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Notes Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response  Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response About our response The Healthy London Partnership and the Mayor have published ‘Social Prescribing: Our Vision for London 2018-28’, a ten year vision for how we can embed social prescribing across London. This document is the London Assembly Health Committee’s response to the consultation on the Vision. who are essentially acting as link workers. We heard from a Housing Association project in Thamesmead. We will share all of the responses to our call for evidence with the Mayor’s health team. Like most of the health and care community, we support social prescribing. The evidence is that social prescribing can bring a whole host of benefits to individuals, to communities and to the wider health and social care landscapes. Our two big asks for the Vision are more clarity about how we help the right people, particularly from under- represented groups, and also how we fund the work. Though the Mayor cannot commission or instruct health services, this vision can signal to the health and care sector that social prescribing must be more than an add-on. It is an essential pathway for tackling the inequalities in the social determinants of health and building healthier communities. The Health Committee looks forward to the Mayor’s leadership on this matter. We hope our comments are helpful and that the Mayor’s Vision helps London become a healthier place for all. Dr Onkar Sahota, AM, Chair of the London Assembly Health Committee this work. On behalf of the London Assembly Health Committee, we welcome the Mayor’s Vision and the spotlight that it gives to social prescribing. In November 2018, the Health Committee heard from experts on social prescribing, as well as front line workers and people being supported by social prescribing navigators (known as link workers). We heard moving stories of lives turned around. We heard a chorus of people in support of We also held a public call for evidence and gathered submissions from all sorts of people working in social prescribing. We heard from GPs in Merton who referred clients on to link workers. We heard from link workers in Tower Hamlets who were meeting with people who had self- referred. We heard from Liaison and Diversion police officers in Barking Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response What is social prescribing? Social prescribing is a holistic way of looking at health, recognising that health is determined by a range of socio-economic factors and that clinical interventions are not the only form of support a person can need when they see a health professional. It tries to connect people up with a range of non-clinical services within their own communities. The most common model for social prescribing is the link worker model. A link worker acts as a point of contact for social prescribing clients and helps them find local support. That support could be help filling in a housing benefits application, or attending an art class, or negotiating housing needs, to name a few examples. Link workers are sometimes based in GP surgeries or other healthcare settings, but don’t have to be and some visit clients in their own homes. Who pays for social prescribing? We think that the Vision could be improved with more details about the money. Social prescribing doesn’t work without a healthy voluntary, community and social enterprise (VCSE) sector. But the sector is notoriously underfunded. There is no point in having a vision to help people onwards towards community support if community projects can’t take them in. As far as we can see there is no new money to support social prescribing across London. Even if we can convince commissioners and local authorities of the case for social prescribing they are still hard-strapped for cash to invest Expanding social prescribing is going to be particularly hard for local authorities. Councils across London have seen budgets severely reduced in recent years, and we worry that social prescribing will go into a long list of things that a council would see as “nice to have, but we can’t afford right now”. The Vision needs to give clearer guidance to boroughs in particular, many of which still have no social prescribing options. There is no reason a borough or CCG should have no scheme at all and the Mayor should focus on fixing this. To be fair to the Vision, it is not a budget document and it does acknowledge that “secure funding and the need to support VCSEs to secure funding is critical”. It does mention the emerging work of the Healthy London Fund as a potential source of funding. The Healthy London Fund hasn’t been set up yet and our understanding is that the Fund will come from philanthropy. This is a risky way of raising money – who knows how generous people will be? – and it doesn’t provide secure funding. Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response The Five Year Forward View for General Practice and the NHS Long Term Plan both recommend prioritising social prescribing. The Mayor should use his convening powers to get health and care commissioners to act on this. “Our goal has to be that social prescribing is not seen as discretionary spend but is seen as an integral part of the provision for communities in London, an integral part of the health system, the social care system and the local authority system for London” - Dan Hopewell, Co-Chair of the London Social Prescribing Network One of the more interesting ideas we heard was about social impact bonds as a way of getting upfront investment. We were particularly interested in the “Ways to Wellness” social impact bond in Newcastle. Ways to Wellness secured investment from a social investor to launch at scale, with the promise that, if it saved the local health economy money, it would be able to pay the investment back in full. Repayments were subject to contracts that tied back to outcome payments. Ways To Wellness has already started to pay back its investors early. We think that the evidence is out there that social prescribing is a worthwhile investment which merits cash, upfront. In Greenwich, for example, it is estimated that every £1 invested in social prescribing would save £5 in later costs, and similar stories are heard all over London. We think that up-front investment could be a way forward and the social impact bond model could be replicated in London. This is a new approach and the Health team at City Hall needs to explore how possible it would be to have a social impact bond model. It may have worked in Newcastle, but City Hall needs to have the conversations with central government, with health authorities, and with others about how feasible this investment might be. We need to think about who the investors could be, where the risks would fall, and how repayment would work. There is already experience within City Hall about direct investment that we could be using. City Hall invests in schemes that cut carbon emissions through the Green Fund. City Hall may or may not end up being the investor in any social prescribing bond, but it is the best place to coordinate work exploring the possibility. The Mayor should start looking into it now.  Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response What more should be done to help Londoners to understand social prescribing, how it can benefit them and help them to take more control over their health and well-being? The positive thing to note here is that people are generally open to social prescribing. Dr Zoe Williams told us that when the choice is offered between a clinical intervention or a social intervention, most clients choose the social one. There is a lot of wrangling over the term social prescribing, but we don’t think terminology is a big issue. The term isn’t often used on “Many GPs, nurses and healthcare assistants, on the point of suggesting to the patient that they might refer, it is not, “I am going to socially prescribe you”. It is, “We have this wonderful person called Najnin who works in the next building on the other side of the park and she could probably see you and help to support you with some of the issues you have just mentioned to me”” - Dan Hopewell, Co-Chair of the London Social Prescribing Network the front-line. What is important is knowledge about the activities that social prescribing encompasses and reaching people who might benefit from it in the first place. Reaching people, especially those from under-represented groups, will be key to this vision’s success. Reaching people is what the “Easy Access” strand of the Vision is about and supporting those who are locked out of the current healthcare system is what the Mayor’s Health Inequalities Strategy is about. We are glad that the Vision mentions routes towards social prescribing that do not involve a GP’s office, such as “education services, social care partners, care homes, housing associations and many others”. Our work on other issues, especially mental health, has highlighted particular issues for certain groups in accessing GP services as well as other services.1 We have warned about a trend towards generalist services, which lack expertise in dealing with the needs of marginalised groups.2 Parts of London have few GPs and the whole city is affected by an aging primary care workforce, which may further limit access. The Social Prescribing Vision is based around universal access. We hope to see more details of how this will be “proportionate universalism”, targeted at groups that need it most.  Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response The group that needs social prescribing most include those with protected characteristics, but also those marginalised by a lack of access to rights, resources and opportunities. There is no exhaustive list of who we mean when we say those marginalised from the mainstream social prescribing system. Different people and groups in London experience marginalisation in different ways. People who are marginalised are often subject to multiple layers of discrimination when they belong to more than one marginalised group. Targeted work needs to function within a community. Organisations such as Guy’s and St Thomas’ Charity have run neighbourhood-wide public health interventions with targeted help for the most vulnerable. This community health approach should be the model that social prescribing initiatives fit into. The Vision needs more focus and more specific actions on how it will target marginalised groups, as the “Provision for All” aim says it will. There are action plans in development for each of the four work strands - – Workforce, Evaluation, Digital, Social Welfare and Legal Advice – but these are universal. We think there needs to be more focus on how we tackle Health Inequality through social prescribing. There are also no targets in this Vision. We understand that there will be soon be more detailed action plans but were surprised not to see any targets at all. As a minimum, all 33 boroughs should have a social prescribing programme and there should be a basic standard across the capital. We expect to see some detailed targets soon. The Mayor should also lead the way in showing the benefits of social prescribing, and developing stand-out schemes, through the policies of the GLA family. This could include integrating volunteer schemes like police and fire cadets into social prescribing systems. Social prescribing could be worked into occupational health schemes in the GLA family. Existing time off for volunteering could be re-branded, reformed and expanded to support this. Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response What more should be done to support the growth of digital solutions? Social prescribing needs a lot of partners working together. The Vision correctly identifies digital connectedness as key. When we spoke to GPs they told us, “I am not going to log out of my clinical system and log into your platform. I need that seamless connection” - Jennifer Neff, Co-founder of Elemental Software The Vision as it currently stands does not mention digital exclusion. The Vision says that 94% of Londoners are online. That still leaves 6% of Londoners who are not online, or a good half a million people. The groups who are more likely to be digitally excluded – older people, lower income, unemployed, living in social housing or living with a disability3 - are also those who are more likely to need social prescribing. Some areas are now offering self-referral schemes. Self-referral relies on someone knowing that this support is available in the first place, and then having the ability and time to navigate the self- referral system. There are many Londoners who may find this hard, such as people who do not speak English, people who are disabled or people experiencing unstable living or working conditions. Self-referral rates have traditionally been fairly low, and funding is hard to come by. Self-referral does not help reduce the burden on GPs, as those self-referring often would not have gone to the GP anyway. This means it can be hard to sell the idea to commissioners. Some social prescribing groups who we spoke to want the Mayor to advocate for more access to grants for social prescribing groups to develop self-referral. Some of those we spoke to mentioned creating a portal for GPs to be able to access information on available services. This is similar to the “digital front door” idea within the NHS Long Term Plan. We think this could be a good idea, but stress that the link-worker is the one who links people to community services, and it does not have to be the GP. A pan-London portal may be too difficult to formulate, but City Hall could develop a framework that boroughs could then use to integrate local options. The Sport Strategy named one of its priorities as building a digital platform to enable sport to be included in social prescribing. We Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response would like to understand how this pledge fits with the social prescribing vision. We are aware that some digital social prescribing programmes are in development. We support anything that furthers social prescribing. We think that a basic level of self-care guidance could be provided digitally, or some social prescribing assessment done through video calls, modelled on the NHS’ new plans to provide better digital services. However, we caution against rushing to develop something that may end up duplicated and believe that social prescribing is an inherently interpersonal idea. Digital aids will not solve the workforce and funding issues and risk being exclusive. Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response Some of the people we spoke to suggested that link workers should be able to “fast track” people into social welfare services. This stems from a concern that link workers can of course direct someone to the right housing team, or legal advice team, but if that team is already stretched then the person will face a long wait, which can exacerbate problems. Link workers should be trained in basic welfare and financial advice so that they can understand the services they are referring people onto. RCGP and CAB research shows the benefit of co- location of advice in primary care premises.4 The Mayor should look at how he can enable this. There also needs to be continuity of link workers to reassure the person moving between different systems, from link worker to local authority housing to legal advice and back to link worker, for example. With every new step and new referral there is a risk that the person will not receive the right response and stop looking for support. This might be because of capacity issues, and this comes back to the question of funding and co-location. A good link worker will be in touch with the person all throughout, but good processes are needed to make sure that people do not slip through the cracks when they are referred on to already busy services. What more should be done to ensure more/better access to social and welfare advice in London? We fully welcome the Vision’s focus on social and welfare advice. One of our guests told us that a quarter of all social prescribing work is to do with social, housing or welfare issues. These issues can sometimes be very immediate for the person involved, for instance someone may need to pay their rent by next week or face eviction. “People are not going to go and join Parkrun if they are trying to work out how they are going to pay their rent” - Jennifer Neff, Co-founder of Elemental Software We hope that this social and legal advice will be as accessible as possible to under-represented groups. Last year we asked the Mayor to provide a London Dementia Legal Advice Clinic and he committed to exploring the idea. We thought that there were considerations specific to people living with dementia that needed a different approach. We hope that this is the first of many advice clinics that aim to help particularly under-represented Londoners. Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response The Work and Health programme has been devolved to London since March 2018. While this is sub-region led, it should integrate with the social prescribing vision, given that the participants are likely to benefit from this and can be referred in easily. Social prescribing must begin with what the client believes are the problems and assets in their life, not be used as a tool to push people back into work, particularly poor work. But in the many cases where an individual wants to find a job, there is evidence that social prescriptions can help.5 “Sometimes with things like Citizens Advice Bureau or housing, they go and often they come back and feel that the way they were treated put them off and they were intimidated” - Dr Zoe Williams, RCGP Clinical Champion for Physical Activity and Lifestyle Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response What more should be done to support workforce development, in particular the link-worker role, including improving career pathways and providing effective support for staff? We believe that workforce development is a really important part of the social prescribing landscape and are glad that the Vision puts the link-worker at the heart of what makes a good scheme. Right now, there are very few link-workers in London. The Bromley-by-Bow Centre, the leading centre for social prescribing in London, has six link-workers. Merton covers half of its GP practices with just three link-workers. With so few link-workers it is essential that we support those we do have as best we can. The Vision says that there will be accredited pathways for link- workers, as well as training and support. We welcome this and agree that a link-worker should be an accredited career choice. There should be a London-wide network of link workers with training and networking programmes. One of the calls that we heard multiple times was about getting social prescribing into the health curriculum. If social prescribing is going to become “mainstream” then we need to teach the next generation of doctors, GPs, nurses and other healthcare professionals exactly what it is. Our guests fully agreed with the Vision’s promise to try and get new modules into medic training about what link-workers can offer. We know that the NHS is developing a level 3 qualification. We would support this but also question how link workers will pay for the training, as well as find the time to study. We think that there needs to be more emphasis on support. There are so few link-workers in London, yet this Vision aims to make social prescribing mainstream within ten years. It is a very emotionally demanding job. Link-workers are going above and beyond to deliver at the current level of demand. Without the right support we risk losing a fragile work-force. “Currently, link workers are going above and beyond just to make sure that they are connected to the right services. We need to be very careful that we do not lose the existing workforce that we have and that we protect them” - Najnin Islam, Social Prescribing Scheme Manager Bromley-by-Bow Centre ” Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response “We need to make sure that we support social prescribers so that they are not overloaded. Their role is to link people to services and to sources of support, not to casework somebody for a long time. Social prescribers need the support themselves to know where their role ends” - Sue Hogarth, Assistant Director Public Health, Camden & Islington Councils A link worker needs to become a normal role, that has a job description, that has line management, that fits into a structure and has a career path. Only this way can link workers feel confident in what they can expect from their career and employer. Integrating the role into existing structures and ensuring workers are supported and treated fairly across the city will be difficult. It can only be done in partnership with recognised NHS and local government trade unions. Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response What more should be done to support GPs and other health professionals to engage with social prescribing? Firstly, we would like to emphasise it is not just GPs and health professionals who should be engaging with social prescribing. Secondly, the hardest part of getting social prescribing embedded into local systems is not any lack of desire, but a lack of knowledge. When presented with an approach that better serves patients as well as saves time and resource, there are very few who would say no. “It takes no selling, really, for GPs. You only have to stand up in front of them and say, “Have you seen anybody who clearly has loneliness issues, problems with debt, problems with their job in the last week or so?” Everybody nods their heads. We say, “What if we put social prescribing in across the borough that could help your patients deal with some of those issues that you do not have time to deal with?”” - Sue Hogarth, Assistant Director Public Health, Camden & Islington Councils The biggest barrier is a lack of knowledge. 40% of GPs say they would refer to social prescribing networks if they had more information about available services.6 Social prescribing teams are trying to keep primary care professionals informed and confident about what is on offer. This does not just mean the GP; receptionists and other support staff act as the gateway to the clinical setting of the GP’s room itself. With proper training and job re-evaluation, receptionists might be able to spot things that don’t quite fit into clinical need but where there is still support available. Social prescribing is community-focussed and place-based. We are concerned that the link between GPs and the community they serve is becoming harder to maintain, and this may undermine efforts to make social prescribing mainstream. In London increasing numbers of GPs are choosing to remain as salaried staff rather than becoming partners, which can weaken their connection to the community. The Health Committee would like to see more salaried GPs taking up positions on the boards of community organisations local to their practice. Keeping GPs on board and up to date is a hard task. Some of the things that we heard social prescribing teams are doing include: • Sending volunteers directly into GP surgeries. • Having a social prescribing “champion” in each GP surgery.  Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response • Sending feedback to the GP about how the person is doing, in a letter that is put onto the patient’s notes. • Offering professional development training that teaches what social prescribing is available in the local area. Social prescribing is not the answer to everything however. Some social prescribing teams expressed concern to us that social prescribing might be seen as the solution for almost everything that primary care cannot do itself. One social prescribing team told the committee that it was having to do a lot of work to try and avoid being seen by GPs as gatekeepers to mental health support. The support that social prescribing teams can help people find is not meant for complex or acute needs, and improper referrals can lead to people being bounced around a primary care system that is already stretched. We strongly support co-location. Firstly, evidence suggests that GPs are more likely to trust and use a social prescribing service if they are physically part of the same team.7 Secondly, patients attending a GP are less likely to take up a social prescription if they have to go elsewhere to even discuss options with a link worker. Thirdly, voluntary organisations have a clearer route in to medical teams if they have space to run services at the primary care centre. Co-location will prove difficult because of space. Too many GPs are based in premises that cannot easily support social prescribing and we are concerned that this will hinder widespread take-up of social prescribing. The Mayor should also keep an open mind on social prescribing in secondary and acute care settings. This will of course be more specialised provision but combines well with the aspiration to discharge people in a timely but supported manner. Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response Evaluation We heard that there is a lot of evidence already out there that social prescribing works. Most of the social prescribing schemes that have secured funding, ongoing or not, will have used case studies or evidence packs in their presentations to commissioners to get the money in the first place. That means there are hundreds of pieces of evidence spread out across London. City Hall can play a lead role in bringing together all of the evidence across London that social prescribing works. We also think that City Hall can help develop a more consistent approach to evaluation, by being that central place that brings partners together to share best practice, and also by helping to develop tools to evaluate with. “All coming together and sharing bits and pieces of evaluation we will be able to demonstrate en masse how useful social prescribing is” - Sue Hogarth, Assistant Director Public Health, Camden & Islington Councils  Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response What more should be done to support volunteers to engage in social prescribing? Firstly, we do not think that we need to support volunteers to “engage with social prescribing”, but just to volunteer at all. The Bromley-by-Bow Centre, for example, has links with Hackney City Farms. The people who volunteer at Hackney City Farms are not doing so to engage with social prescribing, but because they think helping out at a social farm is a good thing to do. Many of those we spoke to told us that the community and volunteer sector cannot cope with a substantial increase in social prescribing. The Vision’s aim is for social prescribing to be “mainstream” by 2028. It will be incredibly difficult for anything to become truly mainstream purely through goodwill. This is why our main call to action is about funding. “As it stands, the community and voluntary sector would not be able to cope with increased social prescribing” - Royal British Legion Some of the social prescribing projects we spoke to talk about “flipping” clients, from a receiver of support to both a receiver and a giver. For example, a socially isolated person might be in touch with a link worker and through the link worker start getting involved in a local art class. Over time the link worker might ask if that person is willing to become a volunteer and spread what they have gained from the experience. This is one way to develop a workforce and help reduce demand, but it will not solve the underlying issue of capacity in the voluntary and social care sector. Social prescribing needs investment. NHS sites can be used to host activities. Strain on NHS staff time means voluntary roles that can work around existing procedures, rather than require additional work, are preferable. The evidence and availability of gardening programmes is particularly compelling.8 This can also bring into use land around NHS buildings and other parts of the public realm. Lambeth’s GP co-op gardening scheme recently received support from the Duchess of Cornwall.9 There is also potential for social prescribing to improve social integration, for example, through “cuppa and conversation” schemes that bring together young and old Londoners.10  Health Committee Holding the Mayor to account and investigating issues that matter to Londoners The Mayor’s Social Prescribing Vision: Our response About the London Assembly Health Committee The London Assembly holds the Mayor and Mayoral advisers to account by publicly examining policies and programmes through committee meetings, plenary sessions, site visits and investigations. The Health Committee reviews health and wellbeing across London, with a particular focus on public health issues and reviewing progress of the Mayor’s Health Inequalities Strategy. The committee’s meetings are open to the public and are broadcast on our website at www.london.gov.uk . The committee also regularly seeks views from the public through calls for evidence, events and meetings in public. You can find out more about the committee’s work on our website at https://www.london.gov.uk/about-us/london-assembly/london- assembly-committees/health-committee 1 London Assembly Health Committee, Supporting Mental Health for All, January 2018 2 London Assembly Health Committee, Supporting Mental Health for All, January 2018 3 NHS Digital, Digital Inclusion 4 Advice in Practice: Understanding the effects of integrating advice in primary care settings, Citizens Advice Bureau & Royal College of General Practitioners, June 2018 5 Social prescribing: a pathway to work?, The Work Foundation, 2017 6 Social Prescribing, NHS England If you would like to be kept informed about our work on social prescribing or other projects, or have a question or suggestion about the Assembly’s work on health and wellbeing, please contact healthcommittee@london.gov.uk. We would love to hear from you. You can also follow us on Twitter via #AssemblyHealth 7 Delivering a primary care-based social prescribing initiative, British Journal of General Practice, July 2018 8 Gardens and health, The King’s Fund, 17 May 2016 9 Camilla praises GPs who prescribe gardening to patients, News and Star, 7 February 2019 10 Children in care homes: “it makes residents feel more human”, The Guardian, 12 November 2018 

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