I have a background in community work and have always seen it as a progressive mechanism for social transformation; challenging oppression; extending inclusion and democracy; offering learning and personal growth opportunities; empowerment, social justice, equity, fairness, participation, self-determination, amongst many other things. Communities potentially provide essential support for individuals, groups and organisations, and opportunities for reciprocity. Good community work promotes human development, and fosters civic responsibility through solidarity, cooperation and mutual aid.
Social prescribing is basically a community-based referral: it’s a means of enabling primary care services to refer patients with psycho-social, emotional or practical needs to a range of local, non-clinical services, often provided by the voluntary and community sector, and it’s aim is to improve people’s mental health, physical health and wellbeing, using community interventions.
In practice this means that GPs, nurses and other healthcare practitioners work with patients to identify non-medical opportunities or interventions that will help, improving support and the wider social aspects of their lives. The services that patients can choose from include everything from debt counselling, support groups, allotments and walking clubs, to community cooking classes and one-to-one coaching. Both evidence and commons sense suggests that social prescribing may be particularly appropriate and beneficial for isolated, marginalised groups. And needs-led community provision that supports and enhances psychosocial health and wellbeing is an excellent idea.
Poor mental health is often correlated with poverty, (Melzer et al. 2004) poor community integration, and competitiveness amongst social groups (Arrindell et al., 2003). Key questions arise as to the efficacy, therefore, of working with individuals, when much research suggests community work would be more effective (Orford, 2008).
So far so good.
I had the following message yesterday from friend and fellow writer, Linda:
“I have received an email from my local Tory MP letting me (and other constituents) know that he is going to be setting up a ‘Mental Health Surgery’ Hub with a ‘Mental Health Expert’ who will be handing out ‘social Prescriptions’ as he says he is aware that many mental health problems are caused by ‘Social Problems’. Im wondering if there is perhaps a wider agenda from the Conservatives.”
This is the relevant paragraph taken from his email:
“Since my election in May I have been surprised at the number of my constituents with different mental health issues, so much so I am looking to run a surgery ‘hub’ with a mental health specialist so people can drop in and have their needs assessed and be issued with a form of ‘social prescription’. I recognise many mental health issues are caused or exacerbated by social factors so sometimes a social solution can be more effective than a medical one.
I did a little research.
The 2010 Marmot Review (Fair Society, Healthy Lives) of health inequalities identified social prescribing as an, “approach [that] facilitates greater participation of patients and citizens and support in developing health literacy and improving health and wellbeing”.
It identified additional NHS healthcare costs linked to inequality as being well in excess of £5.5 billion per year. It is claimed that social prescriptions can cut the NHS bill.
However, despite the growing popularity of social prescriptions amongst cash and resource-strapped professionals, the University of York has surprisingly produced research to show that there is little good quality evidence that social prescribing is cost-effective.
But the thing that bothers me the most is the link that the Conservative government have made between social prescriptions, cost-cutting and (as I deeply suspected) as a mechanism of extending behavioural modification (euphemistically called “nudging” by the government’s team of behavioural economists and decision-making “experts”).
I read several current reviews of social precribing, each mentioning both criteria in recommendations for “success.”:
“The work of social prescribing health trainers fits with the approach of the Coalition Government as described in its White Paper on Public Health which emphasises the need to ‘build people’s self esteem and confidence’ in order to bring about changes in behaviour.”
It also fits with the Marmot Review’s recommendation on tackling the social problems that undermine health and with the Coalition Government’s approach to behaviour change as outlined in recent publications such as MINDSPACE.” (Link added by me.)
“In times when finances are under pressure and the NHS is charged with achieving ‘better for less’, primary care needs to be looking at how to do things differently.”
Nesta, who now partly own the Government’s Behavioural Insights Team (the Nudge Unit) are of course at the forefront of promoting social prescriptions amongst medical professionals, firmly linking what is very good idea with very anti-democratic Conservative notions of behaviour change, citizen responsibility and small-state ideology. So, it’s no longer just about helping people to access a wider range of community-based services and support, social prescribing has also places strong emphasis on “encouraging patients to think about how they can take better care of themselves.”
Of course, there is what may easily be construed as a whopping self-serving process of linking behavioural change with social prescribing, opening some potentially very lucrative opportunities for Nesta.
However, taken at face value, the idea of promoting patient participation in their own care sounds very democratic and reasonable. Common sense, in fact.
In this context, social prescribing can be seen as a logical extention of the Biopsychosocial model (BPS) of ill health. The biological component of the model is based on a traditional allopathic (bio-medical) approach to health. The social part of the model investigates how different social factors such as socioeconomic status, culture and poverty impact on health. The psychological component of the biopsychosocial model looks for potential psychological causes for a health problem such as lack of self-control, difficulties with coping, emotional turmoil, and negative thinking.
Of course a major criticism is that the BPS model has been used to disingenuously trivialise and euphemise serious physical illnesses, implying either a psychosomatic basis or reducing symptoms to nothing more than a presentation of malingering tactics. This ploy has been exploited by medical insurance companies (infamously by Unum Provident in the USA) and government welfare departments keen to limit or deny access to medical, social care and social security payments, and to manufacture ideologically determined outcomes that are not at all in the best interests of patients, invalidating diagnoses, people’s experience and accounts, and the existence of serious medical conditions.
Unum was involved in advising the government on making the devastating cuts to disabled people’s support in the UK’s controversial Welfare Reform Bill. (See also: The influence of the private insurance industry on the UK welfare reforms.)
Secondly, this is a government that tends to emphasise citizen responsibilities over rights, moralising and psychologizing social problems, whilst quietly editing out government responsibilities and democratic obligations towards citizens.
For example, poverty, which is caused by political decisions affecting socioeconomic outcomes, is described by the Conservatives, using elaborate victim-blame narratives, and this is particularly objectionable at a time when inequality has never been greater in the UK. Poverty may only be properly seen in a structural context, including account of the exclusion and oppression experienced by those living in poverty, the global neoliberal order, the gender order, the disability, racial, sexual and other orders which frame social life and precipitate poverty in complex and diverse ways. It’s down to policy-makers to address the structural origins of poverty, not the poor, who are the casualities of politically imposed structural constraints.
In this context, social prescriptions are used to maintain the status quo, and are likely to be part of a broader process of responsibility ascription – based on the traditional Conservative maxim of self-help, which is used to prop up fiscal discipline and public funding cuts, the extensive privatisation of public services, defense of private property and privilege, and of course, the free market. The irony of the New Right, neoliberal, paternalistic libertarianism is that the associated policies are not remotely libertarian. They are strongly authoritarian. It’s a government that doesn’t respond to public needs, but rather, it’s one that pre-determines public interests to fit within an ideological framework
A government that regards individuals as the architects of their own misfortune tends to formulate policies that act upon individuals to change their behaviour, rather than to address the structural constraints (and meet public needs,) such as social injustice and unequal access to resources. This isn’t a government prepared to meet public needs at all. Instead it’s a government that expects citizens to change their behaviour to accommodate the government’s ideologically directed needs.
That approach flies in the face of established professional community work values and principles.
Poor people suffering mental ill health because we live in a society that is extremely unequal, are blamed by the government for the “symptoms” of their poverty – poor eating habits and “lifestyle choices”. But poverty is all about limited choices, which is itself not a “lifestyle choice.” No-one actually chooses to be poor. Government policies, social structures and systemic failures create poverty.
The Conservatives extend an economic Darwinism, coupled with an extremely intrusive disciplinary approach, mass surveillance and a stigmatising rhetoric, whilst moralising a free-market framework that constrains many and preserves the privilege of a few. The absurdity is this: if an economic framework isn’t meeting the needs of a population, it isn’t an adequate response for the government to act upon citizens who have become casualities of that framework, to persuade or coerce people into fitting within an increasingly harmful and useless socioecomomic ideology.
There is a clear correlation with low socioeconomic status and poor mental health. Poverty is a complex, multidimensional phenomenon, encompassing the lack of means to satisfy basic needs, lack of control over resources, often, a lack of access to education, exclusion from opportunities, and poor health. Poverty is intrinsically alienating and distressing, and of particular concern are the direct and indirect effects of poverty on the development of psychosocial stress. (See also: The Psychological Impact of Austerity – Psychologists Against Austerity.)
State “therapy” aimed at changing the behaviour of individuals diverts attention from growing inequality, and from policies that are creating circumstances of absolute poverty. It also diverts attention from the fact that if people cannot meet their basic physiological needs, they cannot possibly be “incentivised” to meet higher level psychosocial ones.
I wrote a critical analysis of the government proposal to introduce Cognitive Behaviour Therapists to deliver state “therapy” in job centres earlier this year, with the sole aim of improving “employment outcomes.” There is also an extensive critique of Cognitive Behaviour Therapy (CBT) included in the article, along with some discussion about the merits of community work, which is very relevant to this discussion. (See: The power of positive thinking is really political gaslighting.)
I also wrote earlier this year about how the government has stigmatised and redefined unemployment, problematizing and re-categorising it as an individual psychological disorder. Both articles are very pertinent to this discusion. (See: Stigmatising unemployment: the government has redefined it as a psychological disorders.)
Welfare has been redefined: it is a now a reflecton of a government pre-occupied with assumptions about and modification of the behaviour and character of recipients rather than with the alleviation of poverty and ensuring economic and social wellbeing.
The stigmatisation of people needing benefits is designed purposefully to displace public sympathy for the poor, and to generate moral outrage, which is then used to further justify the steady dismantling of the welfare state.
Many psychosocial problems have arisen because of social conservatism and neoliberalism. The victims of this government’s policies and decision-making are being portrayed as miscreants – as perpetrators of the social problems caused by the government’s decisions.
It’s all too often the case that good ideas are placed in political ideological frameworks, distorted, and are then applied to simply justify and prop up dogma.
Meanwhile, mental health services are facing crisis because of budget cuts by this government, Local Authorities and community services have also been cut to the bone. (See: The cost of the cuts: the impact on local government and poorer communities.) Those with mental health problems are stranded on an ever-shrinking island.
Policy initiatives such as social prescriptions, which focus on how to remediate problems at an individual level, seeing both poverty and mental illness, for example, as simply states of being – rather than dealing with the generative political and economic practices and social relations framework which precipitated that state in the first place, effectively depoliticises political problems leaving people with an internalised state of oppression, disabling them from taking effective action.
The political refusal to permit people to voice their concerns and anxieties in political rather than personal terms further exacerbates sociopolitical marginalisation, low status, it breaks a sense of connectedness with others and wider communities, it reinforces a sense isolation and of personal responsibility for circumstances that are politically constructed and disowned.