The Times recently suggested social prescribing may be “a waste of NHS money.”1 Other sources more accurately reported the “absence of evidence” to support social prescribing.2 Media attention followed publication of a systematic review showing “little or no impact” on mental health or health related quality of life, and little evidence to support other purported outcomes of social prescribing.3
One of the “core principles” of social prescribing, according to the UK government, is the reduction of health inequalities. Social prescribing, the government states, will be “effective at targeting the causes of health inequalities.”4 Social prescribing was included in the NHS Long Term Plan for “tackling health inequalities”5 and claims about its impact on adverse social health determinants and resultant health inequalities are frequently repeated.6
Yet there is not only an absence of evidence behind these claims, but an aberrant logic. Social health determinants—including income, employment, education, food security, housing stability, and experiences of discrimination—result in health inequalities when they are unequally and unfairly distributed. Their impacts occur across society over lifetimes and successive generations. It would be surprising if these determinants, their distribution, and their cumulative health effects could be meaningfully by interventions that targeted single social issues of individuals at specific and limited points in time.
Addressing the social challenges faced by individuals is a vastly different undertaking from addressing health determinants at a societal level, with vastly differenting relevance for the inequitable distribution of health across society. There is a world of difference between the sort of activities included in social prescribing— commonly cited examples include “volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports.”7—and the sort of changes required to reduce health inequalities (the WHO Commission on Social Determinants of Health called for “major changes in social policies, economic arrangements, and political action”8).
Researchers have shown how social prescribing may exacerbate health inequalities. The same social factors that impact people’s health also impact their capacity to engage with social prescribing, meaning that those with greatest need may be least able to benefit from interventions.9 A further means by which health inequalities may be exacerbated is if social prescribing becomes perceived as the solution to that problem10: thereby creating a distraction from the actual changes that are required to reduce unequal health outcomes. This risk may be increased amid the current lack of coherent government policy on health inequalities.11
Health inequalities in the UK are starkly evidenced by the 10 year difference in life expectancy between men living in the most deprived areas of England and those in affluent areas.12 Covid compounded those unequal outcomes, with covid mortality rates more than twice as high in deprived areas,13 and significantly higher for people in ethnic minority groups.14 These outcomes have been worsened too by years of government policy eroding the benefits system, childcare and education, housing policies, labor markets, progressive taxation, and public health.
Many individuals will have had positive experiences of social prescribing, and it is a positive development that the importance of social factors in creating and sustaining health is being increasingly acknowledged. But the authors of the systematic review highlight the opportunity costs and suggest reflection on our investments , as well as our objectives. If we truly want to resolve unequal health outcomes then social determinants must be addressed at a societal level.15 When Michael Marmot chaired a review of evidence-based strategies for reducing health inequities in England his prescription was for a Fair Society; it was not a prescription for individuals.16
Footnotes
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Competing interests: none declared.
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Provenance and peer review: not commissioned, not peer reviewed.