Table 1: Factors within each stage affecting the effectiveness of social prescription

Referral from Primary Care to Community Activity

SCH clinical teams screen patients based on their eligibility and refer them to WBCs who will then co-develop a care plan with patients guided by SBAR4 and PERMA models (Lee & Gan, 2024). SBAR4 is a framework to help patients understand and manage complex co-morbidities (Lee & Low, 2016). This may help to raise awareness of the patient’s health status, which is often self-perceived as less severe, increasing the need for patient action. The integration of the PERMA framework—an evidence-informed Positive Psychology model (Bazargan-Hejazi et al., 2021) which identifies factors contributing to positive wellbeing: Positive Emotions, Engagement, Relationships, Meaning, and Accomplishment—also elevates patient awareness of social determinants of health.

Organisational capacity meaning shared systems and governance such as IT integration, referral pathways, and single point of contact would have to be in place (Southby & Gamsu, 2018). Moreover, investment of resources,such as time for administrative processes, physical spaces for plans to be developed, and funds to compensate workers involved at different touchpoints of this service system, is critical for collaboration between the healthcare and social care systems. SCH has accounted for this in their rollout of an interim training programme which covered relevant knowledge: “biopsychosocial model of care, social determinants of health, theory of social prescribing, assessment tools of social prescribing and wellbeing based on the concepts of positive psychology” (Lee et al., 2023). The training programme also incorporated different modalities to increase engagement and shared understanding among WBCs and clinical teams on patient needs and problems, which is an enabler for the integration of social and medical care (Pescheny et al., 2018; Southby & Gamsu, 2018).

Attending the Community Activity prescribed

WBCs employ motivational interviewing (MI) techniques in their engagement process, ensuring a client-centred approach while moving with the client through stages of pre-contemplation, contemplation, and preparation to internalise the care plan. Moreover, relationships and trust are able to be built with patients, promoting the acceptability of the recommendation, which is a key success factor (Wong et al., 2022; Woodall et al., 2018) for the uptake of the care plan. 

WBC knowledge of available assets in the community and understanding of these services would enable tailored recommendations. This facilitates the process of informed consent for the client (Singapore Association of Social Workers, 2017) and supports the clients through the decision-making process with the belief that they are the experts in their lives. The asset mapping the SCH has done in the community (Lee et al., 2023) improves the efficiency of the process for the WBC, as they may have limited time to sift through the different programmes available due to the heavy caseload.

However, patient needs at the micro-level such as social isolation, mental health conditions, and poor physical health may limit participation in community activities due to lower self-efficacy. As such, alternative arrangements need to be made considering the client’s clinical risk. Residents could be already experiencing chronic diseases, at-risk, or well. In response, SCH has integrated a triage mechanism to push patients to either health promotion and disease promotion or holistic care and follow-up (SingHealth, 2023).

In terms of flexibility in services to accommodate the different accessibility needs of patients (Husk et al., 2019; Woodall et al., 2018), it is uncertain whether the community activities are designed for their needs. Administrative processes such as reminder phone calls, written information, introductory sessions, or the presence of a buddy (Husk et al., 2019) also help to increase attendance although this may incur time costs.

Adherence to the full course of the community activity

According to a UK realist review on social prescription (Husk et al., 2019), community activities that foster interpersonal relationships and trust help to facilitate attendance. This points to the need for community activities to have intentional efforts to build social capital for the elderly, in terms of social networks and friendships, especially crucial for the elderly who live alone, have limited social support, or are experiencing mental health conditions. Efforts include competent community leaders or staff on-site to facilitate and promote a positive environment.

Given that the rollout of social prescription is still nascent, data on programme attendance rates and improvement in well-being outcomes are not yet publicly available, and hence adherence remains an area of success to examine. Nonetheless, WBC will follow up on the care plan that residents have adopted, measuring outcomes on patients’ well-being, perceived social support, and caregiver burden with validated and easy-to-administer tools (Lee et al., 2023). Individuals should be able to perceive improvements in their conditions and the absence of the negative effects due to ill health (Husk et al., 2019), increasing health motivation. 

What are some barriers limiting the effectiveness of social prescription?

Actual and perceived challenges by GPs to social-health integration. 

Overseas literature on social prescription service delivery emphasises the need for coordination efforts between healthcare and social services (Husk et al., 2019; Pescheny et al., 2018; Southby & Gamsu, 2018). Thus far, only 712 out of 1800 GP clinics have enrolled on HealthierSG (Foo et al., 2023) and more needs to be done to encourage GPs to enrol on the initiative. This may be due to the effort required to lay the groundwork for preventive healthcare, which involves extensive training, investment of manpower and resources, and infrastructure readiness as aforementioned given the sectors that were previously working in silos. In response, digital solutions have been adopted to increase the efficiency of resources such as digital social prescribing, augmented mobile applications through HealthHub and Healthy365 (MOH, 2022), and data sharing across management systems between healthcare and community sectors. Funding to support the integration efforts would be critical to ensure the affordability of primary care services and financial sustainability to develop the complex care system (Wong et al., 2022).

Accessibility needs of patients limit participation in the community. 

Uptake of the community activities is likely most feasible for seniors who are not working. This is because there are perceived opportunity costs involved in the decision to participate (i.e., the time could be used to work and earn money for living expenses). This may also be the group of seniors who are socially isolated. As such, alternatives such as long-term community befriending instead of structured community activities may better cater to seniors’ schedules and increase social connectedness. However, this hinges on WBC awareness of the different eldercare services available, which may present difficulty due to the heterogeneity of the social service landscape and referral procedures (Foo et al., 2022). Informational and instrumental support for community activities such as a shared case management system would help to streamline the referral process.

Perception of community/subcultures experienced at sites of community activities limits adherence to social prescription. 

Finally, seniors who have greater openness to the community may be more willing to commit to the community activities prescribed. As Singapore is a multicultural and multi-religious society, social participation is shaped by preferences for cultural grouping and ethnic values, but also a desire for emotional safety (Aw et al., 2017), which will require positive experiences in the community (Foo et al., 2023). An anecdote mentioned in class was that members seen at Active Ageing Centres are typically females and males, and mainly Chinese rather than other ethnicities. This may lead to the formation of more homogeneous groups that pose a barrier to entry to other community members. Therefore, having a community leader on-site would help to manage group dynamics in community settings through efforts such as mixing and door-knocking to reach out to isolated elderly.

Conclusion

Overall, the social prescription model adopted is able to meet well-being outcomes as intended. Some barriers as outlined in the previous section present challenges that service providers face as social prescription may not be perceived as an effective model by GPs and residents even though it is robust and grounded in programme theory. Healthcare clusters may want to increase awareness and enhance perceptions of community participation among the elderly, using a relational approach between the practitioner and client that fosters trust (Foo et al., 2023).