Open Access Research Social prescribing: less rhetoric and ... · Social prescribing: less rhetoric and more reality. A systematic review of the evidence Liz Bickerdike,1 Alison Booth,2

Social prescribing: less rhetoric andmore reality. A systematic reviewof the evidence

Liz Bickerdike,1 Alison Booth,2 Paul M Wilson,3 Kate Farley,4 Kath Wright1

To cite: Bickerdike L,Booth A, Wilson PM, et al.Social prescribing: lessrhetoric and more reality. Asystematic reviewof the evidence. BMJ Open2017;7:e013384.doi:10.1136/bmjopen-2016-013384

▸ Prepublication history andadditional material isavailable. To view please visitthe journal (http://dx.doi.org/10.1136/bmjopen-2016-013384).

Received 8 July 2016Revised 15 November 2016Accepted 13 December 2016

For numbered affiliations seeend of article.

Correspondence toPaul Wilson; [email protected]

ABSTRACTObjectives: Social prescribing is a way of linkingpatients in primary care with sources of support withinthe community to help improve their health and well-being. Social prescribing programmes are being widelypromoted and adopted in the UK National HealthService and so we conducted a systematic review toassess the evidence for their effectiveness.Setting/data sources: Nine databases were searchedfrom 2000 to January 2016 for studies conducted inthe UK. Relevant reports and guidelines, websites andreference lists of retrieved articles were scanned toidentify additional studies. All the searches wererestricted to English language only.Participants: Systematic reviews and any publishedevaluation of programmes where patient referral wasmade from a primary care setting to a link worker orfacilitator of social prescribing were eligible forinclusion. Risk of bias for included studies wasundertaken independently by two reviewers and anarrative synthesis was performed.Primary and secondary outcome measures:Primary outcomes of interest were any measures ofhealth and well-being and/or usage of health services.Results: We included a total of 15 evaluations ofsocial prescribing programmes. Most were small scaleand limited by poor design and reporting. All wererated as a having a high risk of bias. Common designissues included a lack of comparative controls, shortfollow-up durations, a lack of standardised andvalidated measuring tools, missing data and a failure toconsider potential confounding factors. Despite clearmethodological shortcomings, most evaluationspresented positive conclusions.Conclusions: Social prescribing is being widelyadvocated and implemented but current evidence failsto provide sufficient detail to judge either success orvalue for money. If social prescribing is to realise itspotential, future evaluations must be comparative bydesign and consider when, by whom, for whom, howwell and at what cost.Trial registration number: PROSPERO Registration:CRD42015023501.

BACKGROUNDWith estimates of a £30 billion funding gapby 2020, a radical rethink of the way health

services are currently delivered remains highon the policy agenda. The Five Year ForwardView has stressed that developing innovativeapproaches to delivering healthcare are inte-gral to the long-term future of the NationalHealth Service (NHS).1

Social prescribing is one such model and isbeing widely promoted as a way of makinggeneral practice (GP) more sustainable.Social prescribing is a way of linking patientsin primary care with sources of supportwithin the community. It provides GPs with anon-medical referral option that can operatealongside existing treatments to improvehealth and well-being. There is no widelyagreed definition of social prescribing butthe Social Prescribing Network defines it as‘enabling healthcare professionals to referpatients to a link worker, to co-design a non-clinical social prescription to improve theirhealth and wellbeing.’2 Schemes commonlyuse services provided by the voluntary andcommunity sector and can include an exten-sive range of practical information andadvice, community activity, physical activities,

Strengths and limitations of this study

▪ Social prescribing is a way of linking patients inprimary care with sources of support within thecommunity. It is being widely promoted andadopted as means of dealing with some of thepressures on general practice.

▪ This systematic review assesses the effectivenessof social prescribing programmes relevant to theUK National Health Service setting. We havesearched for full publications and grey literaturesince 2000 and identified 15 evaluations. It ispossible that some local evaluations have notbeen identified, but it is unlikely that any uniden-tified evaluations would do little to alter theoverall picture of a low-quality evidence basewith a high risk of bias.

▪ If social prescribing is to realise its potential,future evaluations must be comparative bydesign and consider when, for whom, how welland at what cost.

Bickerdike L, et al. BMJ Open 2017;7:e013384. doi:10.1136/bmjopen-2016-013384 1

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befriending and enabling services. The types of activitiesoffered as part of a social prescribing service can aim tohelp address the psychological problems and low levelsof well-being often manifest in frequent attenders in GP.By addressing these, it is often hoped that there will be asubsequent positive impact on frequency of attendance.3

As early as 1999, the white paper Saving Lives: OurHealthier Nation was advocating that the NHS shouldmake better use of community support structures andvoluntary organisations.4 However, it was in 2006 thatthe Department of Health advocated the introduction ofsocial prescriptions for those with long-term conditions,5

and NHS England has since announced the appoint-ment of a national clinical champion for social prescrib-ing.6 With the current Secretary of State for Health alsopromoting access to non-clinical interventions that takea more ‘holistic view’,1 7 support for social prescribing issignificant at the policy level.Many localities are now offering or considering imple-

menting social prescribing programmes, but is the appar-ent enthusiasm justified? As part of a study which aimedto help NHS commissioners make better use of researchin their decision-making,8 we examined the evidence forsocial prescribing. This systematic review summarises theevidence for the effectiveness of social prescribing pro-grammes relevant to the UK NHS setting.

METHODSThe protocol and amendments were registered inPROSPERO (registration number: CRD42015023501).

Data sources and searchesDatabase of Abstracts of Reviews of Effects (DARE),Cochrane Database of Systematic Reviews and NHSEconomic Evaluation Database (NHS EED) weresearched for relevant systematic reviews and economicevaluations (24 June 2015; no new records added toDARE and NHS EED databases from January 2015 so wedid not run updated searches).We searched the following databases (initial search 26

June 2015; updated search 5 February 2016): AppliedSocial Sciences Index and Abstracts (ASSIA),Cumulative Index to Nursing and Allied HealthLiterature (CINAHL), MEDLINE, Social Care Onlineand Social Policy and Practice.As our focus was on identifying evidence relevant to

the UK NHS setting, we also searched for eligible studiesin key UK knowledge repositories for health and socialcare. The websites of National Institute for Health andCare Excellence (NICE), Social Care Institute forExcellence (SCIE) and NHS Evidence were searched forreviews, guidance, evidence briefings or any otherpapers describing or evaluating social prescribing pro-grammes. Additional searches of the websites of keypolicy think tanks the Kings Fund, Health Foundation,Nuffield Trust and NESTA were also undertaken. Wesearched Google to identify grey literature reports of

relevant evaluations in UK settings (5 January 2016).Reference lists of retrieved articles were scanned to iden-tify additional studies.All the searches were restricted to English language

only and published between 2000 to January 2016. Thesearch strategies are available in online supplementaryappendix 1.

Study selectionSystematic reviews and any published evaluation of pro-grammes where healthcare professionals refer patientsfrom a primary care setting to a link worker or facilitatorfor any form of social prescription were eligible forinclusion. Studies were eligible regardless of whether acomparison group was included.As per the Social Prescribing Network definition, we

included only studies where referral was made from aprimary care setting to a coordinator, link worker orfacilitator of social prescribing (this type of role will bereferred to as ‘link workers’ throughout this review).Any activities or interventions being specifically deliv-ered as part of a social prescribing programme wereincluded in the review.We excluded studies where referral was made from

outside of a primary care setting9 and or where primarycare health professionals refer patients to services deliv-ered as part of mental health or counselling servicessuch as an Improving Access to Psychological Therapiesprogramme. We also excluded evaluations of activitiesthat could be socially prescribed (eg, physical activityprogrammes or community arts projects) but did notinvolve referral to a link worker in the first instance.10–13

The primary outcomes of interest were any measuresof health and well-being, including self-reported mea-sures (eg, levels of physical activity or depression scores)and/or measure of usage of health services. We also con-sidered any other outcomes (eg, health service usage)reported in the included evaluations.Study selection was performed by one researcher and

checked by a second, with any discrepancies resolved bydiscussion or with recourse to a third researcher.

Data extraction and quality assessmentDetails of the setting, participants, the intervention(type, delivery mode and length of time), type of evalu-ation and outcomes of evaluation were extracted andquality assessed by one researcher and checked by asecond. Discrepancies were resolved by discussion or byrecourse to a third researcher.We used the Cochrane risk of bias tool to assess the

quality of the randomised controlled trial (RCT).14 Toassess the quality of the before and after evaluations, weapplied the quality assessment tool developed by the USNational Heart, Lung, and Blood Institute for before–after (pre–post) studies with no control group.15 Ourprimary focus was on effects. As per our protocol, wehave not made a formal quality assessment of studies ofa qualitative or descriptive nature.

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Data synthesis and analysisWe performed a narrative synthesis of the evidence.There were insufficient data to perform meta-analysisfor any of the outcomes of interest. No subgroup ana-lyses were planned. The narrative synthesis was intendedto move beyond a preliminary summary of study findingsand quality to investigate similarities and differencesbetween studies as well as exploring any patterns in thedata.

RESULTSWe identified a total of 431 records through databasesearching and a further 14 records through othersources. After deduplication, 341 titles and abstractswere screened and 70 full-text papers were assessed forinclusion (see figure 1: Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) flowdiagram).

Excluded studiesWe excluded 45 studies on eligibility grounds and wereunable to access the full text for seven identifiedrecords. We also identified two non-systematic reviews ofsocial prescribing schemes.16 17 These were excluded asthey did not critically appraise included studies and werelimited in their synthesis of findings; one reviewincluded a number of evaluations that did not meet ourinclusion criteria.17 We checked the reference lists of

both reviews to ensure we had identified and includedall relevant evaluations.

Included studiesWe included a total of 15 evaluations (reported in 16papers) of social prescribing programmes where someform of link worker role was used.3 18–32 The designsincluded one RCT,18 one non-RCT,19 two qualitativestudies,23 28 four uncontrolled before and afterstudies3 20–22 and eight descriptive reports of six evalua-tions, of which, five included some analysis of qualitativedata.24–27 29–32 Details of the included evaluations arepresented in table 1.In each of the included studies, the link worker ( job

title variously named) met with the patient to discusstheir needs and directed them to appropriate commu-nity/voluntary sector sources of support in their locality.The training and knowledge of people fulfilling thesetypes of link worker role varied between projects. Insome services this was a paid role, in others these roleswere fulfilled by volunteers. Some link workers had goodknowledge and existing networks with local services inplace28–30 and in others they received some basic train-ing and made use of a directory of resources.22

Patients were referred to a range of activities providedby local or national voluntary and community sectororganisations. Interventions received included exerciseand other physical activities, signposting to housing,

Figure 1 PRISMA flow diagram.


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welfare and debt advice, adult education and literacy,befriending, counselling, self-help support groups,luncheon clubs and art activities.The number of referrals made to social prescribing

programmes ranged from 30–1607. Referrals were madeby a range of health professionals but primarily GPs.Three of the studies reported that feedback was given tothe referrer about the actions taken and the partici-pants’ progress in the social prescribingprogramme.22 28 30

Quality of the evidenceQuality assessment and risk of bias for the evaluativedesigns is presented in table 2. In the RCT, onlysequence generation was adjudged to be of low risk ofbias; all other criteria were rated as unclear or highrisk.18 The authors reported that the randomisationprocess was misunderstood in two of the participatingpractices but random allocation appeared to be main-tained. A key inclusion criterion for the CochraneEffective Practice and Organisation of Care ReviewGroup is that a controlled before and after study musthave at least two interventions and two control groups toguard against confounding.33 Here, the controlledbefore and after study includes one intervention andone control group, drawn from the same GP. As such,we rated the study as having a high risk of bias andmade no further assessment of quality with theCochrane risk of bias tool. Uncontrolled before andafter studies are inherently weak evaluative designs andno included study fulfilled all of the specified quality cri-teria. In general, evaluations had small sample sizes(<100 participants), significant loss to follow-up (>20%),were lacking in completeness of outcome data and hadunclear selection criteria for the study population.Follow-up periods were generally short (immediatelypost intervention, up to 4 months post intervention).There is therefore a high risk of bias.

Uptake and attendanceSeven included studies reported the number of peopleattending an initial appointment with a link worker.Where reported, attendance at this initial appointmentwith a link worker ranged from 50% to 79%.18 21–23 25–27

Participants’ attendance at activities to which they weresubsequently referred or recommended by a link workerwas reported in only two studies and varied from 58%22

to 100%.21

Health and well-being outcomesThe RCT,18 two uncontrolled before and afterstudies21 22 and three descriptive reports26 27 32 mea-sured health and well-being outcomes at baseline andagain at up to 6 months after referral to a social pre-scribing programme; one study reported outcomes atup to 12 months. The measures used were Warwick-Edinburgh Mental Well-being Scale (WEMWBS;21 26 32),Hospital Anxiety and Depression Scale (HADS;18),

General Anxiety Disorder-7 (GAD-7;27), Patient HealthQuestionnaire-9 (PHQ-9;27), Clinical Outcomes inRoutine Evaluation-Outcome Measure (CORE-OM;22),Work and Social Adjustment Scale (WSAS;21 22),General Health Questionnaire (GHQ-12;22) and COOP/WONCA.18 Table 3 presents findings for studies usingvalidated measures; all report some improvements inhealth and well-being. However, it is difficult to quantifythe size of the observed improvements due to a lack ofreported detail, a lack of sufficient control group dataand differences in reporting between studies. It is notpossible to determine whether any observed improve-ments were clinically significant. Studies reported short-term outcomes only; there is no evidence about theeffect social prescribing has on health and well-beingoutcomes beyond 6 months.One uncontrolled before and after study used a bespoke

measure, the Wellspring Well-being Questionnaire,comprising PHQ-9 and GAD-7 tools, and items fromOffice of National Statistics (ONS’s) Well-being Index/Integrated Household Survey and International PhysicalActivity Questionnaires.3 A second also used a bespokemeasure which used a 5-point scale across eight domainsassociated with different aspects of self-management suchas ‘looking after yourself’ and ‘managing symptoms’.20

Two further descriptive reports also indicated they usedthe WEMWBS to measure changes in health and well-being but are poor reported and involve what appear to bevery small numbers of respondents.24 25 In the two studiesusing non-validated measures, some positive improve-ments in outcomes such as depression and anxiety at 3–4 months’ follow-up were reported.3 20

Healthcare usage outcomesBoth comparative evaluations18 19 and three uncon-trolled before and after studies3 20 22 reported somemeasure of healthcare usage. This included comparinghospital episode statistics and/or GP record data from 6to 12 months before intervention with data up to18 months post intervention. Reported outcomesincluded frequency of GP consultations, referrals to sec-ondary care, inpatient admissions and accident andemergency (A&E) attendances. Findings were mixed.The RCT reported that the number of primary care con-tacts were similar between intervention and controlgroups and that there were fewer referrals to secondarycare and more prescription drugs for those in the inter-vention group compared with the control group.18 Thenon-randomised trial reported statistically non-significant reductions in primary care contacts(face-to-face and/or telephone) and referrals to second-ary care.19 The before and after studies reported reduc-tions in secondary care referrals, inpatient admissionsand A&E attendances20 in primary care contact22 and inface-to-face GP contact but an increase in telephonecontact.3


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Table 1 Characteristics of social prescribing project evaluations

Project information Referral activity

Participants in evaluation(excluding healthprofessionals and linkworkers)

Facilitator/coordinator skillsand training

Activities patients referred to bysocial prescribing facilitator/coordinator

Project name, location:Amalthea project, AvonAuthor, year: Grant, 2000Date project established(or time period ofevaluation): Aug 1997 toSep 1998Type of evaluation:randomised controlled trial

Referred to link worker: N=90Attended link worker appointment:71/90 (79%)Attended a prescribed activity/services: not reportedGP surgeries involved: N=26

Approached to participate:N=168Agreed to participate: N=161(90 randomised to intervention;71 randomised to control)Participants in the controlgroup received routine carefrom their GPIncluded in evaluation analysis:69% of 90 for intervention an67% of 71 for control followedup at 4 months

Three project facilitators fromdifferent backgrounds weretrained and supervised by theorganisation

Voluntary sector contactsavailable: National SchizophreniaFellowship; Counselling onAlcohol and Drugs; AlcoholicsAnonymous; OvereatersAnonymous; Local eatingdisorders group; Triumph overPhobia; Womankind; CounsellingNetwork; CRUSE; RELATE;Befrienders International; Localcarer support group; PrincessRoyal Trust for Carers; RoyalBritish Legion; Crisis; MigraineTrust; Local assertiveness traininggroup; National Society for thePrevention of Cruelty to Children;Multiple Sclerosis Society;Disability Living Foundation;British Trust for ConservationVolunteers; Citizens AdviceBureau; Local meet a mumassociation; local toddler group;local social group for the elderly;University of the Third Age;Brunelcare; Battle againsttranquillisers; Women’s RoyalVoluntary Service

Project name, location:Connect project, CarlisleAuthor, year: Maughan,2016Date project established(or time period ofevaluation):Oct 2011 toMar 2014Type of evaluation:controlled before and afterstudy

Referred to link worker: notreportedAttended link workerappointment:N=30Attended a prescribed activity/services: not reportedGP surgeries involved: N=1

Approached to participate: notreportedAgreed to participate: N=59(30 in intervention group; 29 incontrol group)Participants in the controlgroup received routine carefrom their GPIncluded in evaluation analysis:28/30 (93%) in intervention; 29/29 (100%) in control

Non-healthcare staff, providedwith brief training about localservices, completingquestionnaires and managingrisk.Not reported

Available services across third,public and private sectors,self-help, self-managementresources, educational, leisureand recreational facilities andfitness-, health- andexercise-related activities.Example given: The EdenTimebank, a skills exchange andsocial network where membersearn credits for helping anothermember or the wider community.

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Project name, location:Rotherham SocialPrescribing projectAuthor, year: Dayson, 2014Date project established (ortime period of evaluation):Apr 2012 to Mar 2014Type of evaluation:uncontrolled before andafter study

Referred to link worker: N=1607Attended link worker appointment:not reportedAttended a prescribed activity/services: not reported (1118people were referred onwards toother funded voluntary andcommunity sector services)GP surgeries involved: N=29

Approached to participate: notreportedAgreed to participate: notreportedIncluded in evaluation analysis:i. Hospital episode dataanalysis: N=451 followed up at6 months; N=108 followed up at12 months (of which n=42referred on to a fundedvoluntary and communityservice provider)ii. Well-being outcomesanalysis: 280/819 followed upat 3–4 months

Not reported. Information and advice;community activity; physicalactivity; befriending and enabling

Project name, location:Dundee Equally WellSources of SupportAuthor, year: Friedli, 2012Date project established(or time period ofevaluation): Mar 2011 toJun 2012Type of evaluation:uncontrolled before andafter study

Referred to link worker: N=123Attended link worker appointment:61/123 (50%)Attended a prescribed activity/services: 26 out of 26 referred toan activity attended that activity(119 link worker referrals weremade into 47 different communityservices or groups)GP surgeries involved: N=1

Approached to participate: notreportedAgreed to participate: notreportedIncluded in evaluation analysis:N=16

Not reported. Community based information,support and/or activities

Project name, location:Graduate Primary CareMental Health WorkerCommunity Link Scheme,north LondonAuthor, year: Grayer, 2008Date project established(or time period ofevaluation):NRType of evaluation:uncontrolled before andafter study

Referred to link worker:N=255Attended link workerappointment:N=151Attended a prescribed activity/services: 58% attended at leastone of the services suggestedGP surgeries involved: N=13

Approached to participate:N=151Agreed to participate: 108/151Included in evaluation analysis:N=75/108 followed up at3 months

Psychology graduates withsome voluntary clinicalexperience but no formal mentalhealth training. Inhouse trainingand supervision from two clinicalpsychologists.Not reported.

Community resources identifiedthrough searches of paper andelectronic directories, telephoneenquiries and other sources.

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Project name, location:Well-being Programme atWellspring Healthy LivingCentre, BristolAuthor, year: Kimberlee,2014Date project established(or time period ofevaluation): May 2012 toApr 2013Type of evaluation:uncontrolled before andafter study

Referred to link worker: UnclearAttended link worker appointment:N=128Attended a prescribed activity/services: not reportedGP surgeries involved: notreported

Approached to participate:N=128Agreed to participate:N=128Included in evaluation analysis:i. Health and well-beingoutcomes N=70 followed up at3 monthsii. GP attendance data N=4012 months before and afterbaseline

Not reported Peer support groups, creative arts,physical activities, cookingcourses, complementary therapies

Project name, location: AgeConcern, Yorkshire andHumberAuthor, year: Age Concern,2012Date project established(or time period ofevaluation): Apr 2011 toSep 2011Type of evaluation:descriptive report

Referred to link worker: N=55Attended link worker appointment:not reportedAttended a prescribed activity/services: not reportedGP surgeries involved: N=12

Approached to participate:unclearAgreed to participate: unclearIncluded in evaluation analysis:not reported

A skilled member of Age UKstaff

Age UK services including:befriending, day clubs, luncheonclubs, information and advice,benefit checks, trips, theatreoutings, computer training,advocacy, legal advice, will-writingservice, volunteering, Fit as aFiddle classes, art groups,memory loss services

Project name, location:ConnectWell, CoventryAuthor, year: Baines, 2015Date project established(or time period ofevaluation): Aug 2014 toAug 2015Type of evaluation:descriptive report (withqualitative element)



Volunteers attend group trainingsession then inductions forspecific role. Additional trainingoffered eg, mentoring, dementiaawareness. Supervised byWCAVA

Befriending, lunch club, adviceand information services, housing/homelessness services,counselling, sport, art,volunteering, support group, socialactivities

Project name, location:Newcastle SocialPrescribing ProjectAuthor, year: ERSResearch and Consultancy,2013



Existing staff member in eachVCSO with knowledge of localcommunity and services, LTCs.Skills and attributes specified.

Support with personalised goalsetting and buddying, self-careand signposting to information,advice and support through anagency: Age UK; HealthWORKS;

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Involve North East, 2013Date project established(or time period ofevaluation): Jan 2012 toMar 2013Type of evaluation: twodescriptive reports (one withqualitative element)

Newcastle Carers; Search; WestEnd Befrienders

Project name, location:CHAT, south and westBradfordAuthor, year: Woodall, 2005Date project established(or time period ofevaluation): Established2004 Piloted Jan 2005 toSep 2005Type of evaluation:descriptive report (withqualitative element)



Non-clinical Health Trainers, apublic health workforcesupported by the DH

Local community and voluntaryservices.

Project name, location:CHAT, south and westBradfordAuthor, year: South, 2008Date project established(or time period ofevaluation): May 2005 toOct 2006Type of evaluation:qualitative study

Referred to link worker: N=223Attended link worker appointment:not reportedAttended a prescribed activity/services: not reportedGP surgeries involved: notreported



Community and voluntary sectorgroups and services such as:Luncheon clubs; Befriendinggroups; Social services;Volunteering organisations;Getting back into work groups;Literacy classes; Debt advice;Access bus; Bereavement groups;Reminiscing groups; Arts and craftgroups; Music groups

Project name, location:Health Trainer and SocialPrescribing Service, southand west BradfordAuthor, year: White 2010Date project established(or time period ofevaluation): Established2006 (evolved from CHAT)Jan 2010 to Sep 2010




Local voluntary and communitysector social groups and supportagencies.Health trainer can developpersonal health action plan.

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Type of evaluation:descriptive report(with qualitative element)Project name, location:Doncaster Patient SupportServiceAuthor, year: Faulkner,2004Date project established(or time period ofevaluation): April 2001 toFebruary 2002Type of evaluation:qualitative study

Referred to link worker: 200Attended link worker appointment:N=132Attended a prescribed activity/services: not reportedGP surgeries involved: N=1

Approached to participate: 17patients and 9 volunteersAgreed to participate: Patients:N=11Volunteers: N=9Included in evaluation analysis:Patients: N=11Volunteers: N=9

Volunteers given 3-day trainingincluding basic counsellingknowledge and skills, teambuilding strategies and visitsfrom community services theymight refer people to. Ongoingtraining and supervisionprovided.

Facilitated access to servicesproviding: advice on disabilityservices, advice on nursinghomes; alcohol support; benefitissues; family/matrimonial support;family support for drug users;advice on housing/social services;legal issues (eg, The Women’sCentre; Mind; Relate; Alcohol andDrug Advice)

Project name, location:WellFamily service inHackney*Author, year: Longwill, 2014Date project established(or time period ofevaluation): Firstestablished 1996; Period ofevaluation: 2012–13Type of evaluation:descriptive report (withqualitative element)

Referred to link worker: N=1466Attended link worker appointment:N=1089Attended a prescribed activity/services:N=712GP surgeries involved: N=32

Approached to participate: notreportedAgreed to participate:NotreportedIncluded in evaluation analysis:GAD-7, PHQ-9: N=387 Patientsurvey:N=92 respondents (out ofactive caseload of ∼120)GP survey: N=27 respondents(out of 160 surveyed GPs)

Family action workers andsenior practitioners with avariety of skills and experience.Some with undergraduate andpostgraduate qualifications incounselling, group therapy,medicine and psychotherapy.Family Action counsellors—professionally qualified andunder regular supervision

Short-term counselling, adviceand practical support.Local voluntary, community, andsocial enterprise sector services.Other social and health servicessuch as debt counselling, housingdepartments and health services

Project name, location:‘New Routes’, Keynsham(Bath and North EastSomerset)Author, year: Brandling,2011Date project established (ortime period ofevaluation):2-year pilotestablished October 2009Type of evaluation:descriptive report (withqualitative element)

Referred to link worker: N=90Attended link worker appointment:not reportedAttended a prescribed activity/services:N=42GP surgeries involved: N=3

Approached to participate: NotreportedAgreed to participate:Not reportedIncluded in evaluation analysis:WEMWBS completed at 6–12 months N=7MYMOP2 completed at 6–12 months N=12Qualitative interviews N=21

Coordinators role modelled onAmalthea project13

Skills and training not reported

46 different types of organisationsand activities were part of thepilot.Most popular activities:volunteering; befriending; walkinggroups; art groups

CHAT, Community Health Advice Team; DH, Department of Health; GP, general practice; GAD-7, General Anxiety Disorder-7; LTC, Long Term Condition; MYMOP2, Measure Yourself MedicalOutcome Profile; NR, not reported; PHQ-9, Patient Health Questionnaire-9; VCSO, Voluntary Community Sector Organisation; WCAVA, Warwickshire Community and Voluntary Action;WEMWBS, Warwick Edinburgh Mental Well-being Scale.

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Table 2 Quality assessment and risk of bias

Uncontrolled before and after evaluationsStudy Quality criteria Risk of bias Notes

Grant 2000RCT

Sequence generation Low Sealed opaque envelopes prepared by research team. Stratificationby practice and blocks of six used (three intervention/three control).

Allocation concealment Unclear Sequentially numbered envelopes opened. In two practices, therewas evidence that the randomisation process was initiallymisunderstood: six patients excluded.

Blinding of participants and personal Not possibleBlinding of outcome assessment UnclearIncomplete outcome data High 32% loss to follow-up at 4 monthsSelective outcome reporting UnclearOther potential threats to validity Unclear Numbers potentially eligible but not recruited unknown

Recruited general practices were not a random sample: participatingdoctors were likely to be more interested in the research questionand may have managed psychosocial problems more actively, whichcould have diminished reported estimates of effects

Maughan2016CBA

Is there a suitable comparison group? Yes One intervention and one control group, drawn from the samegeneral practice with similar patient characteristics.Models environmental costs (in terms of carbon footprint)Data were retrospectively collected from GP health records for a2-year period.Two participants in intervention group excluded from analysisFinancial and environmental impacts calculated for each outcomeusing national averages or accepted conversion factors

Do the authors use theory to underpin the project/evaluation? NoWere appropriate methods used for data collection and analysis? YesWere efforts made to assess patient experience? No

Uncontrolled before and after evaluationsStudy Quality criteria Risk of bias NotesDayson2014

Was the study question or objective clearly stated? Yes Small sample of those referred (N=1607) participated in evaluation—HES data at 6 months N=451, at 12 months N=108; well-being dataat 3–4 months 280/819Methods of qualitative analysis of patient experience unclear

Were eligibility/selection criteria for the study population prespecifiedand clearly described?

Not reported

Were the participants in the study representative of those who wouldbe eligible for the test/service/intervention in the general or clinicalpopulation of interest?

Yes

Were all eligible participants that met the prespecified entry criteriaenrolled?

Not reported

Was the sample size sufficiently large to provide confidence in thefindings?

No

Was the test/service/intervention clearly described and deliveredconsistently across the study population?

Not reported

Were the outcome measures prespecified, clearly defined, valid,reliable and assessed consistently across all study participants?

Yes

Were the people assessing the outcomes blinded to the participants’exposures/interventions?

Not reported

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Table 2 ContinuedUncontrolled before and after evaluationsStudy Quality criteria Risk of bias Notes

Was the loss to follow-up after baseline 20% or less? Were thoselost to follow-up accounted for in the analysis?

No

Did the statistical methods examine changes in outcome measuresfrom before to after the intervention? Were statistical tests done thatprovided p values for the pre-to-post changes?

Yes

Were outcome measures of interest taken multiple times before theintervention and multiple times after the intervention (ie, did they usean interrupted time-series design)?

No

If the intervention was conducted at a group level (eg, a wholehospital, a community, etc), did the statistical analysis take intoaccount the use of individual-level data to determine effects at thegroup level?

Notapplicable

Friedli 2012 Was the study question or objective clearly stated? Yes Details of preintervention and postintervention outcomes not reportedSmall sample sizeTiming of post intervention assessment not reportedMethods of qualitative analysis of patient and provider/referrerexperience unclear


No


Yes


Notapplicable


No


Not reported


No


No


No


No

Were outcome measures of interest taken multiple times before theintervention and multiple times after the intervention (i.e., did theyuse an interrupted time-series design)?

No

If the intervention was conducted at a group level (eg, a wholehospital, a community, etc), did the statistical analysis take intoaccount the use of individual-level data to determine effects at thegroup level?

Notapplicable

Continued

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Table 2 ContinuedUncontrolled before and after evaluationsStudy Quality criteria Risk of bias Notes

Grayer 2008 Was the study question or objective clearly stated? Yes GP practices volunteered and may not be representative of practicesoverallPatients who consented to participate in evaluation were more likelyto speak English as a first language than those who did not consentNo significant differences at baseline between those successfullyfollowed up and those lost to follow-up95% CIs (no p values) reported for changes in GHQ-12, CORE-OMand WSAS scores


Yes


Yes


No


No


Yes


Yes


Not reported


No


Yes

Were outcome measures of interest taken multiple times before theintervention and multiple times after the intervention (i.e., did theyuse an interrupted time-series design)?

No

If the intervention was conducted at a group level (eg. a wholehospital, a community, etc), did the statistical analysis take intoaccount the use of individual-level data to determine effects at thegroup level?

Notapplicable

Kimberlee2014

Was the study question or objective clearly stated? Yes SROI analysis presents data for all baseline completers and thesmaller percentage who were followed up; possible bias towardspositive finding for interventionUnclear whether calculations of mean differences in scale scoresused all baseline data or baseline data for follow-up completers onlyp values reported for change from baseline at 3 months in PHQ-9depression scores


No


Yes


Notapplicable


No


Not reported

YesContinued

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Patient experienceThree before and after studies20–22 and five descriptivereports23 26 28 30 32 reported on patient experience.Studies used semistructured interviews or survey ques-tionnaires specifically designed for the project evalu-ation to assess participant experience.In six of the studies, participants reported overall satis-

faction with social prescribing programmes.20–22 26 28 30

General improvements in feelings of loneliness andsocial isolation,21 30 32 and improved mental and phys-ical health were also observed.21 Issues that may impactthe willingness of patients to participate in socially pre-scribed activities included confidence,21 30 interest in/appropriateness of activities on offer21 30 and literacy ortravel issues.30 32 One qualitative study reported thatpatients had poor knowledge of the service prior toattending their appointment with the link worker result-ing in some feeling that the service did not meet theirexpectations.23 Another evaluation identified a similarissue regarding a lack of understanding of the serviceamong participants.32

Referrer experience and lessons learntA small number of studies conducted semistructuredinterviews with primary care practitioners referring parti-cipants to social prescribing programmes and/or linkworkers.21 26 28–32 GPs in general found that being ableto make a social prescription was a useful additionaltool.21 28 29 31 Key issues identified for successful imple-mentation of social prescribing programmes were centralcoordination of referrals,26 resources and training tosupport coordinators and enabling networking with thevoluntary and community sector,26 29 and good communi-cation between GPs, participants and link workers: socialprescribing is unfamiliar to many GPs and requires goodclear explanation to engage participants;21 23 26 32 deliver-ing feedback on participants’ progress encourages GPsupport for social prescribing.28 30 31

CostsThe two comparative evaluations reported costs. Onefound total mean costs were greater in the interventiongroup (£153) compared with the control group(£133).18 The other reported no statistically significantdifferences between the financial and environmentalcosts of healthcare use between the intervention andcontrol groups.19

One before and after study undertook a cost-benefitanalysis using estimated input costs and benefits derivedfrom 12-month outcome data obtained for 108 patientsreferred to social prescribing (42 of whom were referredto funded voluntary and community service providers).A total NHS cost reduction of £552 189 was generatedby multiplying the estimated per-patient cost reductionby the total number of referrals (n=1118) to funded vol-untary and community service providers over the 2-yearcourse of the pilot programme. This estimate was com-pared with total estimated input costs of £1.1 million.20

Table2

Continued

Unc

ontrolledbe

fore

andafterev

alua

tions

Study

Qua

litycrite

ria

Riskof

bias

Notes

Weretheou

tcom

emea

surespres

pecifie

d,clea

rlyde

fined

,valid,

reliablean

das

sessed

cons

istentlyac

ross

allstudy

participa

nts?

Werethepe

ople

asse

ssingtheou

tcom

esblinde

dto

thepa

rticipa

nts’

expo

sures/interven

tions

?Not

repo

rted

Was

theloss

tofollow-upafterba

seline20

%or

less?Werethos

elost

tofollow-upac

coun

tedforin

thean

alysis?

No

Did

thestatistical

metho

dsex

aminech

ange

sin

outcom

emea

sures

from

before

toaftertheinterven

tion?

Werestatistical

testsdo

nethat

prov

ided

pva

lues

forthepre-to-pos

tcha

nges

?

Yes

Wereou

tcom

emea

suresof

interest

take

nmultip

letim

esbe

fore

the

interven

tionan

dmultip

letim

esaftertheinterven

tion(i.e.,d

idthey

usean

interrup

tedtim

e-se

riesde

sign

)?

No

Iftheinterven

tionwas

cond

uctedat

agrou

pleve

l(eg

.awho

leho

spita

l,aco

mmun

ity,e

tc),didthestatistical

analysistake

into

acco

untthe

useof

individu

al-le

veld

atato

determ

ineeffectsat

the

grou

pleve

l?

Not

applicab

le

CBA,C

ontro

lledBeforean

dAfte

rstud

y;CORE-O

M,C

linical

Outco

mes

inRou

tineEva

luation-Outco

meMea

sure;G

P,g

eneral

prac

tice;

GHQ,G

eneral

Hea

lthQue

stionn

aire;H

ES,h

ospital

episod

estatistics;

PHQ,P

atient

Hea

lthQue

stionn

aire;R

CT,

rand

omised

controlledtrial;S

ROI,Soc

ialR

eturnon

Inve

stmen

t;WSAS,W

orkan

dSoc

ialA

djus

tmen

tSca

le.


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Table 3 Health and well-being outcomes (validated measures)

Study (timing ofoutcomemeasurement postbaselinemeasurement) WEMWBS HADS GAD-7 PHQ-9 CORE-OM WSAS GHQ-12 COOP/WONCA

RCTsGrant 2000(4 months)

Intervention group(N=62) * greaterimprovement thancontrol group(N=48)*

Intervention group(N=62) * greaterimprovement thancontrol group(N=48) *

Before and after evaluationsFriedli 2012 (NR) ‘Statistically significant

improvement’ in mentalwell-being (N=16) (scoresnot reported)

‘Statisticallysignificantimprovement’ infunctional ability(N=16)(scores notreported)

Grayer 2008(3 months)

Small reductionin patientscategorised ascases (N=74)

Improvement in workand socialadjustment (N=69)

Four-fifths werecases at baseline,reducing to half ofpost interventionN=69)

Descriptive reportsERS Researchand Consultancy2013(NR)

Increase in mean scorefrom 22 to 26 (N=16)

Longwill 2014(NR)

2.5 pointsreduction inscore(p<0.001)(N=387)

3.1 pointsreduction inscore(p<0.001)(N=387)

Brandling 2011(6–12 months)

‘General positive trend butowing to low number ofparticipants completingquestionnaires no furtherconclusions can be made’

*calculated from reported percentage followed up at 4 months.COOP/WONCA, Dartmouth COOP Functional Health Assessment Charts; CORE-OM, Core Outcome Measure; GAD-7, General Anxiety Disorder-7; GHQ-12, General Health Questionnaire-12;HADS, Hospital Anxiety and Depression Scale; PHQ-9, Patient Health Questionnaire-9; RCT, randomised controlled trial; WEMWBS, Warwick-Edinburgh Mental Well-being Scale; WSAS, Workand Social Adjustment Scale.

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One other report of an evaluation estimated totalrunning costs of £83 144 for the programme for 1 year.3

DISCUSSIONThis systematic review has examined the evidence toinform the commissioning of social prescribingschemes. Overall, we identified 15 evaluations con-ducted in UK settings but have found little convincingevidence for either effectiveness or value for money.Most of the evaluations of social prescribing activity

are small scale and limited by poor design and report-ing. Missing information has made it difficult to assesswho received what, for what duration, with what effectand at what cost. Common design weaknesses include alack of comparators (increasing the risk of bias), loss tofollow-up, short follow-up durations and a lack of stan-dardised and validated measuring tools. There is also adistinct failure to either consider and/or adjust forpotential confounding factors, undermining the abilityto attribute any reported positive outcomes to the inter-vention (or indeed interventions) received. This is par-ticularly important as most referred patients appear tohave been receiving other interventions and so we haveno way of assessing the relative contributions of theinterventions to the outcomes reported. Despite thesemethodological shortcomings, most evaluations havepresented positive conclusions, generating a momentumfor social prescribing that does not appear to bewarranted.

Strengths and limitationsOur systematic review appears to be the first to assess theeffectiveness of social prescribing programmes relevantto the UK NHS setting. We have searched for full publi-cations and grey literature since 2000 but it is possiblethat we have not identified some local evaluations.Publication bias occurs when the results of publishedstudies are systematically different from results of unpub-lished studies. However, we think it unlikely that anyunidentified evaluations will be more robust than thoseincluded in the review.Many of the evaluations presenting positive conclu-

sions were written as descriptive reports with limited orno supporting data presented. As such, they did notadhere to formal reporting standards that would beexpected in reports to funding agencies or in academicjournal articles. This made extracting any relevant datadifficult and it is possible information relevant to out-comes is missed. Even if this shortcoming of data com-pleteness were to be addressed, we believe that it woulddo little to alter the overall picture of a low-quality evi-dence base with a high risk of bias.

ImplicationsOur systematic review has not established that there isclear evidence that social prescribing is ineffective.Rather, we are not yet able to reliably judge which, if

any, social prescribing programmes demonstrate adegree of promise and so could be considered further.The use of a link worker is the key feature of social pre-scribing. How this link worker role was fulfilled variedsignificantly between projects. So here again, we are notable to reliably judge the type of skills set or level oftraining and knowledge people require to effectivelyfulfil this role. For those seeking to commission new orextend existing schemes, this evidence gap is a hin-drance rather than a help, especially so given the wide-spread support and advocacy for social prescribing atthe policy level.While the tension between rigour and ‘good enough’

evidence has long been recognised,34 even ‘goodenough’ is severely lacking from the social prescribingliterature be that in the design or in the conduct of theevaluations themselves. This may in part reflect the wayschemes have ‘emerged’ rather than being systematicallyplanned with evaluation built in from the outset.Nevertheless, if social prescribing is to realise its poten-tial, then there is an urgent need to improve the ways bywhich schemes are evaluated.Prospective pathways for undertaking rigorous

planned experimental evaluation are well defined,35 butthe opportunity, time and resources needed to employthese in a service context can be limited. However, thisdoes not serve as an excuse for inaction and in thecurrent financial climate we should of course only beinvesting in those services where we can demonstratereal benefit over existing ways of working. What thisshould mean for future evaluation of social prescribingis that a more coordinated approach to the planning,implementation and evaluation of new and existingschemes is undertaken. This could and should involvethe adoption of a common analytical framework whichin turn will facilitate standardised metrics, cross-site com-parison and shared learning. The IDEAL frameworkoffers one such pathway to navigate the evaluation con-tinuum that would allow for the iterative developmentand evaluation of whether social prescribing is likely tosucceed in a particular setting and allow for adaptation,refinement and system integration without losing sightof the need for more rigorous testing before widerspread.36 Whatever analytical framework is adopted,Lamont and colleagues37 have proposed five essentialquestions for evaluation which those planning to under-take evaluations of social prescribing programmes woulddo well to heed. These are:▸ Why—clarify aims and establish what we already

know from evidence.▸ Who—identify and engage stakeholders and likely

users of research at outset.▸ How—think about study design, using an appropri-

ate mix of methods, and adjust for bias where pos-sible (or at least acknowledge).

▸ What—consider what to measure (activity, costs andoutcomes) and combine data from differentsources.


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▸ When—pay attention to timing of results to maxi-mise impact.

Alongside these, we would also emphasise that rigor-ous conduct and transparent reporting (regardless of‘success’ or ‘failure’) are essential. Reporting guidelinessuch as Standards for QUality Improvement ReportingExcellence (SQUIRE)38 with its focus on explaining‘Why did you start?’, ‘What did you do?’, ‘What did youfind?’ and ‘What does it mean?’ could readily be appliedto ensure that learning is systematically captured in ageneralisable format. This in turn would serve to ensurethat any future decisions relating to the continuation orwider spread of social prescribing schemes are transpar-ent and evidence informed.

CONCLUSIONSSocial prescribing is being widely advocated and imple-mented but current evidence fails to provide sufficientdetail to judge either success or value for money. Ifsocial prescribing is to realise its potential, future evalua-tions must be comparative by design and consider when,by whom, for whom, how well and at what cost.

Author affiliations1Centre for Reviews and Dissemination, University of York, York, UK2York Trials Unit, University of York, York, UK3Alliance Manchester Business School, University of Manchester, Manchester,UK4School of Healthcare, University of Leeds, Leeds, UK

Twitter Follow Alison Booth @AliBooth42 and Paul Wilson @pmw777

Contributors PMW took overall responsibility for the systematic review. LB,AB and PMW were involved in all stages of the review from development ofthe protocol, through screening studies and data extraction, to analysis andsynthesis and production of the final manuscript. KF provided input at allstages of the review and commented on drafts of the review. KW conductedliterature searches and contributed to the ‘Methods’ section of the review. Allauthors approved the final version and PMW is the guarantor.

Funding This review was funded by the National Institute for Health Research(NIHR). As part of research funded by the NIHR Health Services and DeliveryResearch programme (Project ref: 12/5002/18), Additional funding for PMWwas received from the NIHR Collaboration for Leadership in Applied HealthResearch and Care (CLAHRC) Greater Manchester.

Disclaimer The views expressed are those of the authors and do notnecessarily reflect those of the NIHR Health Services and Delivery Researchprogramme, NIHR CLAHRC Greater Manchester or the Department of Health.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement All available data can be obtained from thecorresponding author.

Open Access This is an Open Access article distributed in accordance withthe terms of the Creative Commons Attribution (CC BY 4.0) license, whichpermits others to distribute, remix, adapt and build upon this work, forcommercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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