Case-based learning: social prescribing and pharmacy professionals

Social prescribing, also known as ‘community referral’, is a core component of healthcare practices and processes in various countries​[1]​. It was first introduced in the UK in the late 1980s by the NHS, but it was not until the early 2000s that wider ideas around social prescribing began to be embedded in healthcare policy​[2,3]​.

Since its inception, social prescribing has lacked an official definition, which has hindered the efficient implementation of social prescribing in the UK​[4]​. 

Broadly defined, social prescribing encompasses community-based services aimed at addressing non-clinical support and subclinical needs and contributes to the NHS’s commitment to personalised care as outlined in the ‘NHS long-term plan’​[5,6]​. When a need is identified, patients are referred to a social prescribing link worker (SPLW), who provide resources such as training, arts and time spent in nature, which aim to improve health and wellbeing and strengthen community connections​[1,5,7]​. 

SPLWs support patients via a personalised holistic assessment to improve their overall wellbeing. Specific support areas include loneliness and isolation, financial difficulties, physical and mental health, as well as social issues, such as career assistance. The diverse services offered range from bereavement support and pregnancy assistance to befriending services and cancer champions, highlighting an intricate web of integrated care​[8]​. To best identify the patient’s need, the SPLW conducts a social needs assessment that explores personal characteristics, financial resources, family and home life, as well as social and emotional health​[9]​.

It should be noted that the aim of social prescribing is not to replace traditional prescribing, but to complement it, and it is still an emerging area of research with limited studies on its economic and clinical effectiveness in practice. In research published in 2016, Maughan et al. highlighted the economic considerations when treating psychological disorders and suggested that the use of social prescribing could reduce healthcare costs in the long run owing to a reduction in secondary-care referrals​[10]​. Research has found that social prescribing has the potential to improve social networking and vocational skills, indirectly benefitting the economy as a whole​[11]​.

With a growing demand on the use of healthcare resources, further studies have highlighted the impact of social prescribing in reducing environmental costs of healthcare because it offers less carbon-intensive and lower impact alternatives in the community, and a reduction in hospital admissions and medicines production. In the case of green prescribing, it can also encourage people to feel more connected to the environment​[9]​. Therefore, social prescribing can be a way of tackling health and social inequalities in all healthcare settings​[12]​. 

The literature highlights the impact of social prescribing on patients living with long-term conditions in health-related behaviour and has found potential improvements​[13]​. This root-cause approach could aid in medicine management, such as tapering and stopping the use of antidepressants, because improvements in mental health have been observed with a community-based social prescription​[14]​. When navigating this landscape, it is essential for pharmacists to differentiate between social prescribers and social workers, considering factors such as financial considerations, waiting times and the presence or absence of safeguarding measures.

One main challenge of social prescribing is how to measure the success or effectiveness of particular interventions, which are often attempting to address problems that the patient has been living with for many years. This makes impact demonstration more difficult and “prescription renewal” can be a challenge​[15]​. It is estimated that most social prescriptions have a timeframe of just 8–12 weeks. In the bigger picture, the lack of this validation data could affect long-term commissioning and the expansion and survival of the scheme​[4]​.

Pharmacies have been identified as suitable settings for social prescribing, especially in high areas of deprivation, owing to their ability to communicate with patients face-to-face on a walk-in basis. Research published in 2019 by Taylor et al. revealed that the majority of surveyed UK pharmacists were enthusiastic about being involved in local social prescribing pathways, although they highlighted the barriers to involvement, such as the availability of funding, time and training​[16]​.  Lack of funding has forced pharmacies to reduce services provided to patients; this could be a barrier that restricts the role of pharmacies in offering social prescribing​[17,18]​.

Moreover, while prescribing pharmacists offer an opportunity to improve medication optimisation and minimise errors, social prescribing complements the holistic care aspect offered by pharmacists​[19,20]​. Patients have been found to be positive about pharmacy’s role in social prescribing, by reporting high satisfaction with appointment times, communication with the pharmacist prescriber and the services received.

Nevertheless, further research is required to clarify pharmacists’ role in social prescribing and their scope of competency, especially in mental health, where social prescribing can be used to address some psychosocial needs and offers additional capabilities to provide person-centred care​[21,22]​.

The following case studies illustrate some of the ways social prescribing approaches can be used and how pharmacists can engage in the process.

Case examples 

Case 1: Social prescribing to optimise antidepressant use via self-referral 

Since losing his wife one year ago, Raj, aged 52 years, has become more socially isolated, which led to him developing depression. His GP prescribed antidepressants — citalopram 20mg once daily — which are starting to help him feel better, but he is still feeling lonely and would like to wean off of the antidepressants, if possible. 

Raj was looking online at various ways to improve his wellbeing and he came across social prescribing on his GP’s website homepage, which mentioned the availability of extra specialist support for patients in his local area for various social and health issues. There was a link to ‘self-referral’ where he filled out a short form and, a couple of days later, he received a call from a SPLW. He did not need to see his GP to access this service. After discussing his situation, he was referred to a weekly local arts class, which increased his social interaction and led to him gaining a new hobby, which is linked to improved wellbeing​[23]​. He continued attending the class for 12 weeks and met a friend there, with whom he has started another arts class.

In the meantime, as he was picking up his regular medication from the pharmacy, he had a general check up with his regular community pharmacist and told him how he has been feeling much better since attending these classes. The pharmacist pointed out to him that this may be an opportunity to reduce his antidepressant medicine dosage, if he felt ready for it. A dose reduction would be a positive step in medicine management and optimisation, including better condition control and a reduction of potential side effects, such as dry mouth, feeling sleepy, headaches and nausea​[24]​.

On his pharmacist’s advice, Raj requested a review with his GP and he mentioned he was feeling better; therefore, the doctor suggested that he reduce his antidepressant medication strength to 10mg once daily.

Overall, Raj’s experience decreased his loneliness, improved his mental health, expanded his social connections and improved his wellbeing, which aligns with the general social prescribing measures of success​[25]​.

Case 2: Social prescribing referral from secondary care for physical health problems

Alex, aged 65 years, has recently been hospitalised following a fall caused by long-term osteoarthritis. Alex — who also has type 2 diabetes — lives with their partner who has health issues of their own, raising concerns about the need for additional support. During their discharge process, a holistic needs assessment was conducted and the discharge team, including the pharmacist, identified that Alex would require further support with basic chores at home and physical rehabilitation​[25]​. Here, the hospital pharmacist has a role in signposting the patient to either secondary care or primary care SPLWs, bringing their attention to social prescribing and the advantages it has to offer. 

As Alex did not exhibit any other safeguarding issues or mental health crisis risks, they were directly referred to the SPLW based in the local hospital for further support. Alex and the link worker met directly after discharge, when they created a tailored health and wellbeing plan.

Health and wellbeing plans assess each patient’s specific needs and can include onward referrals to various service categories, including physical activity, mental health support, weight management, welfare rights advice (benefits), voluntary work, learning and employment assistance, art-based activities and community based activities​[13]​. With the help of their link worker, Alex and their partner were able to apply for ‘Attendance Allowance‘, which supported them to hire a weekly cleaner.

The SPLW also assisted Alex in applying for a ‘Blue Badge’ — a process they found daunting — to support them when attending their frequent hospital and GP review appointments. Alex and their partner have been very grateful for the extra support they have received, saying that without it they would be overwhelmed to be able to get by otherwise. Specific long-term management of their arthritis and health management will still be under the care of the GP and is out of the scope of the link worker.

Case 3: Exploring the referral pathway in primary care 

Sara, a primary care network (PCN) pharmacist, conducts a structured medication review for one of her patients, Magdalena, aged 46 years​[26]​. As she delves into the patient’s health journey, Sara notices a social issue — one that extends beyond the scope of medications — which prompts her to consider the broader aspects of personalised care​[27]​. Magdalena is a full-time carer for her disabled son, which means she has neglected herself and no longer makes time to socialise or invest time in hobbies, which has meant she has been feeling down and generally burnt out. Evidence from Public Health England published in 2021 shows that carers experience a “carer burden” including experiencing poor mental health, anxiety and depression, stress and poor quality of life, most of which was underreported​[28]​. 

Given the setting within a general practice, Sara has several options to consider. If social prescribers were available within the same practice, she could make a direct referral​[29]​. Otherwise, Sara could take on the role of a ‘signpost’, guiding the patient towards relevant charities or third-sector organisations, such as Age UK, which are equipped with their own SPLWs​[30,31]​.

Sara understands the importance of patient consent in this process. Should she decide on a local referral, she takes the time to engage with the patient, explaining the potential benefits of the referred service. This step is essential to ensure that the patient feels informed and valued, avoiding any perception of dismissal.

Magdalena agrees to be referred to a link worker, who offers her a referral to a respite care service aimed at supporting unpaid carers. This service includes arranging outings for carers; meal and drink preparation; help with light chores; helping with the care of the care recipients, including personal and health care; and playing and reading with care recipients​[30]​. This all meant that Magdalena could have more time for herself.

At her next review, Magdalena thanked her pharmacist for making this referral and said it has been a “godsend” to have this support and that she feels so much better.

Conclusion

Pharmacists, including those working in communicty settings, can make a valuable contribution to the awareness of such services and they play a vital role in promoting self-referral routes, thereby empowering individuals to take charge of their wellbeing​[32]​.

Building and maintaining relationships between community pharmacies and general practices is pivotal. This collaborative effort allows for case-by-case discussions, contingent upon patient consent; however, as of the time of publication, a direct referral pathway from community pharmacies to social prescribers remains a missing link in the continuum of care.

Despite the increased number of resources for pharmacists to harness social prescribing, several challenges hinder its effective implementation. There is a lack of understanding of social prescribing, especially referral routes via different tiers of the healthcare system. Establishing a clear definition of social prescribing across health services is critical because it will catalyse decisive actions towards its integration into pharmacist practitioners’ practices. This would justify the need for increased investment in training and funding to support both prescribing and non-prescribing pharmacists, as well as pharmacy technicians, in embracing social prescribing.

More research is needed on the implementation of social prescribing by pharmacist practitioners. Meaningful change in implementation strategies can only occur through policy shifts and the allocation of resources toward enhancing the time and training provisions for pharmacists and pharmacy technicians.