National framework for social prescribing: integrated impact assessment

Background

Wales, like all countries, experiences and tackles persisting inequalities ^{[footnote 1]} in many areas, including health and wellbeing. There are geographical, demographic and health disparities caused by wider determinants such as poverty, deprivation and social exclusion. The COVID-19 pandemic has exacerbated existing health inequities and vulnerability, evidenced excess mortality, increased incidence and severity of disease, as well as compounding social and economic hardship for those most disadvantaged.

Social prescribing is an umbrella term that describes a person-centred approach to connecting people to local community assets. Community assets include community groups, interventions and services which could be delivered online or in person, as well as buildings, land or even a person within a community.

Social prescribing is a way of connecting people, whatever their age or background, with their community to better manage their health and wellbeing. It can help empower individuals to recognise their own needs, strengths, and personal assets and to connect with their own communities for support with their health and wellbeing.

The Programme for Government 2021 to 2026 recognises the need to tackle these inequalities and improve health and mental wellbeing, with one resultant action being to ‘introduce an all-Wales framework to roll out social prescribing and tackle isolation’, although there are potentially many more benefits to social prescribing than just tackling isolation.

Furthermore, from a legislative and strategic context, the principles of social prescribing, such as an early preventative approach to enhancing people’s health and wellbeing, addressing health inequalities and strengthening community cohesion, are consistent with the Social Services and Well-being Act (Wales) 2014; the Well-being of Future Generations Act (Wales) 2015; and our long-term plan for health and social care ‘A Healthier Wales’.

It is woven into the very fabric of what Welsh Government does in terms of empowering people and communities, whether it’s part of the National Clinical Framework, the Six goals for urgent or emergency care, Together for Mental Health, or Connected Communities, our strategy to tackle loneliness and isolation.

Social prescribing across Wales is not new. Social prescribing interventions have been developed and established in a bottom-up way across Wales, with individual contracted providers, clusters involved in health care, third sector and statutory organisations developing different delivery models.

Expectations of social prescribing are high with it being considered as one of the solutions to:

• improving health and wellbeing of individuals
• reducing inequalities
• mitigating the impact of social determinants on health; and
• supporting recovery from the adverse effects of COVID-19

Though the benefits of social prescribing are wide-ranging, improved physical, mental and social wellbeing are commonly reported. This encompasses aspects of psychosocial health ^{[footnote 2]}, healthy lifestyles and behaviours, social engagement, and self-management of long-term conditions ^{[footnote 3]}.

Indeed, connecting people to their community may have a wide range of benefits, for example, we know that people who are lonely or socially isolated are at greater risk of being inactive, heart disease, stroke and high blood pressure and premature death. They are also more likely to experience depression, low self-esteem, sleep problems and an increased response to stress.

There is also a link between health and wellbeing and employability. There is potential for social prescribing to help people secure employment by creating opportunities to improve health and wellbeing; improve skills, confidence and networking; and directly support people to access volunteering opportunities and organisations who can help navigate job application processes. Similarly, connecting people to community assets which offer financial and housing advice could help ease financial concerns.

By helping to strengthen community connectedness and cohesion there may be benefits to the wider community, a key factor in our Compassionate Cymru vision “to be a compassionate and caring nation that comes together to develop compassionate approaches to support people’s health and wellbeing”. Our trauma framework also advocates for a societal approach to understanding preventing and supporting the impacts of trauma and adversity.

It could also give people a more meaningful connection with nature and an appreciation of the role of culture in supporting their wellbeing, making them value community assets even more. Similarly, connecting with opportunities to be physically active provides multiple benefits to physical health and mental wellbeing, and could provide opportunities for stronger community cohesion.

In addition, social prescribing can present an established route for individuals who may not engage with mainstream services or otherwise face stigma to re-enter the community, for example, those who have experienced homelessness or substance misuse. Re-introduction of people from stigmatised groups also raises awareness of recovery and could diminish the negative perceptions of people with substance misuse or mental health issues.

National Framework for Social Prescribing (NFfSP)

Social prescribing has seen a period of growth and development over the last decade. However within Wales, as in other countries, there has been a lack of standardisation and consistency both in the terminology associated with social prescribing and in the model adopted. This has resulted in confusion on the benefits it can offer amongst both the public and the workforce who deliver or encounter social prescribing. Communication between sectors, professionals and the public has also been impaired.

The NFfSP sets out to describe the preferred model of social prescribing in Wales, help develop a shared understanding of the language used to describe social prescribing and seeks to ensure consistency of delivery regardless of the setting.

The NFfSP will consist of several guidance documents and tools which have or will be coproduced with stakeholders across Wales, including the Wales School for Social Prescribing Research, Health Education and Improvement Wales, Wales Council for Voluntary Action, Public Health Wales, and representatives from delivery partners and providers.

It does not intend to dictate how social prescribing is delivered in different communities. Rather it seeks to support its growth by setting out effective, high-quality standards across the ‘whole system’.

Its core objectives are to:

• develop a shared understanding of the language used and the approach taken to deliver social prescribing in Wales
• support the social prescribing workforce and drive-up knowledge and skills
• ensure quality of provision by community assets
• monitor and evaluate the development of social prescribing as it continues to grow across Wales
• improve outcomes for individuals, organisations, commissioners, and referrers

Accountability

The Deputy Minister for Mental Health and Well-being is accountable for the delivery of a national framework for social prescribing. In terms of implementing the national framework, accountability will rest with commissioners and providers of services.

Long term

The national framework for social prescribing will be developed in line with the well-being objectives as set out by the Wellbeing of Future Generations (Wales) Act 2015. This approach includes adherence to the objectives of ‘a resilient Wales’; ‘a more equal Wales’; ‘a Wales of vibrant culture and thriving Welsh language’; and ‘a healthier Wales’.
 
The development and implementation of a national framework for social prescribing assists in achieving the Well-being of Future Generations (Wales) Act 2015 by seeking to achieve a healthier Wales. The implementation of a national framework will help contribute to the goal of a society in which people’s physical and mental wellbeing is maximised and in which choices and behaviours that benefit future health are understood.

The national framework for social prescribing is being designed collaboratively with a range of Welsh Government departments and with external stakeholders, with a view to ensure that it is fit for purpose in the long term. Development of the national framework will span the Senedd term and use collaboration with stakeholders to assist a work programme that supports implementation. Social prescribing is a mechanism that can be used to address issues not just in relation to loneliness and isolation but to also promote wellbeing and to prevent development of non-communicable diseases.

The national framework will assist with the systematic measurement of evidence to understand what interventions are working and how to improve them. This will assist with long-term planning and implementation and will assist with levelling out the type and quality of services available, helping to check the quality of what is being provided.

Prevention

Prevention is one of the key principles of social prescribing, with it considered to have an important role in helping shift the emphasis from treating illness to promoting better wellbeing, supporting people within their communities to take greater control of their own health and support the broader preventative agenda. COVID-19 has also brought to the fore existing health inequalities and the need for action in several health improvement interventions such as smoking cessation and weight management services, the adoption of social prescribing can help target the causes of ill health by signposting people to the right sources of community/non-clinical support. Furthermore, by involving people in the development of the national framework and associated deliverables, it will foster greater ownership of the issues trying to be resolved.

From a health perspective the case for non-medical support through social prescribing is clear. Social prescribing can improve mental wellbeing, reduce anxiety and depression, enhance self-esteem, reduce loneliness and isolation; it can play a vital role in maintaining healthy body weight, and it can help people live better, for longer.

Integration

The national framework for social prescribing is being developed across government, with relevant external stakeholders and in line with the well-being objectives set out by the Well-being of Future Generations (Wales) Act 2015. The development of the national framework is a direct result of a Programme for Government commitment and integrates with the wellbeing goals of a healthier Wales, a more equal Wales, and a Wales of vibrant cultural and cohesive communities. The national framework for social prescribing will play a key role in helping regional partnership boards, public service boards, clusters and other partnership bodies with the commissioning and delivery of quality, sustainable services for the people of Wales.

Collaboration

Partners who have a shared interest in the national framework are broad in their representation, varying across local government, commissioners, NHS Wales, social prescribing representative bodies, arts, and sport and culture sponsored bodies, to name but a few. All partners have been involved in developing the framework to date, primarily via our task and finish group and additional engagement sessions.

Underpinning the development of the national framework, we have identified several key areas/work streams, where partners will help develop the national framework that enables the delivery of social prescribing in Wales that is of a consistent, effective, high-quality standard across the ‘whole system’. Such examples of the work already being taken forward by partners include Health Education and Improvement Wales who are leading on development of a competence framework for social prescribing practitioners, and the Wales School for Social Prescribing Research/Public Health Wales who are developing a glossary of terms which links directly to consultation feedback regarding the need for standardisation of language associated with social prescribing in Wales. Building on this, following cabinet approval on 3 July 2023 regarding the structure of the national framework for social prescribing, further discussions with external partners is ongoing on how best to co-produce all remaining component parts of the national framework.

Outside of Welsh Government, social prescribing provides a collaborative approach for local areas to reduce inequality and improve outcomes for different people. Furthermore, we have developed a communications plan to identify stakeholders and ensure a diverse range of voices will be involved throughout, specifically in terms of engagement events and consultation exercise.

Involvement

Using Participation Cymru’s national principles for public engagement, we will utilise our communication strategy as a guide to ensure we enable and encourage, in a timely and accessible way, everyone affected to be involved in development. By way of example, a series of engagement events were held to broaden the scope of involvement prior to consultation with officials engaging with almost 1,000 stakeholders to develop a Welsh model of social prescribing that was issued for consultation. The consultation period, which ran 28 July to 20 October 2022, utilised a range of methods to engage with both professionals and members of the public via a range of methods, including face-to-face events throughout the country, Teams meetings, social media and online. The result of this engagement being over 190 responses to the consultation that has directly shaped the structure of the national framework as approved by cabinet. Post consultation stakeholder engagement will continue, specifically identified as a supportive awareness raising programme that goes alongside development of the framework. Our governance structures have and will continue to be developed to fully reflect the range of stakeholders who are involved in this programme of work.

Impact

Social prescribing aims to empower individuals to recognise their own needs, strengths and personal assets, and connect with their communities to access support which will help to improve their health and wellbeing. For example, we know that people who are lonely and/or socially isolated are at greater risk of premature death, of being inactive, heart disease, stroke and high blood pressure. They are also more likely to experience depression, low self-esteem, sleep problems and an increased response to stress.

Through its early preventative approach, social prescribing can help to ease the burden on more front-line specialist services. There is variable evidence to suggest that social prescribing reduces the footfall to GP surgeries by 15% to 28%. One review reported an average 28% reduction in demand for GP services following referral ^{[footnote 4]}. Results ranged from 2% to 70% ^{[footnote 5]}. A mixed methods study found that patients used primary care services less, with a reduction of 25% in appointments ^{[footnote 6]}. Findings from the evaluation of the Rotherham Social Prescribing pilot pointed to an overall trend of participants’ reduced use of hospital resources before and after social prescribing. These included: inpatient admissions reduced by as much as 21% and accident and emergency attendance reduced by as much as 20% ^{[footnote 7]}.

The evidence varies so much because the impact of social prescribing depends on the type of model used, the link workers and their backgrounds, the locality, and the assets available within the community. Given that estimates show around 20% of patients consult their GP for what is primarily a social problem ^{[footnote 8]}, the potential for social prescribing to reduce impact on frontline services is evident if alternative routes are more easily and widely available. The core data set component of the national framework for social prescribing will allow us to strengthen the evidence base and inform ‘invest to save’ options.

We know there is a crucial link between health and wellbeing and employability, and there is the potential for increased availability of social prescribing to help people secure employment by creating opportunities to improve health and wellbeing; improving skills, confidence and networking; and directly support people to access volunteering opportunities and organisations who can help navigate job application processes.

There is potential for social prescribing to support people whilst they are on a waiting list. There are already examples in local health board services where social prescribing related activities such as art classes have been used to improve socialisation and feelings of loneliness and started to introduce effective pain management techniques in a peer group setting.

The National Institute for Health and Care Excellence guidelines for the management of multi-morbidity, emphasise the importance of non-pharmacological treatments and engagement in social activities ^{[footnote 9]}. A systematic review of 40 studies of social prescribing carried out in the UK found a range of benefits reported by participants and referrers. These include: increases in self-esteem and confidence; sense of self-control and empowerment; improvements in psychological or mental well-being; reductions in anxiety and depression ^{[footnote 10]}. A review of 24 studies reported that stakeholders such as GPs and patients perceived that social prescribing improved patients’ mental wellbeing and reduced their health service use, although there is limited quantitative evidence to support this ^{[footnote 11]}. A study of 342 participants on a social prescribing scheme in northern England found improvements in well-being and increased levels of health and social connectedness ^{[footnote 12]}. Reduced levels of loneliness were also found in an evaluation of a British Red Cross delivered social prescribing service in the UK, where 72% of participants reported that they felt less lonely after receiving the support ^{[footnote 13]}.

Within the British Medical Association plans for general practice to be carbon neutral within 10 years’ time, they identify social prescribing as having the potential to improve patients health and well-being whilst also reducing practice attendance and use of the wider NHS. Reducing carbon with fewer journeys to attend GP surgeries, outpatient admissions and accident and emergency attendances, will contribute to improving air quality and individuals’ health, together with a positive impact on the health service.

There may also be benefits to the wider community as the model could help strengthen community connectedness and cohesion, a key factor in our Compassionate Cymru vision “to be a compassionate and caring nation that comes together to develop compassionate approaches to support people’s health and well-being”.

It could also give people a more meaningful connection with nature and an appreciation of the role of culture in supporting their well-being, making them value these important community assets even more.

In addition, social prescribing can present an established route for individuals who may otherwise face stigma to re-enter the community, for example those with a history of homelessness or substance misuse. Re-introduction of people from traditionally marginalised groups also raises awareness of recovery and could diminish the negative perceptions of people with substance misuse or mental health issues.

Development of a national framework for social prescribing will also support Local Health Boards in exercising their functions with a view to securing improvement in the quality of health services, in accordance with section 12A of the National Health Services (Wales) Act 2006 (“2006 Act”).

Costs and savings

From 2023 to 2024 the budget and indicative costs are as follows:

• The £144.6m a year Health and Social Care Regional Integration Fund (RIF) directly supports the development of six national models of integrated care that includes direct investment in social prescribing models that form an important part of the place-based models of care we are seeking to embed as part of the Integrated Community Care System Blueprint.
• Existing budget of £750,000 in total has been assigned to social prescribing from the Health Improvement and Healthy Working budget (BEL 0231) over three financial years: 2022 to 2023 £0.250m; 2023 to 2024 £0.250m; and 2024 to 2025 £0.250m to support the work programme required to develop and implement the national framework for social prescribing.
• Costs could be reduced through the involvement and collaboration of key stakeholders, such as Public Health Wales and Health Education and Improvement Wales, who will be actively involved in developing aspects of the framework.

Mechanism

No legislation is proposed, only guidance and potentially funding for technological solutions.

8.1 How have people most likely to be affected by the proposal been involved in developing it?

The national framework for social prescribing has been developed working in close collaboration with primary care, health boards, NHS Wales, third sector, other relevant public bodies, Welsh citizens, and key stakeholders who have a role in delivery or interest in social prescribing.

Prior to formal consultation, the draft person model within the national framework was developed and tested in close collaboration with a wide range of stakeholder groups, detailed within our communications strategy. In addition, task and finish group stakeholders were involved and met regularly from March 2021 to March 2022. Detailed engagement included with the following:

• NHS Wales
• primary care representatives
• Valley Regional Park
• Older People's Commissioner for Wales
• UK/devolved government officials
• royal colleges
• Welsh Government sponsored bodies
• health board policy leads
• National Lottery Community Fund
• Tier 0 / third sector partners

Through our engagement we have been able to ensure that we have obtained views from children and their representatives, people with protected characteristics and Welsh speakers.

Officials engaged with almost 1,000 stakeholders to develop a Welsh model of social prescribing that was issued for consultation. The consultation, which ran 28 July to 20 October 2022, received over 190 responses, which together with feedback received via online stakeholder events held during the consultation period, has directly shaped the proposed national framework. In addition, there has been a series of positive and constructive meetings between officials across government to understand and develop potential areas of collaboration.

8.2 What are the most significant impacts, positive and negative?

The national framework for social prescribing has been designed to enable delivery of social prescribing in Wales that is of a consistent, effective, high-quality standard across the ‘whole system’. The national framework will consist of a set of standards, guidance and actions developed at a national level to ensure a consistency of delivery at a local level. It will help inform any technological solutions we need to develop and help embed social prescribing services in areas where they either do not exist or need to be developed further.

It is intended that the implementation of the framework to roll out social prescribing will achieve the following positive impacts:

• contribute to delivering the goals of the Wellbeing and Future Generations (Wales) Act 2015 and its focus on building a healthier, more equal and more resilient Wales
• address the wider social determinants of health to promote improved health and wellbeing, in turn having the potential to reduce existing health inequalities
• shift the emphasis from treating illness to promoting better wellbeing, supporting people to take greater control of their own health and supporting the broader preventative agenda
• increase the adoption of healthy lifestyles, and tackling unhealthy behaviours such as the use of alcohol and substance misuse
• developing community resilience
• potentially reduce the carbon footprint of primary care by reducing secondary care use and medication
• provide a referral mechanism to respond to the social causes of health inequalities at an individual level, including those caused by social-economic disadvantaged.

8.3 In light of the impacts identified, how will the proposal:

The national framework for social prescribing has been developed in line with the requirements of the Well-being and Future Generations (Wales) Act 2015, as well as the Social Services and Well-being (Wales) Act 2014. This has ensured that the national framework fully reflects and promotes both the well-being objectives and the seven well-being goals.

Welsh Government recognises that it is vital to ensure social prescribing services are accessible to all people in Wales, rather than being provided in a way that makes them accessible to small groups or pockets of the population. We acknowledge that as we are developing and implementing a national framework for social prescribing, the groups/health inequalities which may be impacted by a particular service will vary from service to service, region to region. We have considered the various factors which will need to be considered during the development of the framework and will consult on what more we can do to address accessibility concerns, ultimately, the social prescribing services themselves are to mitigate the risk that the national and its services could exacerbate health inequalities.

8.4 How will the impact of the proposal be monitored and evaluated as it progresses and when it concludes?

The national framework to roll out social prescribing will not be something that creates an all-Wales social prescribing services that dictates how services should be run. Through the national framework, Welsh Government wants to help support and augment services, and help establish where they do not exist. The national framework, which we are co-producing with stakeholders, will facilitate this. The aim is to support the bringing together of the many different actors in this space, be that regional partnership boards, local authorities, local health boards and the third sector.

Development of the national framework is to be taken forward during the Senedd term (2021 to 2026). Throughout this period feedback from the consultation will inform development, with dialogue maintained with those responsible for delivery of social prescribing services utilising their knowledge and expertise in the development of the commissioning guidance and core data set components of the national framework, supporting the best way to monitor and evaluate progress.

1. Describe and explain the impact of the proposal on children and young people.

The 'Welsh health status equity report' details the global impacts of COVID-19, outlining the effect the pandemic has had on children. For example:

Individuals from low-income backgrounds are disproportionately affected by a double, health and financial, burden. Financial insecurity is leading to food insecurity, having a detrimental impact on children’s development and well-being.

Children from deprived backgrounds have been hit harder by the pandemic due to lack of necessary resources to support their learning progress.

28% of children living in relative income poverty.

There are still many people in Wales who remain digitally excluded including older age, those on low income, and children and young people from deprived households.

Children with social, emotional, and mental health difficulties are more likely to be affected and have longer-term negative impacts due to lack of support.

The development of a national for social prescribing will have a significant positive affect on all people in Wales, whatever their age and background, and including children. The national framework will outline what best practice is and guide the establishment of social prescribing services, providing opportunities for children to connect with services available in their communities. The services provided can be varied and reflect the fluid needs of children, needs that can change daily, but ultimately can assist in providing children with positive wellbeing and positive relationships.

Going forward, using Participation Cymru’s national principles for public engagement, we will utilise our communications strategy as a guide to ensure we enable and encourage, in a timely and accessible way, children to share their views and be involved in the development of the national framework for social prescribing. During the consultation period we will take steps to ensure the proposed model is accessible to all groups, including children. Post consultation, stakeholder engagement with relevant representative organisations will continue to ensure the development and implementation of a nationwide, high-quality standard. Our governance structures have and will continue to be developed to fully reflect the range of stakeholders, including children.

Development of a national framework for social prescribing will support the exercise of existing duties of local authorities and local health boards imposed under section 15 of the Social Services and Well-being (Wales) Act 2014, which places a general duty on local authorities to provide or arrange the provision of preventative services, the purposes of which are described in section 15(2). One of the purposes described in this provision is the promotion of the upbringing of children by their families, where this is consistent with the well-being of children.

Development of the national framework for social prescribing and the likely impact on children’s United Nations Convention of the Rights of the Child (UNCRC) rights, can be aligned with Article 24, health and health services, specifically that every child has the right to the best possible health. The national framework will seek to achieve this, and compliance with the Rights of Children and Young Persons (Wales) Measure 2011, through outlining best practice and guide the establishment of accessible social prescribing and social prescribing practitioner services.

2. Explain how the proposal is likely to impact on children’s rights

The development of the national framework for social prescribing and the likely impact on children’s UNCRC rights, can be aligned with the ‘article 24, health and health services’. Specifically, that every child has the right to the best possible health. The national framework will seek to achieve this through outlining best practice and guide the establishment of accessible social prescribing and community connector services.

In developing the national framework, we will refer to any information or evidence from children and their representatives, to ensure the framework is reflective of their rights, including those of different groups of children.

[1] See: Welsh Health Equity Status Report initiative (WHESRi) - Placing health equity at the heart of the COVID-19 sustainable response and recovery: Building prosperous lives for all in Wales.

[2] Such as how we feel about ourselves and our ability to influence things that happen to us, and emotional factors, including how we understand, regulate and express our emotions and how we recognise and react to others emotions.

[3] Rempel et al. 2017.

[4] Polley, M.,¹ Bertotti, M.,² Kimberlee, R.,3 Pilkington, K.,4 and Refsum, C. 2017 ‘A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications’. University of Westminster.

[5] Longwill, A, (2014) Independent Evaluation of Hackney Well Family Service, Family Action.

[6] Kellezi, B., Wakefield, J.R.H., Stevenson, C., McNamara, N., Mair, E. , Bowe, M., , Wilson, I. and Halder, M.M. (2019) The social cure of social prescribing: a mixed-¬methods study on the benefits of social connectedness on quality and effectiveness of care provision. BMJ Open 2019;9:e033137. doi:10.1136/ bmjopen-2019-033137

[7] Dayson, C. and Bashir, N. (2014) The Social and Economic Impact of the Rotherham Social Prescribing Pilot: Main evaluation report Sheffield Hallam University Centre for Regional Economic and Social Research.

[8] Torjesen, I (2016) Social prescribing could help alleviate pressure on GPs, British Medical Journal 352; 1436.

[9] Farmer, C., Fenu, E., O’Flynn, N., Guthrie, B. (2016) Clinical assessment and management of multimorbidity: summary of NICE guidance BMJ 2016;4843(September):i4843.

[10] Chatterjee, H.J., Carnie, P.H., Latyer, D. and Thomas, L.J. (2018) Non-clinical community interventions: A systematic review of social prescribing schemes Arts and Health 10(2):97-123.

[11] Kilgarriff-Foster, A. and O’Cathain, A. (2015) Exploring the components and impact of social prescribing Journal of Public Mental Health 14(3):127-134.

[12] Woodall, J., Trigwell, J., Burgon, A-M, Raine, G., Eaton, V., Davis, J., Hancock, L., Cunningham, M. and Wilkinson, S. (2018) Understanding the effectiveness and mechanisms of a social prescribing service: A mixed methods analysis BMC Health Services Research 18:604.

[13] Foster, A., Thompson, J., Holding, E., Ariss, S., Mukuria, C., Jacques, R., Akparido, R. and Haywood, A. (2020) Impact of social prescribing to address loneliness: A mixed methods evaluation of a national social prescribing programme Health and Social Care in the Community 29(5):1439-1449.