1.Summary. The budgeted £2 bnpa extra funding for mental health should be spent on proper social prescribing
Social prescribing has a big and growing evidence base as a cost-effective way of improving health and wellbeing of patients in their local community. It has been pioneered for decades by enlightened GPs in a few surgeries in England, such as Bromley by Bow in London, Cullumpton in Devon, and Brighton Health and Wellbeing Centre. GPs signpost patients to social interventions run by the Community and Voluntary Sector (CVS), such as self-help groups, exercise classes, singing groups, dancing, advice centres, gardening and other clubs, for which participants may have to pay small sums.
The problem, which this paper addresses, is that these social ‘prescriptions’ are not officially part of the prescribing system, and are not written on a prescription form, as for drugs. Nor are they paid for out of the NHS prescribing budget, and are not usually free at the point of use for patients, the poorest and neediest of whom may be excluded by inability to pay. This so-called social ‘prescribing’ is provided by GPs working voluntarily under the counter with charities, who have to raise funds from the public to provide these interventions. Furthermore, this paper calls for the £2 bn pa extra mental health budget announced at the recent budget to be spent by the NHS on social prescribing and talking therapies (see other paper: ‘Campaign for Talking Therapies) to make them both free at the point of use, to transform public health.
Brighton and Hove expects an extra £10 mpa, which is one 200th part of this £2bnpa budget allocation. This paper calls for it to be spent by the Clinical Commissioning Group (CCG) on empowering GPs to prescribe these social interventions in exactly the same way as they now prescribe drugs. The providers of those interventions should be paid out of the prescribing budget in exactly the same way as drug companies are now paid for drugs (namely monthly in arrears on presentation of the used prescription forms from pharmacies).
As with drug prescriptions, the GP would write the patients’ name on the prescription form for the appropriate social intervention of the patient’s choice. The GP would give it to the patient, who would take it to an licenced provider, who would provide the patient with the intervention. After the intervention was complete, the patient would be asked to sign the used prescription form, certifying that it was satisfactory, and give it to the provider, who would then send it to the CCG, who would pay the provider at the tariff price, monthly in arrears.
At present, the only licenced providers are pharmacists, who provide drugs and other health-related products. To implement this new social prescribing scheme, the prescribing system should be expanded to include non-drug interventions. Those interventions chosen for inclusion under the social prescribing scheme would need to be designed and specified, and a system of licencing those qualified to provide them would have to be created and implemented, as this paper outlines.
2 Recommendations to councillors on Health and Wellbeing Boards (HWBs).
The HWB is the committee of the Local Authority Councils who are responsible for about 2/3rds of the NHS budget delegated to the CCGs, currently in 2018/19 about £85 bnpa nationally, and £430 mpa for Brighton and Hove. Under their terms of reference, our HWB are required to call the CCG to account to get best value for that money. They should ensure that the CCG spends this extra £10 mpa on social prescribing. This would empower GPs to prescribe these social interventions, which would transform public health, and give GPs job satisfaction, (rather than the soul-destroying job of being only pill pushers for the drug companies) hence ensuring the restoration of the honourable profession (see paper (9.125 of www.reginaldkapp.org) This would solve the crisis in primary care by ensuring the recruitment and retention of GPs. This will require the setting up of a licenced provider system on the principles described below, and inviting the community and voluntary sector to apply to take part in it.
3 Principles of social prescribing.
- a) The social interventions chosen should be those that improve health and wellbeing, and prevent illness.
- b) They should be commissioned as NHS interventions, and follow the same principles as other NHS interventions, including being free to the patient at the point of use, so that nobody is excluded by inability to pay for them.
- c) The licenced provider should be paid for providing the intervention as pharmacists are, at a tariff price based on the going market rate, after submission of the used prescription, monthly in arrears.
- d) The CCGs should design the system with the help of the community and voluntary sector providers.
- e) The CCG should invite providers of interventions to apply to become licenced providers.
- f) To incentivise providers to provide good services, and protect taxpayers interests, payment of providers should be by results, and outcome-based.
- g) Accordingly, before the CCG pays the provider, the patient should be required to sign the used prescription form that the intervention was satisfactory, and that they would recommend it to their friends and family,
4 The interventions that should be included in social prescribing, and expanded with public funding
- a) Singing groups (on the lines of ‘Singing for Pleasure’ and ‘Singing for better health’)
- b) Exercise classes (on the lines of 60+)
- c) Breathe easy groups (on the lines of B&H Breatheasy group)
- d) Bereavement group (on the lines of Cruse)
- e) Befriending groups (on the lines of Neighbourhood Care scheme, Time to talk befriending)
- f) Gardening and allotment groups (on the lines of
- g) Peer support for vulnerable people (on the lines of Groundswell)
- h) Psychoeducation classes (on the lines of Swindon, paper 9.63, reginaldkapp.org)
- i) Gym training (as chagehove.org)
- j) NICE recommended Mindfulness Based Cognitive Therapy (MBCT) 8 week courses, (paper 9.133 reginaldkapp.org)
- k) Family Constellation Group Therapy (FCGT) groups (paper 9.124 of reginaldkapp.org)
- l) Other groups as submitted to the CCG for inclusion from time to time.
5 How should potential providers be licenced?
Those presently providing these interventions in the private, and Community and Voluntary Sector (CVS) should be invited to join together to create organisations that can provide these intervention at the scale required by the NHS. A specification for this is given in paper ‘New licencing scheme to double the number of treatments for depressed patients by 2020, see 9.112 of www.reginaldkapp.org.
If implemented as recommended, the desired outcomes of this campaign will be fulfilled, which are:
- a) To expand the interventions provided by the NHS to include drug-free, community based ones to prevent sickness and transform public health and wellbeing
- b) To make primary care sustainable by empowering GPs to prescribe these nondrug interventions as easily as drugs, and at statutory Referral To Treatment (RTT) waiting times (2 weeks for psychosis, 6 weeks for 75% of mental sickness, and 18 weeks for the remainder) .
- c) This will enable them to fulfil their original purpose as teachers (the work ‘doctor’ comes from latin ‘doctare’ to teach)
- d) This will restore their profession to honourable, ensuring their recruitment and retention in practices, and solve the present crisis in primary care.