Connecting the dots: tackling mental health inequalities in Wales.
This is the fifth chapter of the Health and Social Care Committee ‘Connecting the dots: tackling mental health inequalities in Wales’ report.
On this page:
— Our view
What is social prescribing?
94. Social prescribing is a way of linking people to sources of non-medical, community-based support to help them better manage their health and wellbeing. It generally emphasises seeing and supporting a person holistically, rather than through the lens of treating a specific condition. It is not simply about GPs prescribing gardening or art classes as an alternative to antidepressants, rather it is about exploring an individual’s broader needs and what really matters to them.
95. Professor Carolyn Wallace of the Wales School of Social Prescribing Research (“WSSPR”) told us that, in Wales, the dominant model is not primary-care based social prescribers or referrals, rather social prescribing is based in communities, with the third sector and local authorities working in partnership with primary care.
96. Social prescribing schemes can include a wide range of interventions and activities, for example volunteering, arts or creative activities, gardening, sports, adult learning, and befriending. Support for social welfare issues is an important element. It can be used with a range of patients, including people with mild or long-term mental health issues, vulnerable or isolated people, and people who are frequent users of primary or secondary mental health services.
97. Professor Sir Sam Everington, a pioneer of social prescribing, told us about his work in the Bromley by Bow Centre in east London. Referring to an “opioid crisis”, he told us:
“…the beauty of social prescribing is you then give the tool to every GP to have an alternative. Because there's a lot of pressure on clinicians and doctors and nurses to prescribe, and so that's why we came up with the term 'social prescribing', because we wanted them to carry on prescribing, but actually do something very different to what they were doing before”.
Social prescribing in Wales
98. In 2016, PHW established a Primary Care Hub to explore the evidence base for social prescribing, identify current projects, and share learning. In 2017, WSSPR was set up with an initial aim to establish a Wales Social Prescribing Research Network and build an evidence base for social prescribing in Wales. In October 2018, the Welsh Government announced £1.3m funding to support two social prescribing pilots. This included a Mind Cymru run pilot designed to help people experiencing mild to moderate problems with their mental health and emotional wellbeing. The evaluation report, published in December 2020, found that:
- Clients were included in discussions about available support and felt heard and valued.
- Social prescribing offered a timely intervention for clients, especially in the context of long NHS mental health service waiting times.
- Link workers played a key role, were highly-valued, and helped to facilitate stakeholder and client buy-in and engagement.
99. In June 2021, the First Minister described social prescribing as “an important part” of the future of primary care services for people with low-level mental health and wellbeing needs. He said that many of the opportunities available via social prescribing already exist in the community, but that “sometimes an introduction via a social prescription can break down the barriers that people can feel between their own needs and ways in which those could be met in the community”.
100. The Programme for Government includes a commitment to introduce an all-Wales framework to roll out social prescribing as a means of tackling isolation. Professor Carolyn Wallace, who has been involved in the development of the framework, told us the intention was to provide a framework of principle and guidance rather than develop a national social prescribing service. Between July and October 2022, the Welsh Government consulted on developing a national framework for social prescribing, which it said would provide “a common set of standards and ensure consistent delivery”. Key issues in the consultation include the language used to describe social prescribing; a social prescribing model for Wales; what is already happening, what is working, and what is not; what action could be taken on a ‘once for Wales’ basis; how social prescribing could be embedded or developed; and what technological solutions may be needed.
101. Following initial referrals from a health, social care, housing or third sector professional (or self-referral by an individual), referrals to social prescribing projects are usually undertaken by a link worker. The report of the 2016 Annual Social Prescribing Network conference described effective link workers as having a “critical role in making social prescribing approaches work”, but noted that:
“…there could be difficulties in finding skilled, networked link workers. The person specification is demanding, but pay may be relatively low. It is unrealistic to think volunteers could take on such a linking role“.
102. There is no standard job title for link workers, who may also be known as social prescribers, community connectors, or other more specialist titles. Salaries may vary considerably (for example between £16k and £36k), and while contract terms vary, many are on short term contracts of between 6 and 12 months due to the short term nature of the funding.
103. Professor Sir Sam Everington described what he saw as the core requirements for link workers:
“So, what is a social prescriber? What sort of characteristics do they have? And, for us, in a very deprived community, we actually have lots of people who don't have formal qualifications, often not a lot of GCSEs, but have fantastic talents—invariably, the significant majority of them women in our community—and they are emotionally intelligent, they like working with people. Most importantly, they're motivational coaches, and they are what I call a 'fixer'”.
104. Link workers are not regulated and there is no standardised training or requirements. Professor Carolyn Wallace identified this as a key issue, as she said it could result in inappropriate referrals being made particularly if greater reliance is placed on social prescribing as a way to support people who may face long waiting times for mental health services. She added that link workers themselves were concerned about this, as it was not always clear whether they were liable if something were to go wrong.
105. The Welsh Government’s Connected Communities strategy includes a commitment to developing a national skills and competencies framework for the social prescribing workforce in Wales. This work is being led by Health Education and Improvement Wales (“HEIW”). The Deputy Minister for MHW told us that it will include details of the knowledge, skills and behaviours expected of link workers, will apply to employers, trainers and link workers, and will “enable entry level staff to train as social prescribers and progress to high levels of skill and responsibility”.
Unlocking the potential
106. Many of those contributing to our inquiry have highlighted a need to ‘unlock the potential’ of social prescribing. There are schemes in place in some parts of Wales, but there are differences in approach and the level of service available. We also heard that people, including medical professionals, are often not aware that social prescribing could be an option. During our focus groups, some patients told us about positive experiences of social prescribing, but others said that people did not know about it:
“Pre pandemic I was in England and the GP surgeries were turning into hubs with lots of services. That as a way forward feels good. Right now there is nothing in my surgery—no social prescribing at all. Making GPs less venerated and more part of the community is the way forward.”
“We need to talk about social prescribing. GPs shouldn’t just be prescribing antidepressants. Young people don’t know they can access free gym passes for example and they don’t get told this. My learners don’t have a clue it’s an option – it needs to be shared more.”
107. Andy Bell said there was “an increasingly compelling evidence base for the benefits of social prescribing”. He acknowledged that it cannot change an individual’s economic or social conditions entirely, but suggested that it can mitigate them, give people more choice and autonomy, and help them to feel that they are part of their community.
108. While he noted the growing evidence base and the contribution social interventions such as employment placement support could make, Professor Rob Poole cautioned that gatekeeping access to social facilities and opportunities on the basis of “a mental health label” could be disempowering:
“If we can only access social facilities by them being prescribed, we haven’t really solved any problems”.
109. Others were also cautious, saying that social prescribing must be seen as one element of a wider package of care and warning against any perception that it could be a “cheap replacement” for clinical services.
110. Digital technology plays a key role in effective social prescribing, both in terms of providing social prescribers with accessible, accurate directories of activities in their areas, and in capturing outcomes data. Professor Carolyn Wallace said that unlocking the potential of social prescribing would be facilitated by ensuring that health boards, GPs and link workers have access to effective digital platforms.
111. The Deputy Minister for MHW described evaluating the impact of social prescribing activity as “challenging”, in part because of variation in social prescribing models across Wales. She and her officials noted that the Welsh Government’s consultation was looking at different evaluation approaches, and that the Welsh Government was working with WSSPR to explore how to understand whether social prescribing pathways were delivering the desired impact for individuals.
112. The evidence shows that social prescribing offers the potential to address people’s needs in a more holistic, personalised way. It is not a ‘magic bullet’ and it is not suitable for everyone or in all circumstances, but it has potential when used appropriately to reduce pressure on NHS services and improve people’s health and social outcomes.
113. There is significant variation in social prescribing provision across Wales, and it is clear there is scope to develop the approach further, beginning with a shared understanding of what social prescribing means. Public and professional awareness of social prescribing are too often patchy and inconsistent, which could prevent people who could benefit from social prescribing from receiving the support they need to alleviate mental distress or build positive mental health and wellbeing.
114. We welcome the development of the national social prescribing framework. It could help to raise awareness and understanding of social prescribing across Wales, provided its publication and ongoing implementation is accompanied by appropriately-targeted communication campaigns to raise awareness among health professionals, services and community groups and organisations to which people could be prescribed, and the general public. Otherwise, the framework may fail to secure buy-in from all relevant partners, including people who could benefit from social prescribing.
To accompany the publication and ongoing implementation of the social prescribing framework, the Welsh Government should develop and deliver targeted communication campaigns to promote awareness of social prescribing and the new framework among health professionals, services and community groups and organisations to which people could be prescribed, and the general public.
115. A key challenge will be the development of appropriate outcome measures to assess the success or otherwise of the social prescribing framework. Where measures exist, they are often skewed towards health measures rather than social measures—this may fail to capture the impact of social prescribing in tackling the wider social determinants of mental ill health and mental health inequalities.
The Welsh Government’s social prescribing framework should include measures by which the health and social impacts and outcomes of social prescribing schemes at local, regional and national levels can be assessed. The Welsh Government should commit to publishing data as part of the ongoing evaluation of the social prescribing framework to enable us and stakeholders to monitor the impact of both social prescribing and the social prescribing framework.
116. Ensuring that people are able to have quality conversations about what matters to them, and that they are supported in a personalised way is fundamental to unlocking the potential of social prescribing and tackling inequalities. We note the draft social prescribing framework includes limited reference to the role of link workers in this regard, and believe that further work is needed to develop a more professional structure that provides more standardisation and greater support for link workers. We welcome the Welsh Government’s commitment to developing a skills and competencies framework for the social prescribing workforce, but we are not yet assured that a voluntary framework will be sufficient to provide clarity to link workers, health professionals, or the public about the role. We are also concerned about the degree of variation in pay, terms and conditions, and the issues that have been raised with us about the lack of sustainable funding for these posts. We agree with recent research that greater professional infrastructure is needed, including job descriptions, salary guides and supervision requirements, as well as a skills and competency framework and training requirements.
In its response to our report, the Welsh Government should outline what actions it will take to develop a more professional structure for the social prescribing workforce, including how it will address variation in pay, terms and conditions, and improve funding sustainability for such roles. In line with our recommendation 22, the Welsh Government should provide us with an update on this work in December 2023.
Table of Contents
— Mental health is 'made' in communities
— Coordinated cross-government action
— Reform of the Mental Health Act 1983
— Annex: Mental health and emotional support
 Senedd Research, Research briefing: Social prescribing, August 2021
 RoP [para 15], 19 May 2022
 RoP [para 359], 19 May 2022
 NHS Wales, Social prescribing [accessed August 2022]
 Welsh Government, Written statement: Social prescribing pilots for mental health, 1 October 2018
 Welsh Institute for Health and Social Care University of South Wales, Evaluation of the pilot mental health social prescribing programme: final report for Mind Cymru, December 2020
 Plenary RoP [para 11], 22 June 2021
 Welsh Government, Welsh Government Programme for Government: update, 7 December 2021
 RoP [para 30], 19 May 2022
 Welsh Government, Consultation: Developing a national framework for social prescribing, 28 July 2022
 Social Prescribing Network, Report of the Annual Social Prescribing Network Conference, January 2016, p.23
 RoP [paras 26-28], 19 May 2022
 RoP [para 361], 19 May 2022
 RoP [para 23], 19 May 2022
 RoP [paras 71-72], 28 September 2022
 Health and Social Care Committee, Mental health inequalities: engagement findings, March 2022
 RoP [paras 204-205], 24 March 2022
 RoP [para 99], 4 May 2022
 RoP [para 210], 6 July 2022
 Health and Social Care Committee, Mental health inequalities: engagement summary: workforce, September 2022
 RoP [para 32], 19 May 2022
 RoP [paras 82-83], 28 September 2022
 Wales School for Social Prescribing Research, PRIME Centre Wales, Data Cymru and Public Health Wales, Understanding social prescribing in Wales: a mixed methods study: a final report, September 2021