HEALTH: So­cial pre­scrib­ing.

The Saturday Paper - - The Week Contents - Sophia Auld

As well as writ­ing pre­scrip­tions for medicine, Aus­tralian GPs are be­ing en­cour­aged to fol­low the lead of

New Zealand and Bri­tain in “so­cial pre­scrib­ing”, where for­mal di­rec­tions are pro­vided on diet, ex­er­cise, med­i­ta­tion and more, writes Sophia Auld.

For many Aus­tralians, a visit to the doc­tor en­tails a brief con­sul­ta­tion, then get­ting handed a script with ad­vice to take some pills and re­turn if you don’t get bet­ter. That could be set to change, in a new ap­proach to gen­eral prac­tice that ac­knowl­edges our health needs are of­ten com­plex and re­quire more than med­i­ca­tion to suc­cess­fully man­age.

Fig­ures from the Aus­tralian Bureau of Sta­tis­tics show that in 2016–17, 83 per cent of Aus­tralians aged 15 and over had seen a GP in the pre­vi­ous 12 months. In the same time, 68 per cent had re­ceived a pre­scrip­tion. In the 2016–17 fi­nan­cial year, govern­ment ex­pen­di­ture on the Phar­ma­ceu­ti­cal Ben­e­fits Scheme was $12.058 mil­lion, an in­crease of 11.3 per cent on the pre­vi­ous year.

Doc­tors over­seas are al­ready em­brac­ing a more holis­tic brand of pre­scrib­ing. This ap­proach con­sid­ers life­style fac­tors such as nutri­tion, ex­er­cise and so­cial con­nec­tion, which have pow­er­ful in­flu­ences on risks for – and man­age­ment of – many of the so-called life­style dis­eases.

In New Zealand, for ex­am­ple, the govern­ment recog­nised the po­ten­tial for GPs to use al­ter­na­tive types of pre­scrip­tions to help pa­tients make healthy life­style changes, and in 1998, the Green Pre­scrip­tion (GRx) pro­gram was born. Un­der GRx, doc­tors and prac­tice nurses give pa­tients ad­vice and a writ­ten pre­scrip­tion for phys­i­cal ac­tiv­ity as part of their health man­age­ment.

Most GRx re­fer­rals are for pa­tients with chronic ill­nesses – such as car­dio­vas­cu­lar dis­ease and di­a­betes – with a fo­cus on help­ing them to self-man­age their con­di­tions. Rather than be­ing writ­ten for a phar­ma­cist, the pre­scrip­tion is pro­vided to the lo­cal sports trust or health or­gan­i­sa­tion, and a sup­port per­son is al­lo­cated to pro­vide help face to face, by phone or in a group, for three to six months. Pro­grams in­clude en­cour­age­ment and ed­u­ca­tion, nu­tri­tional guid­ance, goal set­ting and on­go­ing sup­port. The pa­tient’s progress is re­ported back to the re­fer­ring health pro­fes­sional. More than 51,000 adults were re­ferred in 2016–17.

The pro­gram is over­seen by NZ’s Min­istry of Health and ad­min­is­tered by dis­trict health boards. It de­liv­ers good value for money, ac­cord­ing to a min­istry spokesper­son. “Re­search go­ing back to the 1990s demon­strates the ef­fec­tive­ness and cost-ef­fec­tive­ness of GRx in in­creas­ing phys­i­cal ac­tiv­ity in adults and older adults,” the spokesper­son said, “and pos­i­tive im­pacts on car­dio­vas­cu­lar risk fac­tors such as blood pres­sure, as well as mea­sures of phys­i­cal and men­tal health.”

Pa­tients are happy with the re­sults, too. Sur­veys are con­ducted ev­ery two years, with 2016 re­sults show­ing that 72 per cent had re­ported pos­i­tive health changes since be­ing re­ferred to GRx, the spokesper­son said. Eighty-five per cent of sur­vey par­tic­i­pants were ei­ther very sat­is­fied or sat­is­fied with the sup­port they re­ceived.

Al­though GRx is not strictly an obe­sity ini­tia­tive, 53 per cent of the 2016 sur­vey par­tic­i­pants cited weight prob­lems as the rea­son for re­ceiv­ing their GRx, with pos­i­tive re­sults. “Seventy-five per cent had made changes to their diet, mainly re­duc­ing meal sizes and sug­ary foods and drinks,” the spokesper­son said. “Al­most half had lost weight since be­ing given their GRx.”

Though ini­tially tar­geted to­wards adults, in­creas­ing en­quiries iden­ti­fied the need for a pro­gram tar­get­ing in­ac­tive chil­dren at risk of ad­verse health ef­fects from be­ing over­weight or obese.

“These chil­dren and young peo­ple are usu­ally not par­tic­i­pat­ing in sports-based ac­tiv­i­ties. Their needs are greater and wider-rang­ing in terms of im­prov­ing their over­all health sta­tus and life­style when com­pared to adults,” the spokesper­son said. “The bar­ri­ers to par­tic­i­pa­tion for the child or young per­son can range from ac­tiv­i­ties be­ing in­ac­ces­si­ble or un­af­ford­able, to lack of parental sup­port, lack of con­fi­dence and self-es­teem.”

In re­sponse, New Zealand’s GRx Ac­tive Fam­i­lies now pro­vides com­mu­nity-based health ini­tia­tives en­cour­ag­ing phys­i­cal ac­tiv­ity and im­proved nutri­tion for those aged five to 18 and their fam­i­lies. In 2017–18, ad­di­tional fund­ing was al­lo­cated to sup­port obese fouryear-olds iden­ti­fied through be­fore-school checks, so more pro­grams are now in­clud­ing preschool chil­dren.

Al­most one quar­ter of Aus­tralian chil­dren and two thirds of adults are over­weight or obese, ac­cord­ing to a 2017 re­port from the Aus­tralian In­sti­tute of Health and Wel­fare (AIHW). Other AIHW fig­ures show that half of all Aus­tralians re­ported hav­ing at least one chronic dis­ease in 2104–15.

While “green” pre­scrib­ing hasn’t been for­malised as a way of man­ag­ing chronic con­di­tions in Aus­tralia, the idea is gain­ing ac­cep­tance and mo­men­tum, says Dr Deb­o­rah Sambo, a spokesper­son for the Royal Aus­tralian Col­lege of Gen­eral Prac­ti­tion­ers. “GPs al­ready pre­scribe a range of non-drug/sur­gi­cal ther­a­pies for pa­tients, in­clud­ing ex­er­cise, diet, self­help groups, books, med­i­ta­tion, tai chi, yoga classes and other so­cial groups like men’s sheds,” she says. “Hope­fully, we can start to see more doc­tors us­ing it with more con­fi­dence as a recog­nised man­age­ment op­tion with great ben­e­fits and sav­ings for doc­tors, our pa­tients, govern­ments.”

In Bri­tain, more than 100 schemes al­low doc­tors, nurses and other pri­mary care prac­ti­tion­ers to pre­scribe ev­ery­thing from cook­ing classes to vol­un­teer­ing, in what has been dubbed “so­cial pre­scrib­ing ”. Emerg­ing ev­i­dence shows that so­cial pre­scrib­ing can lead to im­proved qual­ity of life, men­tal and gen­eral well­be­ing, and re­duced lev­els of de­pres­sion and anx­i­ety.

More than a mil­lion pa­tients are seen in British gen­eral prac­tice ev­ery day. Pro­fes­sor He­len StokesLam­pard, chair of the Royal Col­lege of Gen­eral Prac­ti­tion­ers (RCGP) in Lon­don, says, “GPs will al­ways take into ac­count the phys­i­cal, psy­cho­log­i­cal and so­cial fac­tors po­ten­tially af­fect­ing their [pa­tients’] health when mak­ing a di­ag­no­sis and for­mu­lat­ing a treat­ment plan.”

“Some pa­tients, how­ever, might not need tra­di­tional med­i­cal care and in­stead ben­e­fit from so­cial pre­scrib­ing, such as light ex­er­cise, join­ing a lo­cal so­cial group, or tak­ing up a hobby to help them mix with other peo­ple.”

Stokes-Lam­pard ar­gues that ex­pe­ri­enced GPs have al­ways prac­tised so­cial pre­scrib­ing. “It’s just never had a name un­til now. The ben­e­fits, how­ever, are vast: pa­tients need less pre­scrip­tion med­i­ca­tion, fewer con­sul­ta­tions, and are more likely to take an ac­tive role in their own health.”

A 2013 study con­ducted at the Univer­sity of the West of Eng­land looked at the ef­fec­tive­ness of so­cial pre­scrib­ing in Bris­tol. It found im­prove­ments in anx­i­ety lev­els, and in par­tic­i­pants’ feel­ings about their gen­eral health and qual­ity of life.

An­other study, from Sh­effield Hal­lam Univer­sity and con­ducted be­tween 2013 and 2017, ex­am­ined a scheme in Rother­ham. They found that more than 80 per cent of pa­tients re­ferred to the scheme who were fol­lowed up three to four months later re­ported re­duc­tions in their use of the Na­tional Health Ser­vice (NHS).

“For GPs, so­cial pre­scrib­ing can po­ten­tially free up pre­cious time which can then be spent on pa­tients with com­plex health needs, and, in turn, help to ease pres­sures on surg­eries and the wider NHS,” StokesLam­pard says. The RCGP is call­ing for the NHS to fund ev­ery prac­tice for a ded­i­cated so­cial pre­scriber.

So­cial pre­scrib­ing tri­als have started in Aus­tralia, look­ing at its role in help­ing in­jured work­ers get back on the job. “A cou­ple of pi­lot pro­grams have been run­ning for a while with the sole aim of iden­ti­fy­ing the so­cial, men­tal and well­be­ing needs of the in­jured pa­tient, con­nect­ing them to avail­able com­mu­nity ser­vices and giv­ing them a bet­ter chance at holis­tic well­be­ing and health while they re­cover from their in­jury,” ex­plains Sambo. “The re­sults are very … en­cour­ag­ing. I fore­see these pi­lot pro­grams go­ing na­tional soon.”

While trial re­sults may be promis­ing, Aus­tralian doc­tors still face bar­ri­ers to im­ple­ment­ing new meth­ods of pre­scrib­ing, Sambo says. These in­clude a lack of re­sources, as well as what she calls “old habits”.

“Once peo­ple break the con­ven­tional think­ing of man­age­ment of pa­tients as drugs, al­lied health ther­a­pies and/or surgery only, then that is a big step to­wards em­brac­ing so­cial and green pre­scrib­ing.

“Other is­sues may cen­tre around con­fi­den­tial­ity and pri­vacy, es­pe­cially when you are rec­om­mend­ing so­cial groups or even link­ing peo­ple to other peo­ple – be they sup­port peo­ple, or peo­ple with sim­i­lar ail­ments.”

Once such bar­ri­ers are over­come, so­cial pre­scrib­ing has ben­e­fits for ev­ery­one in­volved. Sambo says its po­ten­tial is “huge”, pro­vided ap­pro­pri­ate sup­port and pro­tec­tion is avail­able for doc­tors will­ing to con­sider it.

“For the doc­tor, so­cial pre­scrib­ing comes with de­creases in the num­ber of side ef­fects and com­pli­ca­tions of­ten as­so­ci­ated with con­ven­tional treat­ment modal­i­ties like drugs and surgery. There is also a de­crease in hos­pi­tal­i­sa­tions or use of acute-care ser­vices like emer­gency depart­ments, which we all know cost tax­pay­ers a for­tune.”

So­cial pre­scrip­tions don’t usu­ally re­quire ex­pen­sive equip­ment, and they come at min­i­mal to no cost, she says. “These trans­late as big sav­ings for pa­tients and govern­ments alike.”

All that re­mains is for Aus­tralia “to har­monise and crys­tallise so­cial pre­scrib­ing as a treat­ment op­tion in its own right,” she says. “We will cer­tainly see more and more GPs ac­tu­ally us­ing so­cial/green pre­scrib­ing as a first man­age­ment op­tion, or as an ad­junct to other

• man­age­ment modal­i­ties.”

Dr Deb­o­rah Sambo, spokesper­son for the Royal Aus­tralian Col­lege of Gen­eral Prac­ti­tion­ers.

SOPHIA AULD is a free­lance writer and edi­tor based on the Sun­shine Coast.

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