Health policy 142 (2024) 104992
Available online 21 January 2024
0168-8510/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A comparison of social prescribing approaches across twelve
high-income countries
☆
Giada Scarpetti
a
,
*
, Hannah Shadowen
b
, Gemma A. Williams
c
, Juliane Winkelmann
c
,
Madelon Kroneman
d
, Peter P. Groenewegen
d
, Judith D. De Jong
e
, Inˆ
es Fronteira
f
,
Gonçalo Figueiredo Augusto
g
, Sonia Hsiung
h
, Siˆ
an Slade
i
, Daniela Rojatz
j
, Daniela Kallayova
k
,
Zuzana Katreniakova
l
, Iveta Nagyova
l
, Marika Kyl¨
anen
m
, Pia Vracko
n
, Amrita Jesurasa
o
,
Zoe Wallace
o
, Carolyn Wallace
p
, Caroline Costongs
q
, Andrew J. Barnes
b
, Ewout van Ginneken
a
a
Technische Universit¨
at Berlin, European Observatory on Health Systems and Policies
b
Virginia Commonwealth University, Richmond, Virginia, USA
c
European Observatory on Health Systems and Policies, World Health Organization
d
Nivel (Netherlands Institute for Health Services Research, Utrecht, the Netherlands
e
Nivel (Netherlands Institute for Health Services Research, Utrecht, Netherlands and Maastricht University
f
Global Health and Tropical, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
g
Comprehensive Health Research Center (CHRC), Escola Nacional de Saúde Pública (ENSP), Universidade NOVA de Lisboa (UNL), Lisboa, Portugal
h
Canadian Institute for Social Prescribing, Canadian Red Cross
i
Nossal Institute for Global Health, University of Melbourne, Australia
j
Austrian National Public Health Institute, Vienna, Austria
k
Ministry of Health of the Slovak Republic, Bratislava, Slovak Republic
l
Department of Social and Behavioural Medicine, Faculty of Medicine, PJ Safarik University in Kosice and Slovak Public Health Association (SAVEZ), Kosice, Slovak
Republic
m
Finnish Best Practice Portal for Health and Wellbeing Promotion, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
n
National Institute of Public Health, Ljubljana, Slovenia
o
Public Health Wales, Cardiff
p
University of South Wales, Wales School for Social Prescribing Research (WSSPR), UK
q
EuroHealth Net, Belgium
ARTICLE INFO
Keywords:
Social prescribing
Community referral
Link worker
Person-centred care
Social determinants of health
ABSTRACT
Background: Social prescribing connects patients with community resources to improve their health and well-
being. It is gaining momentum globally due to its potential for addressing non-medical causes of illness while
building on existing resources and enhancing overall health at a relatively low cost. The COVID-19 pandemic
further underscored the need for policy interventions to address health-related social issues such as loneliness
and isolation.
Aim: This paper presents evidence of the conceptualisation and implementation of social prescribing schemes in
twelve countries: Australia, Austria, Canada, England, Finland, Germany, Portugal, the Slovak Republic,
Slovenia, the Netherlands, the United States and Wales.
Methods: Twelve countries were identified through the Health Systems and Policy Monitor (HSPM) network and
the EuroHealthNet Partnership. Information was collected through a twelve open-ended question survey based
on a conceptual model inspired by the WHO’s Health System Framework.
Results: We found that social prescribing can take different forms, and the scale of implementation also varies
significantly. Robust evidence on impact is scarce and highly context-specific, with some indications of cost-
effectiveness and positive impact on well-being.
☆
This article has been made Open Access through funding by the European Observatory on Health Systems and Policies as part of its Health Systems and Policy
Monitor (www.hspm.org), an innovative platform that provides a detailed description of health systems and provides up to date information on reforms and changes
that are particularly policy relevant.
* Corresponding author.
E-mail address: [email protected] (G. Scarpetti).
Contents lists available at ScienceDirect
Health policy
journal homepage: www.elsevier.com/locate/healthpol
https://doi.org/10.1016/j.healthpol.2024.104992
Received 8 May 2023; Received in revised form 6 December 2023; Accepted 8 January 2024
Health policy 142 (2024) 104992
2
Conclusions: This paper provides insights into social prescribing in various contexts and may guide countries
interested in holistically tackling health-related social factors and strengthening community-based care. Policies
can support a more seamless integration of social prescribing into existing care, improve collaboration among
sectors and training programs for health and social care professionals.
1. Introduction
Growing evidence suggests that the social determinants of health, the
conditions in which people live, work, and age [1], play a major role in
shaping health outcomes ([2–4]; WHO, n.d.). These determinants range
from education and housing conditions to social inclusion and social
support. Social isolation, defined as a lack of social contact or support
(CDC, n.d.) significantly increases the risk of premature death from all
causes (Ibid) as well as the risk for several physical and mental condi-
tions such as high blood pressure, anxiety, depression, and cognitive
decline [5,6]. Loneliness and social isolation are a growing public health
concern and exacerbated by the COVID-19 pandemic, where repeated
and prolonged lockdowns and shifts from in-person to online in-
teractions deprived individuals of the fundamental need for human
connection [7].
Traditional disease-centred models of healthcare focus predomi-
nantly on medical interventions and less often address the social de-
terminants of health. However, it is increasingly recognised that medical
care should take a more holistic perspective of patients and their envi-
ronment and focus more on health and well-being promotion rather than
just treating illness [8]. To achieve this, health care systems must shift
toward a more integrated, equitable and person-centred care model [4,
8–11]. The need for better-integrated services to address the increas-
ingly complex health needs of the population requires addressing the
social determinants of health that impact an individual’s ability to live a
healthy life [12].
In response to the call for a person-centered care approach that ad-
dresses social determinants, social prescribing has received recent
attention. The practice of social prescribing, based on the bio-
psychosocial model of health and illness, attends to all domains of health
including physical, psychological, and social well-being. While there is
no consistent, international definition of social prescribing, a common
definition given by the Kings’ Fund is “social prescribing, also some-
times known as community referral, is a means of enabling health pro-
fessionals to refer people to a range of local, non-clinical services care”
(The King‘s Fund, 2020). Others have refined this definition to differ-
entiate social prescribing as “a mechanism for linking patients with
nonmedical sources of support within the community” [13]. Ultimately,
the goal of social prescribing is to help people with a variety of social,
emotional, lifestyle-related or practical issues. Social prescribing can be
also seen as a facilitator for self-determination, intended as a person’s
ability to make their own choices concerning their health and wellbeing.
Many programmes are geared toward enhancing mental and physical
welfare (The King‘s Fund, 2020). If implemented correctly, social pre-
scribing could potentially deliver cost savings by reducing the utilization
of primary care while improving patient health and well-being [14,15].
In addition, as the main characteristic of social prescribing is to connect
patients to programmes that are often already accessible in their com-
munities, there is a potential to make a difference at rather low cost.
Indeed, numerous studies have assessed the social prescribing model’s
cost-effectiveness and provided evidence of long-term savings [16–18].
In 2023, the National Academy for Social Prescribing (NASP) has
released 13 evidence publications affirming that social prescribing holds
the potential to reduce costs and alleviate pressure within the healthcare
system [19].
Other studies have assessed the effects of social prescribing on pa-
tient outcomes. Research has indicated that social prescribing may
enhance psychological health, lessen anxiety, and raise the perceived
quality of life [20]. However, this evidence is highly context-specific.
While the definition of social prescribing is still evolving, it is
generally thought of as a process within a healthcare system that uses a
formal pathway to refer patients to locally available resources, though
different models exist. Some social prescribing schemes use a link
worker (also known as community navigator) who works together with
health professionals to refer individuals to local sources of support while
other schemes use general practitioners for referrals. Social prescribing
schemes can address various needs, including healthy behavior pro-
motion, social support, and economic needs through connections to
programs or activities offered by government agencies, volunteer or
community sectors. This may include a referral to a housing program or
to activity groups that include for example art making (substantial ev-
idence shows that arts can improve wellbeing, WHO, 2019), garden and
culinary activities, group learning, healthy eating guidance, and a va-
riety of sports (Fig. 1).
Social prescribing has been gaining more attention in recent years.
The first International Social Prescribing Day took place in 2019, rec-
ognising the importance of community involvement, dedicated support
from workers, and the promotion of cross-sector partnerships. However,
it is not a new concept. The NHS in England has used social prescribing
since the mid-1980s and 1990s. However, the practice was mostly per-
formed in local areas and remained largely unacknowledged by national
NHS agencies (The Kings‘ Fund, 2020). Although different countries
may have less formal definitions of social prescribing than England, this
paper focuses on the practice in countries in which social prescribing is
emerging. The twelve countries discussed in this paper, identified in two
phases (see Methods) are Australia, Austria, Canada, England, Finland,
Germany, Portugal, Slovak Republic, Slovenia, the Netherlands, the
United States and Wales. Table 1 highlights some general characteristics
of the countries included.
This article aims to add to the literature on global developments of
social prescribing by providing a detailed description of the scope and
breadth of programmes, supply/workforce, financing, and early evi-
dence on outcomes across the twelve countries.
Source: 1) World Bank, 2021; 2) UKpopulation.org; 3): GovWales; 4)
OECD
Notes: CHE: Current Health Expenditure; SHI: Statutory Health In-
surance; NHS: National Health Service
2. Methods
This article originated from a research proposal pitch through the
Health Systems and Policy Monitor (HSPM) network (https://euroh
ealthobservatory.who.int/monitors/health-systems-monitor/network).
This was followed by desk research to identify relevant social pre-
scribing programmes globally. Seven countries were identified through
this search (Australia, Canada, England, Germany, Portugal, the
Netherlands, and the United States). For the seven countries identified,
country experts and members of the Health Systems and Policy Monitor
(HSPM) network and experts on social prescribing beyond HSPM were
asked to participate in a survey and agreed to collaborate between
February and June 2022. In May 2022, five additional countries
(Austria, Finland, Slovenia, Slovak Republic, and Wales) were identified
through a dialogue with the EuroHealthNet Partnership. Experts from
these countries agreed to participate, which provided a more extensive
overview of social prescribing practices. This resulted in a sample that
covers different geographies (Australia, Europe, North America) and
different types of health systems (tax-financed, health-insurance based,
and mixed systems).
G. Scarpetti et al.
Health policy 142 (2024) 104992
3
The data presented in this paper was collected through a survey
containing twelve open-ended questions (Table 2).. Following the con-
ceptual model inspired by the WHO’s Health System Framework (WHO,
2007. The questions aimed to contribute to the literature on social
prescribing by focusing on five main topics:, 1) Framing social pre-
scribing and links to the health system; 2) Scale and scope of social
prescribing programmes; 3) Workforce; 4) Financing; and 5) Evaluation
and evidence.
Only countries with established social prescribing practices in pilots
and programmes were included. To ensure the relevance of the selected
programmes, given the lack of a universal definition of social prescribing
programmes, the survey included a working definition of social pre-
scribing. Email exchanges with local experts were also conducted to
identify initiatives at the country level.
Responses were submitted for all countries,and collated in one table
in Excel to facilitate analyses. Responses were supplemented with a re-
view of the available literature, as well as with findings from the
EuroHealthNet Country Exchange Visit on Social Prescribing in May
2022 in cooperation with the National Institute of Health Doutor
Ricardo Jorge in Lisbon, Portugal.
3. Results
Table 3 presents an overview of the results, based on the five topics
identified in the conceptual framework.
Each topic will be discussed in further detail in the following
sections.
3.1. Framing social prescribing: definition; relationship with other efforts
to address social determinants of health; links to the health care system
Overall, most of the countries surveyed had no common definition of
social prescribing. However, an often-used definition in England and
Australia is the King’s Fund definition of social prescribing (see Intro-
duction), and Austria is currently adopting a working definition inspired
by Polley et al. [17]: ‘Social prescribing is a means by which healthcare
professionals seek to address the non-medical causes of ill health with
non-medical interventions‘. Social prescribing in Wales is defined as
‘connecting citizens to community support to better manage their health
and well-being’ (Rees et al., 2019).
When asked to provide distinctions between programs that address
social determinants of health and social prescribing, most countries
noted that there were distinctions, but these two concepts were inter-
connected. Programs to address social determinants were generally
thought of on a broader scale and over the entire life course. Addition-
ally, programs addressing social determinants of health typically
involved other government policies and government priorities at the
population level (England, Finland, Slovakia, and Wales). In compari-
son, social prescribing programs occur at the individual level and
involve personalized plans that take into consideration the needs of
individuals and the availability of resources in the community (Canada,
Germany, the Netherlands, Portugal, the US). Other countries noted
additional components of social prescribing including having a sys-
tematic process (Austria) as well as coordination across multiple sectors
(Australia, England, Germany, Portugal, Canada, the US).
While a clear, individualized process that involves self-
determination is an inherent component of social prescribing, the
entry point into the process can vary. For example, this process starts
within the health care system for some countries (Austria, Canada, US),
such as in the primary care setting or in the hospital setting. However, in
the Netherlands, this process is organized through the municipalities
because individualized programs focused on social determinants are
considered prevention activities and are mainly funded through the
Social Support Act and the Youth Act. Similarly, in Slovenia, certain
social needs (such as available social assistance services) are addressed
through a network of social care centres, which operate under the
Ministry of Labour, Family, Social Affairs and Equal Opportunities,
while the “community health approach” (Slovenia’s terminology for
social prescribing) is organized and financed through its health sector.
Last, the third sector (defined as non-governmental and non-profit-
making organizations or associations, including charities, voluntary
and community groups) in Wales provides a starting point for the social
prescribing process [21].
Fig. 2 illustrates how (and if) social prescribing is linked to the health
system. In Australia, Austria, Canada, England, Germany, Portugal, and
Slovenia, social prescribing programmes are in primary and community
care. In Germany, social prescribing programmes are also available in
secondary outpatient care. In the Slovak Republic and the United States,
social prescribing can take place at the primary, secondary and inpatient
levels. In Finland, it is mostly in in primary care. In Wales, social pre-
scribing can be defined as a mixed model, where the third sector plays a
key role, in addition to local authorities and primary care [21]. In the
Netherlands, social prescribing is outside of the health system, as it is
linked to the work of municipalities.
3.2. The scale and scope of social prescribing: which services are available
and for whom?
The scale of implementation of social prescribing across the twelve
countries varies significantly. It ranges from pilots (e.g., Australia,
Austria, Canada, Finland, Portugal, the Slovak Republic, the US) to
initiatives implemented in many municipalities across the territory (e.g.,
Germany, the Netherlands), to a wider country-wide roll-out (e.g., En-
gland, Slovenia, Wales, the US). Countries are also looking at how to
understand the place of social prescribing in policy, for example an
ongoing feasibility study of non-clinical prescribing n Australia being
conducted for the Commonwealth government.
In general, the needs that can be addressed by social prescribing
range from structural determinants (food, housing), psycho-social sup-
port networks (eg. bereavement groups, patients’ self-help
Fig. 1. Examples of social prescribing: for whom, how, and what.
Source: Authors‘ own
G. Scarpetti et al.
Health policy 142 (2024) 104992
4
organisations), health promotion (e.g., walking), and social and recre-
ational supports. Although most countries include programs for social
support, these services are uncommon in US social prescribing schemes.
Services that individuals can be referred to in all countries include those
in almost every sector, including government programs, voluntary,
community and social enterprise groups (see Fig. 1), although services
can vary between local areas.
Overall, social prescribing programs have been considered appro-
priate for individuals with a wide range of conditions, but each specific
program usually involves a targeted population. In Canada, England, the
US, and the Slovak Republic, social prescribing can be used for in-
dividuals with various attributes or needs (e.g., with long-term condi-
tions; mental health issues; lonely or isolated). One example of such
programmes is GreenSpace in Nottingham and Nottinghamshire (UK),
which aims at improving people’s mental health through nature-based
activities and green groups, projects, and schemes. People are usually
referred by a link worker based at a GP practice or another primary care
professional. The programme is available to everyone. It will offer spe-
cific initiatives to support some of the most underserved groups that
have been disproportionately impacted by the coronavirus crisis,
including people with long-term conditions, particularly older people,
Black, Asian, and Minority Ethnic (BAME) communities, and those
without access to gardens, balconies, or green space. [22]
Still, there may be differences in regional conditions and priorities of
the participating institutions. In Austria, AmberMed is a Viennese pri-
mary care centre for persons who are not covered by Austrian health
insurance. The project aims to address various social, economic, politi-
cal, medical, and psychological stresses in a holistic and patient-
centered way through the Social Prescribing Project. AmberMed now
comprises over 50 volunteers, including GPs, specialists, physical ther-
apists, and psychotherapists. Three full-time social workers took on the
role of link workers. Patients undergo an initial assessment with the
social workers after joining at AmberMed. Then, follow-up visits are
scheduled, or a (return) referral to the extended link network is made if
necessary. There, the patient and the contact points or offers relevant to
the particular case are discussed in detail. On-site native-language
counselling or case-related interpreters are provided to all patients. In
the Viennese social and service landscape, this process is complemented
by long-term networking by project managers and link workers to
reduce and anticipate bottlenecks. (https://amber-med.at/)
Current programmes in Australia assist those with specific health or
social conditions such as mental illness, cardiovascular diseases or
isolation, while the pilot in Finland targets adults with specific health
and social conditions. Other programs in England and the US focus on
individuals who use care frequently regardless of their medical
conditions. Beyond medical conditions and utilization, some programs
focus on individuals with socioeconomic risks. For example, pro-
grammes in Slovenia mostly target vulnerable or at-risk groups, such as
the economically disadvantaged, and in Germany, programmes are
implemented especially in deprived urban areas. Pilots in Portugal focus
on communities with a high proportion of migrants. Most social pre-
scribing in Wales relates to adult populations, but approaches for young
people are emerging, particularly in England and the US. Additionally,
programs in the US focus on individuals with particular health behav-
iours such as individuals who smoke.
3.3. Workforce: the role and training of care navigators/link workers;
referral process
There are differences in link workers among the countries surveyed.
A specific role for link workers/social prescribers was only reported in a
few countries. For example, in Canada and the US, some pilots have
funding for a dedicated link worker role while other pilots use existing
staff (e.g., nurse, nurse practitioner, settlement worker, health pro-
moter, social worker, etc). In Portugal, the link worker is a social worker.
A few programs are using trained volunteers as link workers, for
example in the US. In England, social prescribers are now additional
roles in primary care (i.e., distinct from other roles such as nurses, health
care assistants, etc).; the NHS Long Term Plan has committed to adding
1,000 new social prescribing link workers and that at least 900,000
Table 1
Characteristics of the twelve countries surveyed.
Australia Austria Canada England Finland Germany Portugal Slovak
Republic
Slovenia The
Netherlands
United
States
Wales
Type of health
system
Public/
private
state/
territory
SHI NHS NHS NHS SHI NHS SHI SHI SHI Public-
private
mix
NHS
Population size
(2022)
1
25.9
million
9.0
million
38.9
million
56.4
million
(2)
5.5
million
84.0
million
10.3
million
5.4
million
2.1
million
17.7 million 333.2
million
3.2
million
(2)
% of population
over 65 years
of age (2022)
1
17% 20% 19% 19% (UK
value)
23% 22% 23% 17% 21% 20% 17% 21%
(3)
CHE as % of GDP
(2021)
1
10.6%
(2020)
12.1% 11.7% 11.9% (UK
value)
9.6%
(2020)
12.8% 11.2% 7.3%
(2020)
9.1% 11.2% 18.8%
(2020)
11.9%
(UK
value)
Social spending
(Public, % of
GDP, 2022 or
latest
available)
4
20.5%
(2019)
29.4% 24.9%
(2020)
22.1%
(2021,UK
value)
29.0% 26.7%% 24.6% 19.1% 22.8% 17.6% 22.7%
(2021)
22.1%
(2021,UK
value)
Table 2
Survey questions.
1. Social prescribing can exist in many different forms and names. Is there a
common definition for social prescribing in your country?
2. How widespread is social prescribing in your country? (e.g., only pilots,
adopted nationally)
3. Does social prescribing target specific groups or is it available in general?
4. Which (non-clinical) services are offered?
5. What is the role of care navigators/link workers?
6. Who is tasked with SP (e.g., is there a formal role for care navigators/link
workers)? Do they require specific training/qualifications?
7. Which professionals (GPs, nurses, social workers) can initiate the referrals to
the care navigator/ link worker?
8. Is social prescribing linked to a specific part of the system? (e.g., Primary care,
emergency)
9. From which source is social prescribing funded? And how are Social
Prescribers remunerated?
10. Are evaluation schemes for social prescribing in place?
11. Is there evidence on impact?
12. Did COVID-19 play a role in the implementation of SP? Is it being used/
promoted more during the pandemic?
G. Scarpetti et al.
Health policy 142 (2024) 104992
5
Table 3
Overview of survey results across the twelve countries.
Australia Austria Canada England Finland Germany Portugal Slovak
Republic
Slovenia The
Netherlands
United
States
Wales
Links to the health
system
primary and community care Primary,
care
Primary
and
secondary
outpatient
care
Primary and
community
care
Primary,
secondary
and
inpatient
levels
Primary and
community
care
Outside the
health system
Primary,
secondary
and
inpatient
levels
Primary care,
local
authorities
and third
sector
Scale Pilots Wider country-
rollout
Pilots Wider
country-
rollout
Pilots Pilots Wider country-
rollout
In different
municipalities
Wider
country-
rollout
Wider
country-
rollout
Scope Individuals
with specific
health or social
conditions such
as mental
illness,
cardiovascular
diseases or
isolation
Individuals
with specific
health or
social
conditions (e.
g.,
loneliness)
with some
differences
based on
regional
conditions
and priorities
of
participating
institutions
Individuals with
specific health or
social conditions
Individuals
with specific
health or social
conditions
Individuals
with specific
health and
social
conditions
Mostly in
deprived
urban
areas
Mostly
migrant
populations
Individuals
with
specific
health or
social
conditions
Mostly
vulnerable or
at-risk groups,
such as the
economically
disadvantaged
Individuals
with specific
health or
social
conditions
with some
differences
based on
regional
conditions
and priorities
of
participating
institutions
Individuals
with
specific
health or
social
conditions
orwith
certain
health
behaviors
Mostly adult
population
Workforce (who does
the referrals?)
Mainly GPs All
healthcare
professional
Any clinical or
interprofessional
health provider
Several
professionals in
social
prescribing
connector
schemes with
integrated
working
All
healthcare
professionals
GPs and
specialists
GPs, family
nurses or
psychologists
All
healthcare
professional
GPs, primary
care
paediatricians,
primary care
nurses, social
workers at
social care
centres, and
workers at
employment
centres
GPs, practice
and district
nurses, social
workers
GPs, health
insurance
companies,
or
individuals
themselves
All healthcare
professionals,
and
individuals
themselves
Financing Philanthropic
and charitable
organisations,
and some state
government
funding
Funding calls
from the
Ministry of
Social
Affairs,
Health, Care
and
Consumer
Protection
Some funding
from the
provincial
Ministry of
Health and other
funding from
private donors/
foundations
NHS England
pays 100%
reimbursement
of the salary of
a full-time
social
prescribing link
worker
Ministry of
Social Affairs
and Health
Health
insurances
are the
primary
funder for
link
workers’
salaries
Link
workers’
salaries are
funded
through the
budget
allocated to
the FHU and
supported by
the
municipality
N/A Funding can be
from the
Ministry of
Health and/or
municipalities,
the National
Health
Insurance Fund,
or the Ministry
of Labour,
Family, Social
Affairs and
Equal
Opportunities
Municipalities Grants or
research
funds
Most link
workers are
employed on
fixed-term
contracts paid
for by the
integrated
care fund, GP
cluster
funding,
health boards
or local
authorities
(continued on next page)
G. Scarpetti et al.
Health policy 142 (2024) 104992
6
people will be referred to social prescribing by 2023/2024 [23]. Link
worker roles in Wales are most commonly based within the third sector,
GP practices or local authority venues, and in some cases in universities.
In general, no specific training/qualifications are required for care
navigators/link workers. However, in Austria, as part of a pilot program,
health professionals underwent a 4-day training to introduce them to the
concept and process of social prescribing (including information on
health determinants, and motivational interviewing). In Slovenia pro-
fessionals who serve as link workers have specific training in health
promotion and disease prevention. In Wales, a national competency/
capability framework and training programme is being developed.
Many countries noted that health care professionals were the point of
referral into the program. In the Netherlands, GPs may refer someone as
well as practice nurses (from GP practices), district nurses, and social
workers. This is also the case in Finland, where all health professionals
initiate referrals. . In the US, connections to link workers are made
through GPs, health insurance companies, or the patient themselves. In
Germany, both GPs and specialists can refer individuals. In Austria and
the Slovak Republic, all healthcare professionals can do referrals, in
addition to Wales, where individuals can also self-refer to programmes.
In Australia, referrals may come from GPs, allied health or others such as
community referrals, and patients may also self refer into support.This is
similar to Canada, where programmes tend to have an open referral
structure where any clinical or interprofessional health provider can
make a referral, though there is a strong emphasis on encouraging the
clinicians to do so. Also, in Slovenia referrals can be made by GPs, pri-
mary care paediatricians, primary care nurses, social workers at social
care centres, and workers at employment centres. In England, in current
social prescribing connector schemes operating through integrated
working, members of multi-disciplinary teams can all refer to the link
worker, as can social workers, allied health professionals, local author-
ities, hospital discharge schemes, police and fire services, pharmacies,
job centres, housing associations and other voluntary, community, and
social organisations. In Portugal, referral into the social prescribing
program takes place at the GP office at the Family Health Unit (FHU),
after evaluation by either the GP, the family nurse or the psychologist.
The situation is reported and described in an internal platform and the
patient is referred to the link worker. Then the social worker from the
FHU, together with available partners in the community, finds the best
response for the patient.
3.4. Financing: sources of funding and workforce remuneration
Different funding mechanisms have been exploited for social pre-
scribing programs such as philanthropic funding, government funding,
health insurance reimbursements, and research funds. In Australia,
funding comes from a mixture of philanthropic and charitable organi-
sations, as well as some state government funding. Similarly, in Canada
funding sources differ based on the project with some funding from the
provincial Ministry of Health and other funding from private donors/
foundations. In Austria, social prescribing is funded by funding calls
from the Ministry of Social Affairs, Health, Care and Consumer Protec-
tion. Similarly, in the US, most of the funding has been obtained through
grants or research funds for randomized control trials, testing the
effectiveness of social prescribing. Generally, health insurance com-
panies do not provide these services in the US, although state Medicaid
Managed Care Organizations have started to pay for link workers.
Some countries pay for link workers through a salaried position.
Starting in 2019, NHS England has paid 100 % reimbursement of the
salary of a full-time social prescribing link worker for every 13,000
patients. With this, link workers became salaried employees of primary
care practices. In Germany, health insurances are the primary funder for
link workers’ salaries (e.g., for Hamburg/Billstedt four large health in-
surance funds are partners). In Slovenia, health-related NGOs are funded
by the Ministry of Health and/or municipalities, while primary health
care services, including health promotion centers, are funded by the
Table 3 (continued)
Australia Austria Canada England Finland Germany Portugal Slovak
Republic
Slovenia The
Netherlands
United
States
Wales
Evaluation &
evidence
Schemes for
the evaluation
of social
prescribing
projects are
developing
The project
call was
evaluated
externally
Evaluations are
in place for each
pilot or
programme
Government,
individual
providers and
independent
think tanks
have funded
recent
evaluations of
social
prescribing
Evaluations
are in place
N/A Developed a
research
group
Currently
no
evaluation
schemes
Currently
developing an
evaluation
platform for
social
prescribing
services
Limited
evaluation in
place
There are
evaluations
of
individual
projects or
pilots both
at the
federal and
state level,
and clinical
trials
Schemes for
the evaluation
of social
prescribing
projects are
developing
Notes: N/A- not available; GP- General Practitioner; FHU- Family Health Unit
G. Scarpetti et al.
Health policy 142 (2024) 104992
7
National Health Insurance Fund. Workers in the social sector are funded
through the Ministry of Labour, Family, Social Affairs and Equal Op-
portunities. In Wales, most link workers are employed on fixed-term
contracts paid for by the integrated care fund, GP cluster funding,
health boards or local authorities [21]. The pilot project in Lapland,
Finland, is funded by the Ministry of Social Affairs and Health. In
Portugal, link workers’ salaries are funded through the budget allocated
to the FHU and supported by the municipality, requiring no additional
remuneration. Similarly, in the Netherlands, link workers are funded
exclusively by municipalities.
3.5. Evaluation & evidence: evaluation schemes for social prescribing and
evidence on the impact
In Australia and Wales, schemes for the evaluation of social pre-
scribing projects are developing, although overarching coordination is
limited [24]. Similarly, Slovenia is currently developing an evaluation
platform for social prescribing services at the National Institute of Public
Health, and in Portugal, a research group has been formed at the Na-
tional School of Public Health, NOVA University Lisbon. In Canada and
Finland, evaluations are in place for each pilot or programme. In
particular, during the year-long Rx community pilot in Ontario, CA, the
11 participating Community Health centres provided over 1,100 clients
with about 3,300 social prescriptions, and found that: 1) Clients re-
ported improved mental health and a greater ability to self-manage their
Fig. 2. Social prescribing links to health systems in the twelve countries surveyed.
Source: Authors‘ own
G. Scarpetti et al.
Health policy 142 (2024) 104992
8
health, reduced loneliness and a stronger sense of community; 2) Social
prescribing is beneficial to healthcare providers in terms of boosting
client well-being and reducing repeat visits. Providers understood the
importance of the care navigator role and saw a need for extra support
where it wasn’t there; and 3) Through co-creation, social prescribing
facilitated deeper integration between clinical treatment, interprofes-
sional teams, and social support, as well as increased community ca-
pacity. For example, clients were encouraged to become volunteer
Health Champions and help organise activities.
In terms of impact, several countries reported that evidence is limited
and there is a lack of systematic research evaluating social prescribing
outcomes (Australia, Canada, England, Finland, Portugal, US, Wales). In
Germany and the Netherlands, there is some evidence that social pre-
scribing reduces healthcare consumption and is cost-effective, although
it is difficult to generalize the conclusions to all social prescribing [25].
Austria reported early qualitative indications of the benefits of social
prescribing, e.g., relief of physicians‘ work burden, and patient satis-
faction. In the US, past work has focused on the feasibility and accept-
ability of link workers in different patient populations.
Finally, one survey question focused on the COVID-19 pandemic and
its potential impact on social prescribing activities. While information is
scarce, most countries expect that COVID-19 both challenged the
progress of social prescribing while at the same time emphasising the
importance of these services. In Canada, for several projects, social
prescribing was stalled during COVID-19 due to clinical and health staff
being redeployed. However, other projects transitioned to more virtual
support and telephone check-ins. Similarly, in Australia services
switched online and largely continued to operate as near-normal. In
Wales, COVID-19 disrupted the previous social prescribing models but
demonstrated ‘remote’ forms of social prescribing are an important and
core feature that should be continued for many years. In Slovenia, which
has been actively developing the social prescribing network for several
years, activities in the health promotion centers almost ceased during
the COVID-19 pandemic, as the workers were temporarily relocated to
provide COVID-19-related services, while mental health support ser-
vices developed considerably, driven by increased mental health needs
during the COVID-19 pandemic. In Austria, the "Social Prescribing"
project is part of "Health Promotion 21+" (2021) and "Agenda Health
Promotion" (2022-2024), which focused on health promotion with the
aim of strengthening healthy living environments and reducing the
health and psychosocial impacts of the Covid 19 pandemic. The COVID-
19 pandemic only had a limited impact on the scaling up of social pre-
scribing in England, as implementation was already planned in 2019.
Collectively, the COVID-19 impact demonstrated that social prescribing
is necessary and allowed for innovation in delivery methods that will
persist beyond the pandemic.
4. Discussion
In recognition of the importance of the social determinants of health
in health promotion and person-centered care, the momentum to
implement social prescribing schemes is growing internationally. Within
the context of social prescribing research, it is important to recognize the
dynamic nature of this field. A substantial amount of information can be
found in the grey literature or remains unpublished. This paper adds to
the existing literature on social prescribing by providing a detailed
overview of the organization and implementation of social prescribing
across twelve countries in Australia, Europe, and North America.
This paper, in line with several other publications, found that social
prescribing offers a patient-centered, personalized approach to
addressing the wider social determinants of health through a range of
different activities and emphasizes a partnership between individuals
and support schemes to improve health and wellbeing. It allows health
professionals to act on some of the root causes of ill health and to
capitalise on (or benefit from) diverse resources already available in the
community. While a consistent definition of social prescribing may be
lacking, all programmes in the countries surveyed had common ele-
ments such as an individualised approach and referrals to community
resources and activities.
Social prescribing caters to different groups, such as people with
long-term conditions as well as socioeconomically vulnerable groups,
and offers a wide range of services for a diverse set of needs. Social
prescribing encourages cooperation between individuals, families, local
and federal governments, as well as the business, nonprofit, and com-
munity sectors. When implemented properly, it enables individuals to
self-manage their circumstances even while they deal with psychologi-
cal, emotional, and social difficulties [17]. Social prescribing can
therefore be a useful support tool to empower people to overcome their
specific problems and needs and help reduce health inequalities [26].
While in general social prescribing has been available mostly for adults,
programmes could be expanded to include several groups that have not
been historically included, such as children, given the significance of
childhood experiences for health and wellbeing throughout one’s life
(EuroHealthNet, 2022). Interestingly, in Austria pediatric facilities are
included in the current funding call for social prescribing programmes.
This paper also recognised that given the tailored approach of
various social prescribing programmes serving different populations,
there is no clear pattern based on type of health care (and welfare)
systems. Employing social prescribing practitioners (and other de facto
link workers) that have strong links to the community, that are able to
gain patients‘ trust and involve them in designing services could increase
the success of some programmes and add improvements over time. In
general, we could posit that the implementation of social prescribing
tends to be more feasible under the following conditions: 1) unified
funding: social care and primary care have a common funding source, (e.
g., national taxation), and funding is collected at the same level (na-
tional or both local/regional); 2)financial incentives: Primary care
providers have financial motivations or incentives to embrace social
prescribing; 3) urgency of social prescribing: the likelihood of successful
social prescribing increases when there is a heightened urgency, e.g., in
instances of heavy workload in primary care that still allows room for
innovative approaches like social prescribing; 4) clear information
pathways: availability of information regarding the professionals or
organizations that patients can approach following a social prescription,
at a more local or regional level; and 5) available infrastructure: in
countries with a less established tradition of primary healthcare, where
individuals tend to seek medical attention directly from hospitals, there
may be fewer local infrastructures conducive to social prescribing.
Social prescribing programmes can encounter several challenges.
First, a critical point for the success of the programmes is the willingness
of individuals to participate. As identified in the EuroHealthNet report,
some individuals tend to resist the idea of committing to social pre-
scribing activities and question their usefulness. Second, in some cases,
the division between the health and social sector is so pronounced that it
interferes with the true integration of services such as social prescribing.
As social prescribing operates cross-sectorally between health and social
care, it has to overcome differences in administration, monitoring, and
budgeting, which will require changes in current structures. Clear
frameworks that underpin collaboration between the health and social
care sectors can also promote the use of social prescribing among health
and social care professionals. Third, it is difficult to track patients
throughout the referral process. In some cases, if the follow-up process is
in place, it is not used appropriately (Ibid.). It will also be critical to
identify a way to continue addressing needs even when the social pre-
scribing process is theoretically complete. Digital solutions could play an
important role in supporting better access for patients as for example in
England and Wales through the Elemental platform. Fourth, funding is
often unstable or not renumerated for social prescribers/link workers,
calling into question the longevity of these programs as well as limiting
the ability of community health workers to grow lasting relationships.
Social prescribing activities necessitate suitable funding to facilitate
cross-sector collaboration and not shift the burden on already stretched
G. Scarpetti et al.
Health policy 142 (2024) 104992
9
health and social care workers. Adjusting funding mechanisms can be a
facilitator to support sustainable changes in the ways of working and
implementation of skill-mix innovations [27]. This paper did not assess
whether activities require cost-sharing from users, which may impact
the accessibility for certain groups. Last, patient screening for social
prescribing needs is not consistent across countries, which may lead to
issues in access. Work in the US has focused on the appropriateness and
acceptability of widespread screening for these needs but that has not
been a focus in other countries.
In addition, it is worth considering the strengths and weaknesses of
the terminology used for social prescribing in the context of the ongoing
debate on the medicalization of social issues. On one hand, the pre-
scribing label leads to a certain degree of medicalization of socialization.
On the other hand, as the activities are recommended (prescribed) by a
professional, it could increase the likelihood that patients would accept
them as legitimate. This prompts careful consideration of how to inte-
grate and complement services without over-medicalizing social pre-
scribing. Further, medicalizing socialization signals that health sector
financing may be appropriate to cover service referrals and provision.
Overall, as identified in other studies on this topic, there is a lack of
robust evidence in favour of the effectiveness of social prescribing
(Bickerdicke et al., 2017) and, as discussed in the introduction, evidence
is highly context-specific. A review by Polley et al. [28] found that social
prescribing points to a potential reduction of demand for primary and
secondary care, although the quality of the evidence is weak. A recent
systematic review found little to no evidence of the effectiveness of link
workers in people with multimorbidity and social deprivation [29]. It is
also important to note that social prescribing is not an intervention in
and of itself per se; the effectiveness of the services the patient is referred
to is critical as it determines how well social prescribing works [26].The
countries surveyed echoed this scarcity of evidence of the effectiveness
of social prescribing programmes, although some evidence points to a
positive impact of social prescribing in terms of improved well-being
and mental health, as well as cost-effectiveness. Quality assurance is
also a key element to consider (EuroHealthNet report, 2022), especially
since the population referred to social prescribing programmes is likely
more vulnerable [26].
Ultimately, social prescribing can play a role in addressing health
inequalities, for example by improving health literacy and self-efficacy
[26]. Social prescribing aims to improve health and well-being by pro-
moting patient empowerment, supporting them to engage with their
health needs and finding personalized solutions. The COVID-19
pandemic further highlighted the inequality gap, placed a high burden
on many health systems around the world and exacerbated social vul-
nerabilities. As the COVID-19 pandemic recedes, increasing attention is
being paid to the social determinants of health and mental health [30,
31].
5. Conclusions
Although the twelve countries surveyed in this paper have different
health (and welfare) system contexts, all are increasingly experimenting
with using social prescribing as a way to address patients’ social needs
more holistically and overcome the fragmentation of the health and
social systems. Countries developed different approaches, with some
relying more on primary care, but these usually include screening for
social needs (such as social isolation or access to food), referring to
community-based services, and a supporting person to guide the use of
relevant services (often but not always through a care coordinator or
link worker). Hence, the concept of social prescribing is (and should
remain) flexible which also allows for transferability to a range of set-
tings and countries and opportunities for scaling up. Supporting health
and social care workers with the transition into new ways of collabo-
rating, for example with clear frameworks for collaboration and
adequate funding, can promote the use of social prescribing among
professionals and improve the uptake of activities. This should also be
backed by policies to train health and social care professionals with the
skills to understand and support social prescribing activities.Ongoing
discussion on medicalization of social issues, and how it raises questions
about the terminology used for social prescribing, as well as the po-
tential benefits of medicalizing socialization are needed. Further, as
social prescribing is developing, scaling up, and spreading, robust
evaluations are being conducted. However, further research is needed to
identify the most effective type of support for certain groups, how to
address needs once the support ends, the cost-effectiveness of social
prescribing programmes and the sustainability of programmes.
Strengthening this evidence, to which this article contributes, can help
inform policymakers and countries interested in addressing individual
patient needs beyond the clinical realm and bringing more integrated
into routine care.
CRediT authorship contribution statement
Giada Scarpetti: Conceptualization, Formal analysis, Project
administration, Writing – original draft, Writing – review & editing.
Hannah Shadowen: Conceptualization, Data curation, Formal analysis,
Validation, Writing – original draft, Writing – review & editing. Gemma
A. Williams: . Juliane Winkelmann: Data curation, Validation,
Writing – original draft. Madelon Kroneman: Data curation, Valida-
tion, Writing – original draft, Writing – review & editing. Peter P.
Groenewegen: . Judith D. De Jong: . Inˆ
es Fronteira: . Gonçalo Fig-
ueiredo Augusto: . Sonia Hsiung: Data curation, Validation. Siˆ
an
Slade: . Daniela Rojatz: Data curation, Validation, Validation, Writing
– review & editing. Daniela Kallayova: Data curation, Validation.
Zuzana Katreniakova: Data curation, Validation. Iveta Nagyova: Data
curation, Validation. Marika Kyl¨
anen: . Pia Vracko: Data curation,
Validation. Amrita Jesurasa: Data curation, Validation. Zoe Wallace:
Data curation, Validation. Carolyn Wallace: Data curation, Validation.
Caroline Costongs: Conceptualization, Data curation, Methodology,
Validation, Writing – original draft, Data curation, Methodology, Vali-
dation, Writing – original draft, Writing – review & editing. Andrew J.
Barnes: . Ewout van Ginneken: Conceptualization, Data curation,
Formal analysis, Methodology, Supervision, Validation, Visualization,
Writing – original draft.
Declaration of competing interest
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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