Thursday, 5 December 2019

Social Prescribing for people living with cancer?

Sir Sam Everington at Penny Brohn
At the Penny Brohn AGM last month we heard from the passionate, enthusiastic Sir Sam Everington, who has worked as a GP in Tower Hamlets since 1989 in the Bromley By Bow partnership. He spoke about the social prescribing delivered at the centre and how it is about more than medicine to meet the holistic needs of people. 

Social prescribing is a way for GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services. These can include volunteering, art, gardening, cookery, healthy eating advice, sports and more. There are different models for social prescribing, but most of them involve a link worker who works with people to access local sources of support. 
The Bromley by Bow Centre in London is one of the oldest and offers most patients several sessions to help them get involved in more than 30 local services ranging from swimming lessons to legal advice. It is also a beautiful community space; indeed Gloucestershire’s Barnwood Trust highlights it in a leaflet of good examples of welcoming community spaces.

Barnwood Trust leaflet
There is a useful report here that shows the wonderful impact the Bromley By Bow Centre has had on people (i). In their annual GP Practice survey an amazing 100% of respondents wished to see the social prescribing service continue. The Kings Fund note how hard it is to measure impact but there seems to be growing evidence that it can lead to a range of positive health and well-being outcomes (ii). In 2017 a report 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% (iii).

NHS England has described the approach as a key component of the NHS Long Term Plan and has committed to funding primary care to employ 1000 new social prescribing link workers by 2020/21 “with significantly more after that”. 

This approach is great as it recognises that our health is determined by a range of social, economic and environmental factors; you can see my previous blog here on how we so need that more holistic approach. I’ve seen a number of good social prescribing projects which really seek to address people’s needs in an holistic way. Health journalist Amanda Barrell (iv) writes: “ prescribing has the potential to shift the dial. With a more holistic approach, it could take the NHS from a reactive health service to a proactive wellness  service, while reducing pressure on secondary care and general practice. But quite how it will fit in with the already fragmented health service and its various stakeholders is unclear. As with most paradigm shifting projects, social prescribing has some high logistical hurdles to clear before its benefits can be reaped."

Certainly at present services are patchy and approaches vary considerably in the network of some 2,000 or more projects across the country. Some focus on areas like arts and culture (v) or exercise, some are are much broader, some spend a lot of time matching people to their activity, others hand out phone numbers for people to follow up themselves. Some have focused on particular sections of the population or particular conditions. 

Bromley By Bow, is one example where they had a pilot service in partnership with Macmillan aimed at supporting people with cancer; that has ended but their legacy in terms of awareness raising and more lives on (vi). There are various other cancer-related schemes around the country that are also about exploring possible community-based services and activities that best fit and help patients get back to living their lives. Although there are questions about the value of putting people together with the same issue. In these examples it is clearly around the benefits of supporting and understanding each other through a similar journey - but isn't that just another way of creating a cancer support group?

Compassionate Frome

Another interesting project that has elements of Social Prescribing is The Compassionate Frome project, launched in 2013 with paid 'health connectors' to help people plan their care then with volluntary' community connectors' to help people find the support they need within the community. Basically the health centre, community hospital, social services, local charities and other groups have come together to map existing resources. Then brought together the volunteers to help set up groups requested by members of the community and the create one-to-one support relationships. 

Compassionate Frome are having some great outcomes and I know they are keen to share their model. However I also know that what works best is what is created by local people's passions, gifts and connections in the context of their own community; a model doesn't necessarily fit everywhere but of course learning from what others have done can be powerful stuff. See George Monbiot article on Compassionate Frome and communities here (xii) and a Resurgence article here (xiii).

In Stroud there is a group exploring the Frome model to see if something similar might work here. I attended one of the first meetings where over 30 people attended and there is now a group exploring a possible Stroud version. See SNJ article here (ix).

So some Social Prescribing schemes seem very positive but is there room for improvement? In the next bit I outline some of the issues that have been raised about Social Prescribing. As always I’d love to hear others views.

Anti-Social Prescribing!

In London last weekend, as my previous blog noted, I managed to visit the Wellcome Collection including Jo Spence’s ground-breaking photography that included her own cancer journey (vii). In one of the other exhibitions I joined a ’session’ on 'Anti-Social Prescribing’ which was part of a special 'Festival of Minds and Bodies’ (viii). 
Anti-Social Prescribing
 Dolly Sen, performer, poet and film-maker gave out an “anti-social prescription”; these included a walking group to nowhere and an anger mismanagement course. I got a prescription from her for mindfulness colouring-in, only to find we had swear words or politician’s faces to colour. Sen, who in the past has experienced her own mental health challenges, says she created these prescriptions as 'a response to the increasing trend of prescribing activities that emphasise an individual’s responsibility instead of dealing with the underlying issues causing them difficulties’. I found myself saying 'yes, yes, yes’ as we see this in so many aspects of life; too often the individual is seen as the problem and wider factors are not even looked at.

Obesity, for example, is framed as an individual or family problem that needs to be sorted with diets. Yet this ignores the fact that it is a product of social inequality and requires a collective social response. Research shows how poorer people are pushed towards unhealthy eating due to a host of factors like income, knowledge, preparation time and skills. A 2007 Government report outlined over 100 factors which contribute to an individual’s weight with genetics playing a key role (ix). 
Martin Cohen writing in The Independent (x) says: "The point is that we need to collectively tackle the places where obesity germs breed – in stressed communities characterised by insecure and erratic employment, inadequate education, stress, depression and a lack of social cohesion. That this requires an enormous shift in public priorities is only to be expected – but the consequences of not acting are far worse.”

Cancer can often be seen as similar; the focus on individual responsibilities rather than dealing with the causes of those difficulties. In terms of the above example of obesity, Cancer Research UK, launched a campaign last year about obesity causing cancer. Cancer Research UK said being obese or overweight is linked to 13 different types of cancer, but only 15% of people in the UK are aware of the connection. However many were critical of this. Comedian Sofie Hagen saw it as ‘fat shaming’ and her tweet led to many more criticisms of the campaign and a backlash against herself for raising the issue. In a similar vein the graffiti on one of their billboards (see photo) tryies to make the point that it is not that simple. Certainly there are some challenges with the ad as, not least, it frames obesity as a lifestyle choice and encourages weight stigma.

A top-down programme?

Cormac Russell, Managing Director of Nurture Development and a faculty member of the Asset-Based Community Development (ABCD) Institute at Northwestern University in Chicago talks about how some 40% of people visiting their surgery are lonely. There is also research showing that people can extend their life by up to four or five years if they are members of their local community groups and associations. So for many it is not necessarily medical attention that will be needed but community connection. Cormac, from whom I was fortunate to receive mentoring in the past, says; “Doctors hold keys to the medicine cabinet, but what they don’t hold is the keys to the community. So how can we support our GPs to figure out how they can refer people who need to build relationships in the community?”

In terms of social prescribing, Cormac acknowledges that the idea that a GP would not medicalise somebody is progress and that it is also better that GPs hand on folk to third sector organisations. However the challenge is now about how do we make sure that lonely, isolated people can themselves identify what they care enough about to get involved in. So instead of GP’s prescribing groups what we think are best for 'patients', we need to deeply listen to what those people care enough about to act on. Then support them to build relationships that are reciprocal not in groups where they sit passively in receipt of some activity. 

Of course schemes like Bromley By Bow already seem to be taking on that challenge with link workers helping people identify what they want to do. However I, like Cormac, have some difficulties with the term ‘social prescribing’. I don’t think it appropriately describes what is happening when someone is supported back to connecting with their community. Furthermore there seems to be an unhelpful power dynamic at play between medical services and patients. Health is maximised by empowering doctors and patients to develop `adult-adult’ rather than `adult-child’ relationships.

In Kelly Turner’s book ‘Radical Remission, Surviving Cancer Against All Odds’, she covers nine key areas that helped people with healing their cancers, one of those was how you 'take control of your health’. The current, all too prevalent view, in health services is that ‘patients’ who listen and follow instructions are good patients, others who challenge can get labelled ‘difficult’ or ‘annoying’. Yet the evidence Turner pulls together shows how important it is to take an active, rather than passive role in our health, be willing to make changes in our lives and deal with resistance or criticisms from others.

This highlights how crucial perceptions can be; some prescribing schemes may well locate the power more in the individual but I have heard of others where they are instructed that they do some certain activity. Indeed Turner suggests we should never be a ‘patient’ again but rather one who decides to take an active and engaged role in their life and health. Yes to that!

Danger of turning relationship building into a programme?

Lastly Social Prescribing is too often about referrals to community and voluntary sector activities, usually run by paid workers, so it rarely enables socially isolated individuals to participate and connect with their own neighbourhoods. This misses an opportunity to build more reciprocal relationships where each person is received and celebrated for their gifts. Indeed some Social Prescribing can be about referral and signposting with no emphasis on enabling communities.

So the question for me is more about how we can invest more in supporting local residents in building welcoming communities? We know this will also enhance health outcomes and reduce inequalities plus a host of other benefits like feeling safer. But then I could be considered bias as I have a part-time job working alongside Community Builders in Gloucestershire! It is also worth adding that some of the Social Prescribers I’ve met in the County are doing a great job and that it has been good to be working alongside them.

Cormac Russell (xi) puts it nicely when he writes: "Supporting people to create pathways towards a good life is not about prescriptions or referrals, it is about walking alongside people in their life’s journey. A doctor can’t do that alone, but they can advocate for greater participation and ensure that social issues are not medicalised, and community efforts are not devalued”. 
What do others think? What would be most useful for folk living with cancer in Gloucestershire?

More info
You can see Cormac Russell's thought-provoking ten minute video here plus his four part blog which includes a look at how social prescribing can be shifted into more effective practice in terms of connecting people into reciprocal community relationships and why a community building approach is part of the answer:
Glos Cancer Exercise

(vii) See my blog about the Jo Spence exhibition at the Wellcome Collection:
(viii) 'Festival of Minds and Bodies’ was a series of exhibitions and events to challenge assumptions about what’s ‘normal’ and what we value. There were also some great events that I missed like a panel of disabled people talking about ’The Trouble with Charity’, another talk on 'The Politics of Deafness’, various dance and other performances including a woman roaming through the exhibition with her collecting tin for fictional charity Help the Normals. The exhibition was full of creativity and humour - not a surprise to me when I saw the exhibition was curated by Jess Thom and Matthew Pountney, co-founders of Touretteshero. I met Jess a long while back and was totally impressed by her then - particularly the way she talked about Tourettes in an accessible and fun way. You can see my film from when she spoke about Tourettes in Nailsworth in 2013:
And a second film with Jess answering questions:

1 comment:

  1. Great to see new film from Bromley-by-bow:


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