Prescribing pills or people : the perplexity of social prescriptions DISCUSSION

Social prescriptions are increasingly being integrated into the medical curriculum – whether that be prescribing physical exercise for heart disease or a book group for depression. This is unknown territory for many medical students (and indeed doctors) with the risks and benefits being largely uncharted. Medical schools today adopt a holistic approach to medicine, teaching students to consider the whole patient rather than just their disease and encouraging shared decision making between doctor and patient. Social prescribing goes hand in hand with this, and so will undoubtedly become increasingly popular in the future despite conflicting evidence. For these reasons, it is important for medical students to understand exactly what social prescribing is and how it can potentially benefit their future patients.

Everybody knows that one of a doctor's main roles is to prescribe, whether that be pain medication for a joint problem, antibiotics for an infection or chemotherapy for cancer.The possibilities are endless.Receiving a prescription could be a patient's main expectation following a GP consultation, with many expecting a prescription involving a trip to the pharmacy and physical medication.Recent movements, however, is diverging from this 'traditional' route and encouraging the prescription of a wider range of therapies, such as exercise or an art class.Initially, this may seem slightly odd to patients and convincing them of the benefits could potentially be a consultation in itself.Despite this, emerging evidence suggests that it could make a real difference to their health and wellbeing.

What is social prescribing?
Social prescribing refers to a non-clinical recommendation, often to local services, which can improve the health of a patient in some way.The options available vary widely but some examples include support groups which help with pain and fatigue management, language support for those with learning disability, and respite care for carers.(1) Rather than fixing a problem in the short-term, this enables doctors to tackle the root of a problem with the aim of preventing the patient from presenting again in the future with a similar problem.Not only could this drastically change our patients' lives for the better, but it could change the approach to many conditions, and ultimately healthcare.The World Health Organisation places an emphasis on preventing disease and allowing patients to take control of their own health; (2) furthermore, the Secretary of State for Health has expressed his view that the government should not "stand in the way of" what a GP thinks is necessary to improve a person's health.(3) Social prescribing is a unique, holistic way to empower both doctors and patients to make decisions regarding care.

The importance of holism
Holism within healthcare has been encouraged for a long time; it promotes selfreliance and breaks down the paternalistic walls which were historically placed within the doctor-patient relationship.(4) It emphasises prevention rather than cure, and accounts for entire communities rather than just the individual.( 5) Not only does social prescribing do this, but it could also be the cure.The World Health Organisation defines health as a state of not just physical, but also mental and social wellbeing (6) and many patients may consult their GP due to concerns regarding their social situation rather than a 'traditional' health problem.Interestingly, studies have shown that patients from more socially-deprived backgrounds rate consultations based on whether their doctor takes a holistic approach to care as opposed to the quality of care given.( 7) Moreover, doctors who socially prescribe tend to take a more holistic approach in general and believe that encouraging a patient to take control of their own health is at the core of general practice.( 8) With the current fragile state of the NHS and the increasing burden of an ageing population, it is important now, more than ever, that the public have trust in their doctors.By prescribing socially, not only could it benefit the patient's health, but it could also improve their satisfaction with the system.

The evidence
Although social prescribing is being promoted as revolutionising general practice, (9) the evidence is conflicting.In fact, several systematic reviews have found little evidence to suggest that social prescribing is cost-effective or successful.(10) One particular outcome that has been measured many times is physical activity following the social prescription of exercise.In their meta-analysis, Pavey et al. found no significant difference in the amount of physical activity per week, cardiorespiratory fitness at follow-up, systolic and diastolic blood pressure and depression and anxiety in patients who were in the exercise referral scheme compared to those who were not.(11) However, the quality of the evidence is low in that many of the primary studies have a high risk of bias and are only small, given that they are pilot studies.In order to determine whether such an intervention is worthwhile, further research is required such that higher quality studies can be included in a systematic review and metaanalysis.
However, the amount of evidence which favours drug-based therapies is overwhelming and is not as difficult to promote as social prescribing.For example, informal diet and lifestyle advice is the first-line treatment for a patient presenting with high blood pressure, closely followed by a drug prescription.The evidence to support this is vast (12) and many may argue that adding a social prescription to this list has the potential to waste time, especially due to the existence of evidence which shows that a patient is no more likely to experience any benefit from it.(11) If a patient would benefit from a drug, then it could be viewed as detrimental to instead prescribe something else which has not been found to be successful.
To determine the feasibility and effectiveness of social prescribing, it is true that further studies and analyses are needed.However, social prescribing varies from gardening to poetry, and can be prescribed for multiple problems.Consequently, it would be almost impossible to commission such a large-scale study, and the number of singular studies needed to incorporate everything would be endless.Instead of hoping for this unlikely definitive evidence, it is more realistic to place a focus on the patients themselves, especially given that they are the group who would be most affected by the formal introduction of social prescribing in general practice.Studies have found that, in terms of mental health, patients benefit enormously.For example, when addressing specific mental health issues, such as depression and anxiety, the social prescription of a self-help computer program is beneficial and is recommended by the National Institute for Health and Care Excellence, following several randomised-controlled trials.( 13) Furthermore, several meta-analyses have found that the prescription of bibliotherapy improves the mental health of those who suffer from depression.( 14) A review which evaluated 35 of the UK's social prescribing schemes using 42 papers found not only an increase in confidence and self-esteem, but also physical health, amongst patients who fulfilled their social prescriptions.(15) This can be translated into quantitative evidence, for example in the Rotherham 'Social Prescribing' pilot, which found that hospital admissions and outpatient appointments reduced by half in selected patients following the implementation of a social prescribing scheme.(15) Despite there being an overall lack of evidence for social prescribing, the pooling of results from current schemes undeniably show the potential advantages to patients.
The British Student Doctor Volume 3, No. 1 (2019) The future As more and more studies gradually emerge, it is inevitable that social prescribing will become increasingly integrated into general practice.The impact of this is currently unknown.It is hoped that it will help to reduce the number of consultations for those who see their GP often and as a result reduce the burden on general practice, which was observed amongst a group of socially isolated patients in London.( 16) Furthermore, increases in mental wellness and patient satisfaction may be observed, which is driven by the behavioural changes encouraged by social prescribing.( 17) 'Heartsink patients' will no longer be a source of anxiety and stress, clinic lists will no longer consistently be behind schedule, and consultations for social problems will reduce.Although optimistic, this future is one that is desired amongst many general practitioners.( 18) Social prescribing, although perhaps not the answer, could be the first baby-step in this direction.Although currently unclear as to how drastic these changes may be, the benefits clearly outweigh any potential damage and current schemes suggest that the future looks promising.

Conclusions
This promising future lies in the hands of current students, which is an exhilarating prospect.In order to truly make changes, the patient must always come first, a fact which both students and current doctors must always remember.Social prescribing, which may involve venturing into unknown territory for many, puts patients in charge and allows them to drive their own healthcare forward.This contrasts with the passive role a patient adopts when handed a drug prescription.This shift away from paternalism is still occurring and promoting patient autonomy and empowerment is at the heart of the future of medicine.As medical students, it is especially important to adapt to this movement and take the lead.This way, we can truly make a difference -even if it is just seeing your patient smile.