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Michael Dixon LVO, OBE, MA, FRCGP is an English general practitioner and healthcare leader. He is Co-Chair of the National Social Prescribing Network and medical doctor for King Charles III. Dr. Dixon served as chair of the NHS Alliance from 1998 to 2015 and is a past President of the NHS Clinical Commissioners. He also chairs the College of Medicine. He is a visiting professor at University College London and the University of Westminster and National Clinical Champion for Social Prescribing (NHS England).

 

 

Dr. Bogdan Chiva Giurca is the Founder and Chair of the NHS Social Prescribing Champion Scheme (2016-2021) consisting of thousands of UK junior doctors and medical students. Over a four-year period, the scheme has delivered over 700 teaching sessions in all UK medical schools, as well as developing a National Consensus for Teaching Social Prescribing. His work has influenced national healthcare policy and has driven key changes within the medical school curriculum, contributing to several peer- reviewed publications and policy documents.

 

Doctors to prescribe less pills and more ballroom dancing, museum visits, art classes, nature walks, and gardening

A conversation between Dr. Michael Dixon, Chair, College of Medicine UK, and Dr. Bogdan Chiva Giurca, Lead, Global Social Prescribing Alliance

Dr. Michael Dixon: Did you know that right now we treat over 10% of our population with antidepressants or tranquilizers, every day of their lives? And all of that might be okay if we would actually be achieving anything, but we’re not. At the moment in the health service, we have an ever increasing rate of long-term disease of mental health problems – diabetes, obesity, just about everything – which we are failing to contain.

If we look at our adolescents, 25% of every 14 to 16-year-old girls are at any one time is self-harming. 40% of 11-year-olds in London are obese. Modern medicine is not sorting out these problems. What we want to convey today is the fact that we need to change, we need to change absolutely and radically. Otherwise, if we’re taking cues from the U.S., our health system will be using 100% of our GDP in 40 years’ time if we carry on as we are. With that we need to recognize that the physical and social environments are actually fundamentally important for our health services to provide, and that we need to start investing in that.

Dr. Bogdan Chiva Giurca: We have a lot of research going on in medicine, but when it comes to the actual application, the treatment of people, it has pretty much degraded to a culture of fixing what’s already broken, sticking a plaster on someone and sending them back home into the local community to what made them sick in the first place. Prescribing (and often overprescribing) yet another pill without having the time to understand what really matters to the individual, when the root of their problem might be financial, psychological or social in nature, for example.

So, Michael, how did we get here in the first place? How did we get to this ‘sick-care model’ over the years?

Dr. Michael Dixon: Well, I think, because we’re focused on short-term acute care and are always patching up. Over time, we have designed the health service as a disease service rather than a proper health service. There is also a vested interest in the system to carry on as it is. The pharmaceutical firms and doctors – they’re all in it together, in a way. As you well know, in America, the sicker you become, the more wealthier we become as doctors. So, there wasn’t a real push towards preventative medicine and keeping people healthy in the first place.

Dr. Bogdan Chiva Giurca: And did you know that in 1948 there was a definition from the World Health Organization which said, “Health is not the mere absence of disease. Health is a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity”. So it’s not just pills, it’s about mental, psychological and social wellbeing. That was proposed in 1948. We’re in 2022 and we’re still not practicing what that definition stated in the first place. So, Michael, tell us a bit about where this has taken us and why it is becoming impossible to continue in light of recent demographic changes and challenges.

These are some of the newspaper headlines that we’re seeing in the UK: The workforce is on its knees, doctors are threatening to leave, there’s an overwhelming amount of patients on waiting lists: In England alone, seven million people are waiting for surgeries because there’s not enough doctors, there’s not enough service to provide because we are all acting in a reactive way.

We focus on the one-third of people who are sick at a given time, and we are leaving behind the two- thirds of people who are healthy now, but who will become sick in the future. That includes you and me. Most people don’t seek health or engage to prevent disease, until we have a disease. That’s what we have been taught: You have a disease, you go to the doctors. But what about the concept of ‘creating health’, what about developing values and beliefs to encourage each and every single one of us to create health at home and in the local community, before illness strikes. Tell us a bit Michael, why can’t we continue with reactive ‘sick care’?

Dr. Michael Dixon: Part of it is because it’s not working. We’re just having an increasing cost, increasing yield population in spite all the efforts you made so far.

I’ve had three Secretary of States over the last three years who promised there will be more GPs. The first said 4,000 more GPs, the second said 5,000 more GPs, and third 6,000 more GPs. The truth is that over the last 10 years the number of GPs has gone down by a 1,000 in spite of all these promises. Therefore, because we’re facing a shortage in doctors, nurses, or hospital resources, we’ve got to think differently.

Dr. Bogdan Chiva Giurca: Absolutely, and just to touch a bit upon the topic of overprescribing. Did you know that one in five (20%) of the individuals we see in the hospital are admitted due to side effects from unnecessary drug prescriptions that should have never been prescribed in the first place?

One in five individuals I see in the emergency department have been admitted because an unnecessary drug was prescribed to them. The chief pharmaceutical officer in England did a report that showed that 10 to 15% of all drugs prescribed in hospital are not only useless and unnecessary, but also cause side effects and harm to our patients and individuals. That’s the national chief pharmacist making these suggestions based on evidence. So, I think if he says 10 to 15% we can probably double that number!

But slowly, we have started to move toward the solution that Michael has been working on for many years, even when there were lots of naysayers around. It’s called ‘social prescribing’. This is a model where you prescribe something for the healthy, a model where we prescribe something that will keep people well and live as best as they can over time. Tell us more, what is this new concept of ‘social prescribing’ that we’re talking about, Michael?

Dr. Michael Dixon: It’s about using local assets, the physical and social environment to keep people healthy and to heal them. And a few of us a few years ago struck on this. There was a precedence called the Peckham Project in the 1930s and 40s where two GPs started a gym, and swimming pool and ball room in their own surgery. Unfortunately, they lost their funding. And then, a few years ago, some of us were finding the patients who are getting better for all sorts for odd reasons. A friend of mine in Newcastle found that fishing groups were helping young men to get jobs and to socialize and not be depressed. Another friend in another region where people die earlier than any part of the country found that giving people job experience and volunteering opportunities was better than giving them Prozac.

In my own surgery we work with many groups and organizations, but things like reading groups, green exercise, et cetera, is part of being what it is, but it’s more complex. What’s essential to the social prescribing worker is doing more or less what I did 40 years ago as a family GP when I had more time: Getting under the skin of that person who can’t lose weight, who can’t get a job, and feels completely demoralized in order to try to understand things from their perspective, what their hopes, wants, beliefs and challenges are, and then adopting a program which may start with benefits, advice, and housing, employment, but eventually can go much further, up to helping people to find meaning to life.

So, it’s a very simple idea, like all good ideas, but it can be very powerful. When we succeed, it’s because we’ve increased what we call the patient activation index that puts them in a different place in terms of control of their lives.

As a society and medical community, we tried a lot of things, and many haven’t worked. For example, we have a five a day program nationally for people offering vegetables, didn’t change a thing. But here is something that worked. Together with a friend, David Dunman up in Stockport, we took 140 - 150 diabetics and we gave them such social prescriptions, and within nine months, a third would no longer die of diabetes. Just think of the improvements of those people’s lives, but also in terms of cost or money saved. All through social prescribing.

I also found that 20% of the people who come to see me are coming for social reasons. They are lonely, they want to talk to someone, and that someone speaks with them. That someone cares, has an interest in them.

Dr. Bogdan Chiva Giurca: So, 20% of the patients that come to see us are due to drug side effects and then another 20% we mentioned for pure social reasons. There’s also estimated evidence suggesting that 40 to 60% of people who turn up to the emergency department are there with the mental health problems.

As things are going now, these problems are on the rise. By 2050, we will double the amount of people living over the age of 60 and above. This may be reason to celebrate given the increase in lifespan, but for me, Dr. Dixon and the hospitals, this is also a bit worrying as we fear being overwhelmed by people who collect diseases over time. 70% to 80% of funding in the health care system is spent on the long term conditions that we collect over time such as diabetes, obesity, lung diseases and many others.

I once met an elderly lady in clinic. She was on 11 different medications when I saw her in my practice, 11 different pills. She had Parkinson’s disease, so she would walk very slowly as somebody would have the Parkinson’s gait. She would be on anti- depressants, she would be on four different pain killers, antiemetics because she was having side effects from the pain killers. My colleagues pointed to the fact that she comes to see us every single week and were wondering if there is something more happening in her life, but they never had the time to find out. So they suggested that I, as the junior doctor, should go ahead and get to understand her case better.

So, I spent a good hour with her and eventually I learned that her husband died one year ago. She had no relatives, no friends, no siblings, no one to spend time with or to support her with house duties. The only time she was leaving the house was to see us in the hospital. She even said, “I quite enjoy coming here every week because you’re the only people I see.” At which I smiled but of course I also realized how ironic that was. This was a patient that was coming in every single week with a headache and throwing up and we were stacking her with more medications and pills, when in fact the problem was not medical.

We’re not saying we should get rid of all the pills. We know the power of modern medicine, but we just have to give them to the ones that truly need them, not to such individuals whose problem is social or psychological in nature.

We referred this lady to social prescribing and asked her “what did you use to do when you were young?” She said she was salsa dancing, and so she was referred to a salsa dancing group. We didn’t see her for six months. And when she came back, she was only on her Parkinson’s medications. She was no longer on pain killers or on antiemetics. They got rid of all those medications and she stopped seeing us. From 11 medications to just two medications, it was incredible to witness the change.

Until, one day, she turned up again after a period of almost a year. This time she looked brighter, happier. We saw her in the waiting room and she had another friend sitting next to her. She introduced him as ”Jeremy”. Jokingly, I asked “Who’s Jeremy?” And she said, “This is my new dancing partner. And we go out every single week. We’re not married, but we like to say we share our world now.” They were both 81 and 76 years old respectively.

And that is the power of social prescribing. Health does not start in hospitals; it doesn’t start with us wearing white coats with pens lined up our pockets, telling people what to do and prescribing pills. It starts with the creation of health within the local community and at home. That’s something that we as a society and every one of us should strive for.

Evidence suggests that social prescribing leads to a reduction of 4.5 million doctor appointments in the UK alone, estimated to save approximately £350 million to the English healthcare system. Together with the WHO, United Nations and partners, we have launched the Global Social Prescribing Alliance, supporting over 23 countries across the world to implement social prescribing.

We truly hope we’ll shift values and beliefs once and for all, to go beyond pills and procedures, to look at social and psychological support and health that starts with prevention within the community.