The pandemic has put local government on the spot. Massive health inequalities between and within communities demand urgent action, while austerity-stricken budgets continue to squeeze resources for meeting its responsibilities for improving public health.
Social prescribing has been hailed as a welcome solution to this devilish dilemma, but is not going to make a difference if relationships with the voluntary sector and communities remain unchanged. What can local government do to realise more sustainable and less unequal health outcomes?
Addressing health inequalities was one of the motivations for returning responsibility for public health to local government. The Health and Social Care Bill claimed that local authorities are best placed to take action on the social determinants of health that drive inequalities. Over a decade and a pandemic later, health inequalities have worsened while the resources needed to meet ever-more complex and growing local needs have diminished.
Social prescribing is a way to address the social determinants of health by ‘prescribing' people to social, cultural, environmental, or economic community-based activities that help to address medical and non-medical issues.
More than a smart health care innovation, it is seen as a pathway to move towards a social model of wellbeing through place-based collaboration with Voluntary, Community, Faith and Social Enterprise (VCFSE) organisations. Social prescribing is therefore about more than health: it is an opportunity to transform relationships towards genuine co-production of community wellbeing.
Realising this transformative opportunity means overcoming a range of structural issues that have historically bedevilled place-based partnerships and community engagement in health and wellbeing. All too often, holistic ambitions crumble in a maze of silo-working, commissioning processes, and partnership schemes. Social prescribing faces the same fate. This is partly inherent to the term itself, which reinforces assumptions of medical power rather than community control. The upshot is that many of the VCFSE organisations on which social prescribing depends are on the hamster wheel. Under constant pressure to reel in project funding, most lack the time or capacity to pursue structural change in their relationships with public health bodies.
At the same time, a lack of strategic engagement with VCFSE organisations and communities risks doing to them the same thing that local governments have loathed about austerity: being made responsible for something without the necessary resources and support.
Local government can break the mould by co-producing an asset-based infrastructure for social prescribing. Asset-based working has become a popular approach in local government. By focusing on ‘what's strong' (assets) rather than ‘what's wrong' (deficits), an asset-based approach can both enhance community wellbeing and ensure that it is co-produced in an equal and inclusive way.
An asset-based infrastructure would extend this way of working across the local governance system based on the principle that all decisions, support structures, and relationships are community-driven.
In contrast to an institution-led approach, it is about recognising that communities have the knowledge and capacities to understand and strengthen their local assets and creating the conditions in which this can come to fruition.
An asset-based infrastructure would do four things. First, continuous building of relationships of mutual understanding, trust, and support. Second, safe spaces to incubate and sustain grassroots innovations. Third, inclusion of diverse VCFSE organisations on equal terms in policy-making. Finally, shared learning about how to collaborate driven by community assets and needs.
Taken together, these elements could support public health bodies, VCFSE organisations and communities in addressing the structural inequalities in participation, influence, and funding support that make it difficult to sustain the very initiatives on which social prescribing depends.
These ideas have been developed by the Social Prescribing, Assets and Relationships in Communities (SPARC) Network. It is a collaborative learning space developed out of academic knowledge about community co-production and innovative approaches to social prescribing across the UK. Its aim is to examine how asset-based approaches to social prescribing can enable local communities to coproduce better health and wellbeing outcomes and transformative and sustainable change.
We have produced several policy briefings, including on creating an asset-based infrastructure for social prescribing, and are currently undertaking projects in Birmingham and the Netherlands to test and develop our approach.
We invite local government to join in our search for co-producing the conditions and resources needed to enable social prescribing to realise the public health outcomes it aspires.
Dr Koen Bartels is associate professor in the Department of Public Administration and Policy at the University of Birmingham
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