For many Australians, a visit to the doctor entails a brief consultation, then getting handed a script with advice to take some pills and return if you don’t get better. That could be set to change, in a new approach to general practice that acknowledges our health needs are often complex and require more than medication to successfully manage.
Figures from the Australian Bureau of Statistics show that in 2016–17, 83 per cent of Australians aged 15 and over had seen a GP in the previous 12 months. In the same time, 68 per cent had received a prescription. In the 2016–17 financial year, government expenditure on the Pharmaceutical Benefits Scheme was $12.058 million, an increase of 11.3 per cent on the previous year.
Doctors overseas are already embracing a more holistic brand of prescribing. This approach considers lifestyle factors such as nutrition, exercise and social connection, which have powerful influences on risks for – and management of – many of the so-called lifestyle diseases.
In New Zealand, for example, the government recognised the potential for GPs to use alternative types of prescriptions to help patients make healthy lifestyle changes, and in 1998, the Green Prescription (GRx) program was born. Under GRx, doctors and practice nurses give patients advice and a written prescription for physical activity as part of their health management.
Most GRx referrals are for patients with chronic illnesses – such as cardiovascular disease and diabetes – with a focus on helping them to self-manage their conditions. Rather than being written for a pharmacist, the prescription is provided to the local sports trust or health organisation, and a support person is allocated to provide help face to face, by phone or in a group, for three to six months. Programs include encouragement and education, nutritional guidance, goal setting and ongoing support. The patient’s progress is reported back to the referring health professional. More than 51,000 adults were referred in 2016–17.
The program is overseen by NZ’s Ministry of Health and administered by district health boards. It delivers good value for money, according to a ministry spokesperson. “Research going back to the 1990s demonstrates the effectiveness and cost-effectiveness of GRx in increasing physical activity in adults and older adults,” the spokesperson said, “and positive impacts on cardiovascular risk factors such as blood pressure, as well as measures of physical and mental health.”
Patients are happy with the results, too. Surveys are conducted every two years, with 2016 results showing that 72 per cent had reported positive health changes since being referred to GRx, the spokesperson said. Eighty-five per cent of survey participants were either very satisfied or satisfied with the support they received.
Although GRx is not strictly an obesity initiative, 53 per cent of the 2016 survey participants cited weight problems as the reason for receiving their GRx, with positive results. “Seventy-five per cent had made changes to their diet, mainly reducing meal sizes and sugary foods and drinks,” the spokesperson said. “Almost half had lost weight since being given their GRx.”
Though initially targeted towards adults, increasing enquiries identified the need for a program targeting inactive children at risk of adverse health effects from being overweight or obese.
“These children and young people are usually not participating in sports-based activities. Their needs are greater and wider-ranging in terms of improving their overall health status and lifestyle when compared to adults,” the spokesperson said. “The barriers to participation for the child or young person can range from activities being inaccessible or unaffordable, to lack of parental support, lack of confidence and self-esteem.”
In response, New Zealand’s GRx Active Families now provides community-based health initiatives encouraging physical activity and improved nutrition for those aged five to 18 and their families. In 2017–18, additional funding was allocated to support obese four-year-olds identified through before-school checks, so more programs are now including preschool children.
Almost one quarter of Australian children and two thirds of adults are overweight or obese, according to a 2017 report from the Australian Institute of Health and Welfare (AIHW). Other AIHW figures show that half of all Australians reported having at least one chronic disease in 2104–15.
While “green” prescribing hasn’t been formalised as a way of managing chronic conditions in Australia, the idea is gaining acceptance and momentum, says Dr Deborah Sambo, a spokesperson for the Royal Australian College of General Practitioners. “GPs already prescribe a range of non-drug/surgical therapies for patients, including exercise, diet, self-help groups, books, meditation, tai chi, yoga classes and other social groups like men’s sheds,” she says. “Hopefully, we can start to see more doctors using it with more confidence as a recognised management option with great benefits and savings for doctors, our patients, governments.”
In Britain, more than 100 schemes allow doctors, nurses and other primary care practitioners to prescribe everything from cooking classes to volunteering, in what has been dubbed “social prescribing”. Emerging evidence shows that social prescribing can lead to improved quality of life, mental and general wellbeing, and reduced levels of depression and anxiety.
More than a million patients are seen in British general practice every day. Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners (RCGP) in London, says, “GPs will always take into account the physical, psychological and social factors potentially affecting their [patients’] health when making a diagnosis and formulating a treatment plan.”
“Some patients, however, might not need traditional medical care and instead benefit from social prescribing, such as light exercise, joining a local social group, or taking up a hobby to help them mix with other people.”
Stokes-Lampard argues that experienced GPs have always practised social prescribing. “It’s just never had a name until now. The benefits, however, are vast: patients need less prescription medication, fewer consultations, and are more likely to take an active role in their own health.”
A 2013 study conducted at the University of the West of England looked at the effectiveness of social prescribing in Bristol. It found improvements in anxiety levels, and in participants’ feelings about their general health and quality of life.
Another study, from Sheffield Hallam University and conducted between 2013 and 2017, examined a scheme in Rotherham. They found that more than 80 per cent of patients referred to the scheme who were followed up three to four months later reported reductions in their use of the National Health Service (NHS).
“For GPs, social prescribing can potentially free up precious time which can then be spent on patients with complex health needs, and, in turn, help to ease pressures on surgeries and the wider NHS,” Stokes-Lampard says. The RCGP is calling for the NHS to fund every practice for a dedicated social prescriber.
Social prescribing trials have started in Australia, looking at its role in helping injured workers get back on the job. “A couple of pilot programs have been running for a while with the sole aim of identifying the social, mental and wellbeing needs of the injured patient, connecting them to available community services and giving them a better chance at holistic wellbeing and health while they recover from their injury,” explains Sambo. “The results are very … encouraging. I foresee these pilot programs going national soon.”
While trial results may be promising, Australian doctors still face barriers to implementing new methods of prescribing, Sambo says. These include a lack of resources, as well as what she calls “old habits”.
“Once people break the conventional thinking of management of patients as drugs, allied health therapies and/or surgery only, then that is a big step towards embracing social and green prescribing.
“Other issues may centre around confidentiality and privacy, especially when you are recommending social groups or even linking people to other people – be they support people, or people with similar ailments.”
Once such barriers are overcome, social prescribing has benefits for everyone involved. Sambo says its potential is “huge”, provided appropriate support and protection is available for doctors willing to consider it.
“For the doctor, social prescribing comes with decreases in the number of side effects and complications often associated with conventional treatment modalities like drugs and surgery. There is also a decrease in hospitalisations or use of acute-care services like emergency departments, which we all know cost taxpayers a fortune.”
Social prescriptions don’t usually require expensive equipment, and they come at minimal to no cost, she says. “These translate as big savings for patients and governments alike.”
All that remains is for Australia “to harmonise and crystallise social prescribing as a treatment option in its own right,” she says. “We will certainly see more and more GPs actually using social/green prescribing as a first management option, or as an adjunct to other management modalities.”
This article was first published in the print edition of The Saturday Paper on Aug 18, 2018 as "Flipping the script". Subscribe here.