP:

Social prescribing

T2D:

Type 2 diabetes

VCS:

Voluntary and community sector

References

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Acknowledgements

We are grateful to all the patients, VCS and NHS staff who participated in this research. We also thank Tower Hamlets GP Care Group and Tower Hamlets Council for Voluntary Service for supporting qualitative data collection. We are grateful to our Stakeholders Advisory Group, including Isabel Hodkinson, Alison Robert, Dan Hopewell, Marie Polley, Suzy Willson, the National Academy for Social Prescribing, Diabetes UK and Social Prescribing Network, for their support and invaluable input. Thanks also goes to Cristina García-Mauriño who contributed to the statistical analysis. The data for the quantitative study is made possible by sharing agreements between GP providers in Northeast London and the Clinical Effectiveness Group, Queen Mary University of London, who have access to the deidentified records of all patients registered with Tower Hamlets general practitioners.

Funding

This doctoral research study was funded by ESRC London Interdisciplinary Social Science Doctoral Training Partnership (reference: ES/P000703/1) and Currier's Millennium Healthcare Bursary.

Author information

Authors and Affiliations

1. Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK

Sara Calderón-Larrañaga, Megan Clinch, John Robson, Isabel Dostal, Fabiola Eto & Sarah Finer

2. Bromley By Bow Health Partnership, XX Place Health Centre, Mile End Hospital, Bancroft Rd, Bethnal Green, London, E1 4DG, UK

Sara Calderón-Larrañaga

3. Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK

Trish Greenhalgh

4. Barts Health NHS Trust, Newham University Hospital, Glen Rd, London, E13 8SL, UK

Sarah Finer

Contributions

SCL conceived the idea and led the application for funding with input from SF, MC and TG. Quantitative data extraction was undertaken by SCL, ID and JR. Qualitative data collection was undertaken by SCL with input from SF and MC. SCL analysed the data with input from FE, SF, TG, MC, JR and ID. SCL drafted the manuscript with input from SF, TG and MC. SF, TG, MC, JR, ID and FE reviewed, edited and approved the final version of the manuscript for publication. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sara Calderón-Larrañaga.

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Ethics approval and consent to participate

This study has been approved by London - Bromley NHS REC and HRA (reference: 20/LO/0713). All patients signed a written informed consent to participate in the study.

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N/A.

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The authors declare that they have no competing interests.

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Calderón-Larrañaga, S., Greenhalgh, T., Clinch, M. et al. Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation. BMC Med 21, 91 (2023). https://doi.org/10.1186/s12916-023-02796-9
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DOI: https://doi.org/10.1186/s12916-023-02796-9

Keywords

# data[].attributes.attachment_link.title
Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation - BMC Medicine

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Background Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D).

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Highlights

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Theories of social practice illuminate routine social prescribing delivery in everyday context.

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Social prescribing depended on a variety of practices with different potential to support patients.

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Creative, reflective and adaptative practices facilitated successful social prescribing delivery.

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Limited resources and conditions often led to constrained social prescribing practices.

Abstract

Social prescribing (SP) typically involves linking patients in primary care with a range of local, community-based, non-clinical services. While there is a growing body of literature investigating the effectiveness of SP in improving healthcare outcomes, questions remain about how such outcomes are achieved within the everyday complexity of community health systems. This qualitative case study, informed by practice theory, aimed to investigate how SP practices relevant to people at high risk of type 2 diabetes (T2D) were enacted in a primary care and community setting serving a multi-ethnic, socioeconomically deprived population. We collected different types of qualitative data, including 35 semi-structured interviews with primary care clinicians, link workers and SP organisations; 30 hours of ethnographic observations of community-based SP activities and meetings; and relevant documents. Data analysis drew on theories of social practice, including Feldman's (2000) notion of the organisational routine, which emphasises the creative and emergent nature of routines in practice. We identified different, overlapping ways of practising SP: from highly creative, reflective and adaptive ( 'I do what it takes'), to more constrained ( 'I do what I can') or compliant (' I do as I'm told') approaches. Different types of practices were in tension and showed varying degrees of potential to support patients at high risk of T2D. Opportunities to adapt, try, negotiate, and ultimately reinvent SP to suit patients' own needs facilitated successful SP adoption and implementation, but required specific individual, relational, organisational, and institutional resources and conditions.

Feldman, M.S., 2000. Organizational Routines as a Source of Continuous Change. Organ. Sci. 11, 611-629.

Data availability

Data will be made available on request.

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What does social prescribing look like in practice? A qualitative case study informed by practice theory

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Social prescribing (SP) typically involves linking patients in primary care with a range of local, community-based, non-clinical services. While there...

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NASP Webinar: The latest evidence for social prescribing

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Power point presentation from Tracy Hopkins CEO of Blackpool CAB.