A prescription for curing the social ills

Do non-medical treatments have any real effect?

There was a time when the medical strategy of social prescribing was seen as a folksy gimmick, in which a doctor would fill out a drug prescription form with a written order to get outside, maybe do a bit of gardening, or invite a friend for tea.

It made sense. These activities are associated with improved health, and for some, pursuing them can ease their troubles while also relieving pressure on overburdened family doctors.

Now, the gimmick has gone mainstream. The British health system, where the strategy originated, recently adopted it as a key government policy, and the past year has seen a steep rise in social prescribing in Canada as well.

This is the practice of medically prescribing nonmedical treatments to improve social determinants of health, such as loneliness, despair, and poverty. Common examples of recommendations include those for exercise, social interaction, walking, gardening, cooking in groups, or taking up artistic hobbies such as painting or knitting.

Since November, for example, Quebec doctors have been able to prescribe visits to the Montreal Museum of Fine Arts.

The Royal Ontario Museum in Toronto is likewise about to launch a pilot program in January, offering free admission with a prescription from a social worker, a health care or community professional.

The strategy is backed by theory widely seen as logical and intuitively attractive, especially for elderly people and the so-called worried well. Less serious ailments such as mild depression and some digestive and metabolism problems are known to respond well to exercise, for example. Social isolation is also a powerful determinant of health.

However, there is as yet no strong evidence of social prescribing’s effectiveness, partly because studies have been small, anecdotal, qualitative and poorly designed. Some studies have shown no effect at all. But, some have found improvements in self-confidence, weight loss, emotional well-being, and other factors that affect health.

Janet Brandling, a health researcher based at the University of the West of England, Bristol, described this evidentiary uncertainty in the British Journal of General Practice. “Is it yet another unwanted role to be foisted onto (general practitioners), or a welcome path away from the medicalization of society?”

Health care funders have adopted the strategy even in advance of widespread acceptance. In Britain, a large-scale monitoring system was recently launched to gauge the effects of social prescriptions, both in objective measures such as blood chemistry or weight, and in subjective measures such as social connectedness.

British Prime Minister Theresa May has called this a “loneliness strategy,” and “a vital first step in a national mission to end loneliness in our lifetimes.” To that end, Health Secretary Matthew Hancock has supported a drastic increase in social prescribing as a way to take pressure off the heavily burdened public health service, even going so far as to say social prescribing “can be better for patients than medicine.”

In September, Sadiq Khan, the mayor of London, included social prescribing as part of a strategy that aims to help doctors deal with the roughly one in five patient visits that are for non-medical problems.

In Ontario, the Alliance for Healthier Communities, a network of community health centres, recently launched a program to similarly measure the use and efficacy of the social prescribing strategy.

“People can be their own best resource for their health and well-being, when they’re connected to each other and the right services,” Kate Mulligan, director of policy and communications at the Alliance for Healthier Communities, said in a statement. “Social prescribing changes our lens from seeing individuals as patients with conditions, to understanding them as people with gifts.”

Brandling’s review of published science on social prescribing found that nearly all patients had a history of mental health problems and were “frequent attenders” at doctors offices. Many had chronic conditions, such as irritable bowel syndrome, fibromyalgia, or chronic fatigue. Most were female, and a common thread was limited benefit from medical interventions.

A 2017 U.K. study in the medical journal BMJ Open found social prescribing “engendered feelings of control and self-confidence, reduced social isolation and had a positive impact on healthrelated behaviours including weight loss, healthier eating and increased physical activity.”

PEOPLE CAN BE THEIR OWN BEST RESOURCE FOR THEIR HEALTH.

But another review in the BMJ surveyed 15 other studies and found most were small, poorly designed, with a high risk of bias, lack of controls, and short on followup. However, the article conceded that: “Despite clear methodological shortcomings, most evaluations presented positive conclusions.”

Another study from the U.K.'s Centre for Reviews and Dissemination at the University of York found no difference from exercise referral schemes as compared to usual care, but did find a significant reduction in mild depression, though not anxiety.

“Many trends begin as great, well-intentioned ideas,” Ranit Mishori, a professor of family medicine at Georgetown University School of Medicine, wrote in the Washington Post. “Before we start proselytizing, we need to make sure that the resources are there, that the evidence of benefits is there and that we, as physicians, are well trained in how to push a change without causing any harm.”