In January 2019, the Department of Health and Social Care (DHSC) published the highly anticipated NHS Long Term Plan (NHS, 2019). While the publication of a White Paper is not typically celebrated, some of the key paradigms outlined in the Plan signal a move away from a traditional view of health being ‘what's the matter with someone’ to a more personalised approach that embraces a philosophy based on ‘what matters to someone’. Against the backdrop of the increasing number of children, young people and adults living with at least one long-term condition, the change from the pathogenic to the salutogenic model heralds a very different approach to care based on the comprehensive model of personalised care (NHS England, 2018) which highlighted the significance of the ‘person’ and not just the ‘patient’. This article will outline this model and focus on social prescribing as integral to successful operationalisation of the personalised approach.
The NHS Long Term Plan
Personalised care promotes the health professional to consider the ‘person’ as opposed to the ‘patient’ (NHS England, 2018). In doing so, the person's needs are placed central to decision-making, facilitating patient choice and control over their care.
The NHS Long Term Plan (NHS, 2019) promoted a paradigm that actively encourages the shift from pathogenic to salutogenic approaches through its comprehensive personalised care model. Salutogenesis focuses on factors that promote and support health and wellbeing rather than factors that cause disease. It is estimated that up to 2.5 million people will benefit from the model by 2024 and that personalised care will become ‘business as usual’ (NHS, 2019). Re-orienting healthcare with the underpinning theory of salutogenesis is not a new concept (World Health Organization (WHO), 1986; Lindström and Eriksson, 2005); however, its resurgence provides opportunities to alleviate the challenges and demands of general practice nursing in the 21st Century (The Queen's Nursing Institute, 2015).
Delivering universal personalised care using the comprehensive personalised care model will involve the implementation of trained ‘social prescribing’ link workers, personal health budgets, and the coproduction of personalised care and support plans to help individuals experiencing long-term conditions; 75 000 clinicians and professionals will be needed to provide support for personalised care in their practice (NHS England, 2019). Underpinning this approach are six core principles:
- Shared decision-making
- Personalised care and support planning
- Enabling choice
- Social prescribing and community-based support
- Supported self-management
- Personal health budgets and integrated personal budgets across the NHS and the wider healthcare system (NHS, 2019).
These are all necessary ingredients for a universal personalised care model. Key to the success is the social prescribing systems and processes that will help professionals and individuals navigate the many non-medical, community health assets available to support the personalised approach to wellbeing. All communities have local health assets which can include the skills, knowledge, motivation of individual community members, existing friendships and neighbourliness, formal or informal voluntary groups and associations, physical, environmental and economic resources available in the community, as well as assets brought by external agencies (Public Health England (PHE), 2015a).
Social prescribing
One of the key components to enabling personalised care is social prescribing. This is a form of community referral that enables frontline staff to refer a person for non-medical, non-clinical support. It involves using assets in the community to support a person through a wellbeing conversation, predicated on what matters to the person rather than what is the matter with them. Understanding a person's perspective of a ‘community’ (place, geography, interest or identity) is an integral part of valuing people as active participants in the planning and management of their own health and wellbeing (PHE, 2015a). This strengths-based approach focuses more on the individual's assets rather than their deficits, and embraces a personalised approach to care. Putting this into operation this has led to a Government pledge for 1000 trained social prescribing link workers to work with primary care networks (PCNs) and the voluntary community and social enterprise (VCSE) sector to create pathways for people into social prescribing interventions. Essentially, this approach considers the wider determinants of health by placing an emphasis on wellbeing rather than on health alone. Social prescribing uses non-medical, asset-based, salutogenic approaches to promote a personalised paradigm that places the person at the centre of decision-making.
Social prescribing models
Anchored in primary care, social prescribing is considered a pathway to participation in the family of community-centred approaches for health and wellbeing (PHE, 2015a). Although social prescribing is influenced by national agenda, the way in which it has been implemented across the UK can differ significantly. Kimberlee (2015) identified four different types of social prescribing models:
- Social prescribing signposting, a frontline practitioner can send someone to an organisation, such as a knitting group, for social conversation
- Social prescribing light, sending at-risk or vulnerable population groups to specific social prescribing programmes
- Social prescribing medium, there is a conversation between an individual and a dedicated social prescribing practitioner to understand what matters to the person and determine an appropriate referral, for example someone who may be overweight maybe referred to a walking group
- Holistic social prescribing, actively promotes personalised care using the ‘wellbeing’ conversation as integral to empowering personal choice.
There are a number of non-medical services available ranging from art workshops to nature-based interventions
The wellbeing conversation is led by a link worker, who may have up to eight meetings to determine what matters to the individual, after which, the person is referred to a non-medical service to support them. The holistic approach is predicated on multi-professional, cross-agency communication and collaboration; integration is therefore considered to be the fabric of the model, enabling the person to have a choice over their care.
The need for a different approach
There are a number of non-medical services and interventions available across the UK. These range from Arts on Prescription (a series of art workshops for people experiencing depression, anxiety and other mental health conditions), to nature-based interventions, such as allotment or gardening groups. Evidence suggests that nature-based activities such as gardening or walking outdoors can improve our wellbeing (Annersted and Währborg, 2011). Interestingly, joining a gardening group can help reduce social isolation for older people (Howarth et al, 2016) and those with mental health problems (Wood et al, 2015). It is estimated that being socially isolated can have significant detrimental effect on health and social isolation is known to cause early death (Holt-Lunstad et al, 2010). Equally, mental health is now a major global burden (WHO, 2019) and is the main cause of ill-health (GBD 2016 Disease and Injury Incidence and Prevalence Collaborators, 2017). Social prescribing can provide a non-medical solution to supporting people across a range of age groups with diverse needs to regain control of their wellbeing and help tackle future and existing long-term conditions.
Public health and wider agenda
To ensure that the comprehensive model of personalised care becomes ‘business as usual’, the ten-point action plan for general practice nursing (NHS England, 2017) recognises that practice nurses need access to educational programmes to develop skills to support case-finding and promoting self-care for all people with long-term conditions.
To deliver the radical upgrade still needed in prevention (NHS, 2019), a new online learning platform called All Our Health has been developed with GPNs in mind to help embed and extend prevention, health protection and promotion of wellbeing and resilience into everyday practice (PHE, 2015b; NHS England, 2017; Health Education England (HEE), 2019).
PHE (2013) re-emphasised its vision that public health practice becomes every nurse's responsibility at an individual, community and population level vision more than 5 years ago. The All Our Health framework for personalised care and population health (PHE, 2015b) identified seven evidence-based approaches that all health professionals, including nurses, could adopt to ensure that public health is embedded into practice:
- Improving the wider determinants of health
- Health improvement
- Health protection
- Supporting health, wellbeing and independence
- Life-course approaches to improving health and wellbeing
- Place-based services of care.
Social prescribing provides numerous aspects of this framework of evidence that aims to help all health professionals, including practice nurses, to use their skills and relationships to maximise their impact on avoidable illness, health protection and the promotion of wellbeing and resilience (PHE, 2018).
An all-age, whole-population approach to social prescribing
The comprehensive personalised care model sets out how social prescribing is a universal population intervention that can be used in primary care to support people to stay well and build community resilience (NHS England, 2018). This suggests that health improvement efforts such as Making Every Contact Count (MECC) could routinely include non-medical solutions such as social prescribing to address MECC's five core elements: stopping smoking, reducing alcohol use, maintaining a healthy weight and diet, and promoting mental health and wellbeing (PHE and HEE, 2018).
The estimated 30% of a general practice population living with long-term physical and mental health conditions will benefit from targeted support to build knowledge, skills and confidence to live well with their health condition(s) and self-manage. A further 5% of the practice population living with complex needs will benefit most from specialist interventions that empower people, including the use of personal health budgets. NHS England (2018) is clear that people living with long-term physical and mental health conditions will benefit from targeted interventions plus universal interventions, and that those with complex needs will benefit from specialist interventions plus targeted and universal interventions, thus suggesting that social prescribing offers an effective intervention for the whole population.
Conclusion
The comprehensive personalised care agenda provides nurses with an opportunity to revisit the significance of salutogenesis and the call to action for every nurse to maximise their impact on the public's health – in practice, education and research. Keeping abreast of the social prescribing movement in communities and working in collaboration with link workers will help the practice nurse community to empower patients and not just regain control of their health – but also invigorate and promote their wellbeing.
KEY POINTS
- Salutogenesis is an asset-based approach to supporting an individual's wellbeing
- There is a need for practice nurses to be aware of and work with social prescribing link workers to enable them to form part of the social prescribing pathway and support them
- Practice nurses may already be familiar with the concept of community referral; the wider personalised care agenda has refreshed the language used and social prescribing offers an opportunity to rebalance practice through salutogenic principles
- All Our Health is a call to action for every nurse to maximise their impact on the public's health – in practice, education and research