Non-clinical community interventions: a systematised review of social prescribing schemes

Figures & data

Figure 1. Extent of evaluation in peer-reviewed journal articles and reports, 2000–2015.

Table 1. Social prescribing schemes with evaluation of primary research material.

Scheme	Authors	Intervention	Participants	Measures	Analysis and findings
Arts on prescription	Crone et al. (2013)	Mixed methods study of 10-week arts programme “Art Lift” delivered in general practice surgeries or community facilities in Gloucestershire	Patients (n = 202) from differing socio-economic backgrounds referred through primary care for anxiety, depression, stress, low self-esteem, and chronic illness	Change in well-being on 14-item WEMWBS 7-item scale SWEBWS; completion rates; observation and interviews	Pre-post comparison of WEMWBS using t-test found significant well-being improvement with 7- and 14-item scale; of those referred nearly 78% attended and nearly 50% completed programme
	Potter (2013, 2015)	2013: RCT with wait- list controls: 12 weekly sessions over two phases across Cambridgeshire and Peterborough	Patients referred by primary care practitioners (n = 66) with mild to moderate anxiety and/or depression	Self-reported measures at baseline and 12-weeks: GAD-7; PHQ-9; WEMWBS; SI, plus analysis of semi-structured interviews	2013: Percentage change found positive outcomes for 78% patients: increase in mental well-being (83%); decrease in social isolation (44%), anxiety (61%) or depression (67%)
					2015: Percentage change found positive outcomes for 91% patients: increase in mental well-being (76%); decrease in social isolation (69%), anxiety (71%) or depression (73%)
		2015: Mixed methods, 12 weekly sessions in Cambridgeshire
	Griffiths (2002)	Qualitative study: “East London Arts on Prescription”, in Tower Hamlets, South Hackney, Newham, and Waltham Forest	Young men from African and Caribbean communities (n unknown) with mental health issues facing racism and discrimination	Interviews and consultation explored benefits of art and creativity in mental health promotion to develop alternative approaches to mental well-being	Suggested priorities included building partnerships involving arts, creativity, spirituality, and alternative therapies and integrating these with education, training, and employment as the basis of holistic approaches
	Eades & Ager (2008)	Isle of Wight “Time Being” qualitative study of 12 weekly, creative sessions	Patients (n = 59) referred from primary care; follow-up patients (n = 22)	Interviews, focus groups, and pre-post questionnaires for depression, negative state, self-esteem, social anxiety, and ease of talking to people; plus 6-month follow-up	Increases in positive mood, confidence, and sociability; follow-up responses suggested that for some people, benefits were sustained
	Secker, Spandler, Hacking, Kent & Shenton (2007)	Retrospective quantitative analysis of Isle of Wight “Time Being” study	Patients from “Time Being” (n = 53) with mild-to moderate mental health issues	Interviews, focus groups, and pre-post questionnaires for depression, negative state, self-esteem, social anxiety, and ease of talking to people	Statistical analysis found significant improvements in ratings of mood, self-esteem, ease of talking to people, one symptom of depression (difficulty falling asleep) and two negative emotions (sadness and anxiety)
	Stickley and Eades (2013)	Follow-up qualitative analysis two years after “Nottingham Arts on Prescription” scheme	Patients (n = 10) who were currently using or had previously used mental health services	Follow-up interviews conducted with participants two years after programme end	Found increased motivation and aspiration, self-confidence, improved social and communication skills; emerging themes included education: practical and aspirational achievements; broadened horizons: accessing new worlds; assuming and sustaining new identities; and social and relational perceptions
	Stickley and Hui (2012a)	Qualitative study used narrative enquiry approach for 3-year programme (2008–2011)	Participants currently or previously using mental health services (n = 16)	In-depth patient interviews conducted in community-based arts venues	Programme regarded as creative and therapeutic environment, a safe place with others with similar experiences, leading to a sense of social belonging; peer support, social and employment opportunities
	Stickley and Hui (2012b)	Qualitative study for above programme	Referrers (n = 10) from 148 who referred participants 2008–2011	In-depth semi-structured interviews	Thematic analysis found referrers valued intervention as it offered a professionally led, therapeutic, relaxing, and safe environment; referrers reported that participants took pride in the work that helped them to build confidence, find meaningful occupations, develop skills and express themselves
	White and Salamon (2010)	Mixed methods interim evaluation of 18-month “Arts for Wellbeing” pilot phase in County Durham consisting of six weekly sessions	Patients referred by GP practice (n = 220: 70 males and 150 females) aged 18–99 with physical and or mental ill-health; participants in focus groups (n = 6–10 per group)	Participant demographics; pre-post well-being measure: WEMWS (7- and 14-items), activity evaluation after six weeks; participant comments and narratives from six focus groups with 15 open-ended questions	Two-thirds of patients improved on two WEMBS items (“I”ve been feeling useful; “I”ve been feeling relaxed) but no statistical analysis; activity evaluation found positive relationship with artist-educator and enjoyment: focus groups indicated programmes should exceed six weeks
Education on Prescription	Aylward & James (2002)	Qualitative study “Prescription for Learning” in Nottingham aimed to reduce dependency on health professionals	Patients (n = 196) referred by GPs, health visitors, practice and mental health nurses, for anxiety, low self-esteem and chronic pain; two-thirds had no academic qualifications and had not accessed learning since school	Semi-structured interviews with patients (n = 10) and health care professionals (n = 8)	Patients reported enhanced confidence and self-esteem; lifted mood; improved sleep; increased activity; widened social networks; greater sense of control, hope and optimism; and healthier behaviours
Exercise on Prescription/Exercise Referral	Cock, Adams, Ibbetson, and Baugh (2006)	Pilot study trialled modified measure for evaluation of service quality	Patients attending exercise referral scheme (n = 627) referred through primary care	REFERQUAL questionnaire developed from SERVQUAL questionnaire	Pearson and Spearman correlations found significant association between questionnaire items; Cronbach’s alpha showed internal consistency
	Crone, Johnston, Gidlow, Henley, and James (2008)	Study of patient uptake, initial progression, and completion of scheme over three years in Gloucestershire	Comparison of mental health (n = 134) and physical health (n = 2767) groups	Rates of uptake, initial progression, and completion as percentages	Chi Squared test found that participants with mental illness had significantly poorer initial progression and completion rates than those with physical illness
	Dinan, Lenihan, Tenn, and Iliffe (2006)	Pilot study of two-phase progressive exercise programme with 14 London-based general practices	Patients (n = 158) aged 75+ deemed borderline frail by their GP or practice nurse	Timed Up and Go test (TUG) in seconds at baseline and programme end	Paired sample t-test (n = 76) found highly significant improvement in TUG scores, mean difference = 3.5 s
	Duda et al. (2014)	Cluster randomised controlled trial (RCT) compared 10–12-week exercise referral with or without Self Determination Theory (STD: Deci & Ryan, 1985)	Patients (n = 347) referred by GP or practice nurse, randomly allocated to standard referral (n = 163) or STD group (n = 184)	Self-reported 7-day PAR at baseline, 3- and 6-month HADS and physiological measures	Multi-level modelling of log-transformed, skewed PAR data found significant gains for both groups at programme end largely sustained for 6-months with no significant group differences
	Edmunds, Ntoumanis, and Duda (2007)	Mixed methods study of individually tailored exercise programmes of 3-month duration grounded in STD principles for primary care patients in the West Midlands	Overweight/obese patients (n = 49) referred by GP, aged 16–73 with coronary heart disease (CHD) risk factors and body mass index (BMI) =38.75	Self-report questionnaire at baseline, 1- and 3-months; rating scales for exercise behaviour, motivation regulation, perceived autonomy and support, psychological need satisfaction and well-being; rated adherence (1–5 scale) of attendance	Cronbach’s alpha showed internal consistency of measures; multilevel regression analysis found that participants who adhered to programme reported greater self-efficacy and relatedness decreasing over time; no significant differences in other variables at 3-months
	Flannery, Loughren, Baker, and Crone (2014)	Mixed methods study of 12-week programme of 30- minute sessions; general practices across South Gloucestershire	Patients (n = 2505: 987 m; 1518 f) aged 18–94 years; White British (95%); referred for BMI >30 and depression; patients with chronic illness (n = 312)	Self-reported pre-post WEMWBS; physiological measures; phone interviews with patients (n = 14) and practice nurses (n = 2); and cost analysis	Paired samples t-tests found significant increases in well-being and session number at programme end; significant decrease in systolic blood pressure and waist measurement; no difference in BMI, weight loss, hip measurement, or diastolic blood pressure; cost per patient completing programme: £13.77
	Gidlow et al. (2007)	Doctoral research project, patients referred by health profession to exercise provision at leisure centres across several English counties	Participants (n = 3568) referred over 3 years (2000–2003) aged <92 years	Referral uptake 1+ session and completion 80+%; age, gender, rurality of location and level of deprivation as percentages of county population as a whole	Chi squared and Mann–Whitney tests found referred patient demographics significantly different from rest of county: more older adults, women, and those in deprived areas; logistic regression showed participants in rural areas with greatest deprivation dropped out sooner
	Harrison et al. (2005)	RCT compared exercise referral plus written information with written information only for physical activity; single borough-based 12-month scheme in North West England	Primary care patients (n = 545) defined as sedentary by GP, randomly assigned to intervention or control group, stratified for gender, age and baseline CHD risk	Percentage of patients meeting physical activity target 90+ minutes per week of moderate/vigorous physical activity; 7-day PAR at 6- and 12-months	Logistic regression of intent-to-treat analysis (due to missing responses) found significant increase in intervention group at six months (10%) but no significant increase at 12 months (5%); and no interaction with gender, age or CHD risk
	Isaacs et al. (2007)	RCT with three arms: effectiveness and cost-effectiveness of two, 10-week programmes of exercise (leisure centre or leisure instructor-led walking programme) or tailored advice-only, in outer London borough	Patients (n = 943) aged 70–94 years, not currently physically active with at least one CHD risk factor referred by GP	Comparison of three groups at baseline, 10 weeks, 6- and 12 months (control group randomised to intervention at 6 months) for percentage change in self-reported exercise, blood pressure, lipids, and cholesterol	Increase in patients achieving 150+ minutes per week of moderate activity: leisure centre (13.8%), walking group (11.1%) and advice-only (7.5%); significant reduction in blood pressure in all groups at each assessment point compared with baseline; advice-only was the most cost effective for percentage gain
	James et al. (2009)	Longitudinal design over two years (2005–07) across five leisure centres in London borough offering individual and group sessions for up to 26 weeks	Patients (n = 1315) referred through primary care due to metabolic, orthopaedic, and cardiovascular conditions	Data recorded by exercise professional included: outcome completion, blood pressure reduction, and body mass reduction, with age, gender, ethnicity, occupation, and reason for referral	57% patients completed programme, 49% with reduced blood pressure, greater for skilled manual than other occupational groups, and 33% with reduced body mass; 3-stage binary logistic regression found higher completion rates associated with age increase, and lower completion rates associated with pulmonary ill-health
	Lamb et al. (2002)	RCT compared community walking scheme plus advice on physical activity and cardiovascular health by a health care professional, with advice-only controls	Participants (n = 260) aged 40–70 years taking <120 min moderate intensity activity per week, excluding those with recent illness	Percentage of increased activity to >120 min per week at baseline, 6- and 12-months, and measures of aerobic capacity, BMI, blood pressure and cholesterol	Chi squared tests showed significant improvement in aerobic capacity for both groups and no differences in self-reported physical activity for intent-to-treat analysis; health walks more effective than advice only for 73% participants who completed trial
	Milton (2008)	University report on Eastern and Coastal Kent scheme, developed over 14 years; tailored 12-week twice-weekly programmes evaluated over three (2005–08)	Patients (n = 6541) <59 years referred by health professional for conditions including diabetes, hypertension, obesity, muscular-skeletal and mental health issues	Evaluation at baseline and 12-weeks: Demographics and physiological indicators plus qualitative component exploring patient attitudes towards physical behaviour	Participants who completed scheme (n = 1423) showed reduction in blood pressure, decrease in body fat (mean=1.5%); reasons for dropping out: Risk of joint damage, increase in cost of attending after 12 weeks, participants felt programmes were inappropriate and were demotivated at not achieving fitness aims
	Munro et al. (2004)	Cluster RCT with 12 general practices across Sheffield not previously running exercise referral schemes (8 practices assigned to intervention group; 4 to control group); free, locally held exercise classes over three years	Patients (n = 6420) aged 65+ referred by GP excluding those with physical activity score in top 20%	SF-36 and PAQ for older adults at baseline, 2- and 3-years, with covariates of age, gender, smoking, whether living alone and hospital admissions <2 years prior to intervention; and instrumental cost per QALY	No group differences between health service use or death rate; when adjusted for baseline, intervention group showed higher health status for “energy” dimension of SF-36; annual cost per programme around €128,302 euros (mean €126 per session); for survey completers (n = 1052) mean cost per QALY of €17,172 euros seen as cost effective
	Murphy et al. (2012)	RCT “Wales National Exercise Referral Scheme”, compared exercise intervention with normal care; and cost effectiveness of 16-week programme of twice-weekly, one-to-one or group exercise instruction	Sedentary patients (n = 2160) aged 16–88 referred by GP for CHD risk alone or mental ill-health alone (mild-to-moderate anxiety, depression, or stress) or for CHD risk and mental ill-health combined	Measures at baseline and 16 weeks using 7dPARS, HADS and EQ5D analysed on an intention to treat basis; follow-ups at 12 months using telephone and postal questionnaires	47% intervention group (n = 473) completed programme; ordinal regression found exercise effective for CHD-alone only; those referred for mental ill-health showed no significant difference between intervention and control groups; cost per participant for 16-weeks was £385 (participant paid £32)
Healthy Living Initiatives	Dundee Healthy Living Initiative (2011)	Dundee Healthy Living Initiative promoted healthy eating, mental health and well-being, physical activity and smoking cessation	Participants (n = 1400) living in Dundee referred by health practitioner or self-referral	Surveys circulated to all participants compared attendance over three years (2011–14)	Participant attendance of rolling programmes decreased over three years (weight loss 20%, physical activity 13%, smoking cessation 42%); no inferential statistics
Social Prescribing	AgeUK (2011)	Quantitative study of Yorkshire and Humber scheme; offered social emotional, and practical support	Patients aged 55+ referred to AgeUK (n = 62) and other organisations (n = 34)	Smaller number older people (n unknown) completed WEMWBS at baseline and programme end	WEMWBS showed pre-post mean difference (24.5–36.0 out of 70) indicating well-being improvement but no inferential statistics conducted
	Brandling & House (2007)	Mixed methods study of “Refresh” community activities to complement medical care in Salford	Patients referred by GP practices (n unknown)	Patient interviews (n unknown) about frequency of GP visits and medication prescriptions	Initial scheme found 66% patients had fewer GP visits with 34% reduced by three or more, and 46% reduction in medical prescriptions
	Brandling & House (2007)	Qualitative study in Keynsham near Bristol, referrals from three GP practices to local options	GP-referred patients (n = 11), general practice staff (n = 8), community stakeholders (n = 2)	Semi-structured interviews to explored acceptability of scheme as a non-clinical intervention	Patient insight limited as most regarded their GP as person most likely to address their needs despite being embedded in medical model
	Dayson and Bashir (2014)	Quantitative evaluation of “Rotherham Social Prescribing” pilot by Centre for Regional Economic and Social Research, Sheffield Hallam University, involving 29 GP practices	Patients (n = 1607: 627 m; 980f), with 87% aged 60 and older referred by GP or Intensive Case Management team	Well-being measures tool with eight areas designed for service, at baseline and after 3–4 months; HES mapped use of hospital resources over time including Accident and Emergency, outpatient appointments and admissions	Increase in one or more well-being areas (83% patients); reduction in admission rates Accident and Emergency 20%, inpatient 21%, outpatient 21%; NHS cost indicated return of 50p for every £1 invested; service delivery cost for one year recouped in 18–24 months;
	Lovell and Bockler (2007)	Qualitative study of Sefton “North West Social Prescribing Development Project”	Patients with mild to moderate mental health issues (n unknown)	HADS; facilitator diary entries	Analysis not reported as insufficient data; facilitator diary entries of commented on individual progress, confidence and self-esteem
	Secker, Spandler, Hacking, Kent & Shenton (2007)	Qualitative study of Stockport “North West Social Prescribing Development Project”	Patients (n = 51: 24 for social functioning, 17 for depression and 10 for postnatal depression)	Review of patients’ mental health; patient responses to two open-ended questions	Improvement in depression but not social functioning; responses identified improved mental health, self-esteem and social contact, decreased anxiety, renewed motivation, and interest in further arts activities
	South et al. (2008)	Case study of “Community Health Advice Team” (CHAT) by Bradford South and West Primary Care Trust (2005) with three general practices	Patients (223: 75 m; 148 f) aged 16+, through GP- or self-referral (tear-off slip on leaflet)	Semi-structured interviews with patients (n = 10), GPs (n = 3), practice managers (n = 2), practice nurses (n = 2) and healthy living centre co-ordinator (n = 1)	Main patient issues: Social isolation, housing and benefits, training, and families; scheme addressed wider determinants of health through routine clinical services; provided alternative support and improved community-professional partnerships
	Woodall & South (2005)	Qualitative analysis of CHAT, pilot scheme in Bradford; including arts, crafts, and volunteering activities	Patients (n = 10) with non-clinical needs referred by general practices	18 semi-structured interviews with patients (n = 10) and health care staff (n = 8)	82% of patients visited health care professional less in six months after scheme than in six months before it; staff saw intervention as access to expert knowledge and as part of holistic practice
Supported Referral	Faulkner (2004)	Qualitative pilot study of “Patient Support Service” practice-based voluntary patient referral scheme in Doncaster	Patients being treated medically for psychosocial issues (n = 10) referred by GP; voluntary sector employed as advisors (n = 8) to link patients to community support	Semi-structured interviews and case studies with patients and volunteer advisors	Concluded that voluntary patient advisory services broaden the referral options available for managing patients with psychosocial issues in primary care
	Grant et al. (2000)	RCT “Amalthea Project”; liaison organisation between primary care patients and voluntary organisations, in 26 general practices in county of Avon	Patients (n = 161) identified as having psychosocial issues by GP, randomly allocated to Amalthea Project (n = 90) plus routine GP care or routine GP care alone (n = 71)	Measures at baseline and 1- and 4-month follow-ups: HADS; Duke-UNC Functional Social Support Questionnaire; Dartmouth COOP/WONCA Functional Health Assessment, Delighted-Terrible Faces; economic evaluation of contact with primary care	Repeated measures analysis of covariance adjusted for baseline found that Amalthea group showed reductions in anxiety and negative emotion but no significant difference in depression or perceived emotional support; patients were more positive about general health and quality of life; found higher cost of referral to Amalthea project than control group
	Howells (2001)	Mixed methods study of 12-month programme in Swindon; offer included assisted access, coping skills training, support, and self-help literature	Participants (n unknown) referred by health professionals or self-referral	GHQ at baseline and 12 months; interviews with patients	Showed reduction in GP consultation; reduction in referral to secondary care; and increase in patient satisfaction
	Sykes (2002)	Pilot study using qualitative methods in Penge and Anerley Park primary care practices	Participants (n unknown) experiencing psychosocial issues, signposted to services by health practitioners from GP practices	Interviews with patients and health care staff	Complemented primary care; and bridged cap between primary care and voluntary sector; outcomes included: increased patient self-esteem and confidence, reduced social isolation and resolution of practical issues
Signposting/ Information Referral	Blastock, Brannelly, Davis & Howes (2005)	Qualitative study of “Signposting Project” of local services in North Staffordshire	Patients experiencing mental distress (n = 12) referred by general practice staff	Well-being questionnaires sent by post or conducted over the phone; phone interviews with practice staff	Offer valued by participants who reported improvements in well-being but it increased the workload of practice staff
	Phillips (2010)	Qualitative study of “Signpost” in Colchester and Tendring, Essex; offer included computing, job application, CV-writing and basic numeracy and literacy	Unemployed participants from deprived areas of Essex (n = 34) referred through Job Centre Plus	Online survey of participants, interviews with small number of managers, staff and volunteers; analysis of committee meeting minutes and business plan	Range of services met participant needs and increased self-esteem and confidence; identified additional need for services for those coming off incapacity benefit, more benefits advice, and a redundancy support package for organisations making redundancies
Time Banks	Boyle et al. (2006)	Interpretative phenomenological analysis (IPA) of time banks in South East London, Gorbals in Glasgow, and Welsh Valleys	Local residents on three sites (n = 65) and staff (n = 41), co-ordinator training programmes for community action researchers	Interviews with residents; questionnaires and focus groups used to assess impact of co-productive time bank schemes	Found involvement in time banks associated with reduced level of medical care or hospital admission; co-production extended social networks; informal self-help activity needed to be positively encouraged for people outside of paid work

Figure 2. Examples of social prescribing referral pathways in UK primary care.

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