Like most parts of the NHS, general practice is a sector under pressure.
Figures released in recent weeks have shown a fall in the number of GPs per head of population and an increase in the length of time patients have to wait for an appointment.
So perhaps the last thing you would expect a GP to do is to go looking for people who have not already come to their door. But for Dr. Shashidhar Khandavalli, that it is exactly the approach which the health service should be taking - both to help those most in need and relieve pressure across the NHS frontline.
“If you wait for somebody to come to you, you have missed the boat already - and then the intensity of the resources which have to be put into that person is huge,” says Dr. Khandavalli, a partner at the Chorley Surgery.
“We should be targeting different communities, even down to street level, so that we can find out what the specific needs are in those locations. It could help identify why more people from certain areas are turning up at Accident and Emergency, for instance."
It is a vision which reflects the fact that primary care is going through something of a revolution - and one which sped up with the publication of the NHS 10-year plan back in January. As NHS England laid out its long-term ambitions, the Department for Health pledged to put an extra £4.5bn into primary and community services over the next five years.
The result is that the services to which all patients are referred - whether they have come to the doctor or the doctor has gone to them - are set to be broadened. As of this month, groups of GP practices across Lancashire will be adding a new staff member to their books - a social prescriber.
The role of these link workers will be to point patients in the direction of non-clinical services from which they could benefit - especially if their problem is not one which a doctor would traditionally deal with.
“I think it will have a huge impact across small numbers of people,” says Dr. Lindsey Dickinson, another partner at Chorley Surgery.
“The need is massive, because there are so many people who come to primary care frequently, but often struggle to access the right service for them.
“That’s because a lot of the issues they face [stem from] their mental and physical wellbeing - and social prescribing can help them to self manage.”
The move could see patients referred not to a consultant, but a community group run by the voluntary, faith or not-for-profit sectors. The idea is to harness the untapped potential of services which neither patients nor practitioners would necessarily know about.
“As a GP, I’m there to manage people’s medical problems - and it’s really hard for me to be aware of every voluntary service which is out there.
“The social prescriber will have a good understanding of what is available and know how those groups can best support that person - it might be a dementia cafe, for instance.
“The link workers can spend the time they need with a patient to find out what the gaps are in their life and how we can plug them with these services,” explains Dr. Dickinson, who is confident that the voluntary and community sectors have the necessary capacity to help.
However, Chorley Surgery business manager Andrea Trafford warns that social prescribing must be deployed appropriately.
“The community is our greatest asset, but it cannot be used to justify cuts. It is not there to soak everything else up, but it is a vital thing for the NHS to be able to access,” she explains.
Meanwhile, Dr. Khandvalli’s father, Sudhakar - who spent more than four decades in general practice - is enthused about the changes which his son is helping to pioneer.
“This is how it always should have been. People are coming to see their GP who do not have medical problems - so I couldn’t always help them.
“Patients need to know what else is out there,” the recently-retired GP reflects.
For Dr. Dickinson, the changes being made could even make general practice a more attractive place to work.
“Hopefully, we’ll stem the flow of GPs leaving the profession. At the moment, there is a feeling that primary care is not a great place to be - and that’s wrong,” she says.
The new prescription for primary care has already had the desired effect on her colleague, Dr. Khandavalli.
“It's not a panacea, but it has helped me rediscover a love for the job - I’m coming in with a real zeal every day,” he smiles.
POWER OF THE PEOPLE
More than a dozen voluntary, community and not-for-profit groups recently gathered in Chorley to show how they believe their services can support both patients and GPs.
The exhibitors were representing often small-scale organisations keen to make a difference in their communities.
Marjorie Hayward, from loneliness support group “Friends for You”, stressed that it was not only NHS services which can be a matter of life and death.
“You can die of loneliness, so I and a group of volunteers offer one-hour visits to people each week,” Marjorie explains.
“There is a huge benefit in terms of emotional and psychological health - it’s a fixed point in their week to look forward to.
“It also changes how they think about themselves - they suddenly realise they must be important and it transforms their perspectives and horizons.”
The group has a history of accepting referrals from GPs which predates the current reforms. Marjorie says the fact that more than 100 people have so far been sent to Friends for You by official agencies shows that community groups can have an impact where other services might struggle to do so.
Meanwhile, it is the power of music which “Lifelong Song” hopes to be prescribing to patients referred by their doctor.
“There is a real therapy in music whatever the needs of the individual may be,” explains group member Janet Wright.
“We have quite a diverse selection of music-themed events - from a singing group to ukulele workshops.
“The only thing we are really missing is the fact that people don’t know about us - so hopefully working with the NHS will help with that.”
But social prescribing is not the sole preserve of softer services to help with low-level wellbeing issues.
At the stand for not-for-profit group “The Well”, Andrew Owen and Joanne Pilkington describe a service designed to help those dealing with substance misuse.
“We try to stop people switching off from services and help them get the support and treatment they need,” Joanne explains.
Some of those working for the organisation have their own experience of the issues faced by those referred for help.
“You find that people like to give something back and people can relate to them, because they know they have been through similar things,” Andrew says.
But should it be down to the third sector or the NHS to provide services like those offered by The Well?
“Does it really matter?” replies Andrew after a brief pause.
“The main thing is that people get the help they need.”
THE NEW FACES COMING TO A GP SURGERY NEAR YOU
Social prescribers are the first of several new roles which will be rolled out across general practice over the next few years.
As of this month, almost every GP surgery in the country is now part of a primary care network (PCN), a group of practices working together with the aim of expanding services for patients.
PCN’s cover populations of between 30,000 and 50,000 people - and nine of them have been established in Central Lancashire.
As well as social prescribing link workers, the surgeries within each PCN will recruit a clinical pharmacist this year who will focus on medication reviews to ensure that patients are being treated appropriately. According to Dr. Lindsey Dickinson from the Chorley Surgery, patients should notice a change in service, but not structure.
“They won’t necessarily realise where the person they are seeing has come from - they should simply be seeing someone, hopefully within their own practice walls, who is helping them,” she explains.
In the coming three years, other new roles will be added to the roster of PCN positions - physician associates, who support GPs in the diagnosis and management of patients, first-contact physiotherapists, who conduct initial assessments of patients with relevant complaints, and community paramedics, who try to prevent patients being admitted to hospital.
They will be funded from Lancashire’s share of the additional £4.5bn being invested in primary care across the country by 2023/24.
But for Dr. Dickinson, there is an added benefit to PCNs other than extra staff - and that is closer co-operation with GP colleagues across her local patch.
“If I’m unsure, say, about a patient's skin lesion, then instead of referring them to hospital, I might be able to send them to one of my colleagues down the road who is a skin specialist - and he might be able to send me someone who has diabetes, which is my area of interest.
“We’re not quite there yet, but the question is how we can set ourselves up to allow the movement of patients across practices - giving them a much better experience of primary care.
“Sometimes I’m a bit concerned when referring a patient [to hospital], because I don't know how long they’ll wait. But if that service is within our gift, I can see exactly when they are booked in and be sure that they will see the right person - because I know who the right person is.”
WILL IT WORK?
The concept of social prescribing dates back to the 1990s, but it is only in recent years that it has been promoted by the NHS as part of its vision for the future.
According to public services consultancy Cordis Bright, robust evidence on the effectiveness of social prescribing remains limited, because most studies to date have not been comprehensive enough and lack quantitative data. A report published by the organisation earlier this year recommended that "measurable goals" should be set for social prescribing to help evaluate its effectiveness and enable a better comparison between different approaches.
Health think tank The King's Fund has also noted that it is difficult to measure the outcomes of complex interventions like those which form the basis of social prescribing schemes. However, it cites emerging evidence that the concept "can lead to a range of positive health and wellbeing outcomes", including a study which showed reductions in the use of NHS services by patients put on a social prescribing pathway and another in which patients reported improvements in their quality of life.
A report by the Social Prescribing Network in 2016 also stressed the importance of "sustained funding" for the programmes, because of the difficulty of demonstrating their cost effectiveness in the short term.