Morgan Jones on the dubious benefits of social prescribing
We know why things happen. We have known since the late 19th century that carbon emissions at scale will heat the planet. We know overfishing drains our oceans of fish, and we know lack of sex education leads to more teen pregnancies, and we know access to clean water prevents cholera. Public policy-making is not entirely straightforward, but neither is it a vast maze of obliquity where we can only blindly grope towards solutions. The world is complicated and interconnected. Does deworming actually improve educational outcomes? But there are some parts of it that are, thankfully, quite simple, where cause and effect are as aligned as a stone displacing water from a jug.
Among the simplest of all such action/consequence pairings is austerity. When you cut public services, the things designed to support communities and public health, the public services get worse, and accordingly, public health will decline. This is the story of the last 12 years in the UK. The definitive guide to the Conservative record in government is the Marmot review, which documents how life expectancy has stalled – in some places reversed – over 12 years of austerity rule.
At the core of the welfare state in the UK is the NHS, which, after 12 years of cuts, is a late-stage Jenga tower of an institution. Stripped of all stability, it is barely completing many of its basic functions, failing outright to complete others. In July, if you had a heart attack or a stroke, you would wait three times the target time for an ambulance. And yet the Tories, for a set of reasons to do with the cultural role and political popularity of the NHS, profess to love the health service. During the pandemic, they incited us all to clap for carers. Platitudes about the NHS remain at the core of any given Tory platform.
Into this strange space, professing to love a thing you are destroying, cutting all else around it so that more and more of the state falls onto one beleaguered arm, steps social prescribing. Broadly, this is the act of having the NHS, usually GPs, prescribe things that are not medicine. It has been on the rise in the UK over the last decade (the NHS’s long-term plan pledges resources for a large expansion of social prescribing). This often means exercise or community activities – the gov.uk website gives a list of examples of activities which might be social-prescribed (“volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports”) – the kind of things that everyone knows to be, generally speaking, good for you, and that, entirely incidentally, it might have been easier to access for free before local authorities were subject to austerity and had their budgets cut by as much as 42%.
James, a junior doctor in the south of England, is blunt about his views on social prescribing as a function of austerity. “Being unwell shouldn’t be a precondition to accessing something that a generation ago was just seen as a basic service. There are so few of these council services now. There’s a fair chance soon [that] the ones that are GP-related might be the only ones… When getting a limited allotment relies upon getting a limited GP appointment, it’s just bottlenecks all the way down.” He cites Paracelus (“All things are poisons, for there is nothing without poisonous qualities. It is only the dose which makes a thing poison,”) saying, “You need a doctor to prescribe things, because they have the clinical judgement to make that assessment. What’s the poisonous dose of community gardening or aqua aerobics?”
There is also, crucially, much to suggest that social prescribing has a negligible impact on actual health outcomes.
With social prescribing, then, Tory governments show their hand. They have taken away things that are good for everyone, which has had a massively negative impact on public health. Knowing this, they are using the one permissible arm of the state to drip-feed these nice, healthy things back to those most in need. The most egregious example of this came in August, when it was reported that the Government was considering allowing GPs to prescribe energy bill reductions to patients. There is no-one who would not be better off with a warm home and without the stress of how to pay for it. This is dazzlingly obvious. What social prescribing has always been for this government is a means of prescribing exemption from their own policies.
With Jeremy Hunt – who championed the programmes as health secretary between 2012 and 2018 – back to the fore of politics and in control of the public purse, it seems unlikely that social prescribing will be going anywhere soon.