Could fruit & veg prescriptions help a collapsing NHS?

An apple a day keeps the doctor away; unless, of course, it’s the doctor that’s helping hand out the apples. At the end of last year, the Alexandra Rose Charity launched its “Fruit & Veg On Prescription” scheme, the first of its kind in the UK. For the last eight years, Alexandra Rose has offered a financial incentive to low-income families to improve their diet, giving out food vouchers that could only be exchanged for fresh fruit and vegetables from local market traders.

“We all know that one of the key leading indicators of your dietary health is your nutrient and fibre content,” says Jonathan Pauling, CEO of Alexandra Rose (an apple, it turns out, is comparable to statins for cholesterol issues). For low-income families, though, eating everything the government advises requires an “unrealistically high percentage of their disposable income” compared to cheaper-per-calorie options, something which leads to an overall poor diet, which in turn, contributes to more deaths in the UK than smoking.

While the charity focuses on families with young children, Pauling was confident that it could be just as beneficial for other segments of society. After putting out a call-out for partners, the public health teams of Tower Hamlets Council and Lambeth Council offered to fund a prescription model, now in its trial stage with 122 patients.

The project is a form of social prescribing, a type of public healthcare that dispenses with pills and offers anything from fruit, football or financial advice. It’s a key component of Universal Personalised Care – an approach which gives people have more choice and control over how their health and care needs are met. “It’s a way of connecting people with a health and wellbeing need to activities, groups and services that support their needs,” says Rosie Stephens of The National Academy for Social Prescribing. Stephens notes a steep increase in related projects due to new patient anxieties. “It’s estimated that one in five GP appointments are related to essentially non-medical issues, like loneliness, isolation, relationship problems or concerns about debt or housing.” In December, the government announced £3.6m social prescribing funding for mental health support. By 2024, the NHS estimates that at least 900,000 people will be referred to social prescribing, with 2.5 million people benefiting from Universal Personalised Care. 

With the NHS no longer on the brink of collapse but fully on the floor, and GPs overworked to unhealthy levels, it’s little surprise that the NHS is banking on it. Evidence already suggests social prescribing can reduce the use of more intensive NHS services, with 59% of practitioners thinking it can cut their workload. Dr. Professor Sir Sam Everington, a Fruit & Veg Prescription advocate at pioneering social prescribing surgery Bromley by Bow, has previously said that a healthy diet can “often achieve far more than any medicines I can prescribe as a GP…fruit and veg should be part of every prescription”. 

It’s not just fruit and veg, either. The Warm Home Prescription project – founded by innovation centre Energy Systems Catapult to prescribe heating to vulnerable people – started with just 21 patients; now, it’s subsidising the energy bills of 1,000 families across the North East and Aberdeen. With an estimated 10,000 people dying every winter in the UK from living in a cold home, and amid increased fuel poverty, the service couldn’t be more vital.

Neither Alexandra Rose or Energy System Catapult’s schemes take money out of the NHS, instead, they’re funded by local authorities and charitable foundations. Both, too, work relatively similarly, triaging patients with GPs before engaging Social Prescribers. If deemed applicable by a GP, Alexandra Rose offers around six sessions of advice and enrols them onto the scheme. They come to the centre every week to pick up vouchers, take it to the local market and buy their fruit and veg, something Pauling thinks creates “regularity” of routine. “It’s improving your financial situation and improving your dietary situation, which can have a double whammy on your health,” Pauling says.

For patients, though, is it a virtue? At a time when NHS services are stretched thin, social prescribing could be seen as an attempt to plug the gap. And, while the idea of not relying on Big Pharma is welcome, the pharmaceutical industry is currently significantly more evidence-based than social prescribing.

Dr. Kerryn Husk, Associate Professor of Health Services at the University of Plymouth, is cautiously optimistic about the potential of social prescribing. While we know how people might benefit, Husk notes that “we know a lot less about where things go less well, where people don’t engage for example, or where there could be opportunity cost or harm”. He also cites a gap in the research on how it addresses health inequalities, whether it’s truly cost-effective and the need for a coherent system. “We need good evidence to run alongside and tell us how, for whom, in what ways and in what contexts they might most usefully be deployed.”

While schemes such as the ones led by Alexandra Rose and Energy Systems Catapult target physical health, social prescribing is also increasingly being applied to mental health. INSPYRE (Increasing Social Prescribing Youth Referrals), set-up by UCL to engage children and young people in social prescribing. According to Dr. Daniel Hayes, Senior Research Fellow at UCL, INSPYRE will set up social prescribing pathways for young people on the waiting for Children and young people’s mental health services (CAMHS). It will enable a selection of NHS mental health trusts to offer a myriad of activities ranging from dancing, surfing, roller-skating and gardening depending on local area and individual needs. A small pot of money is allocated, too, to pay for necessary expenses, like football boots or bus trips.

“Research suggests that it can improve mental health and wellbeing outcomes,” Hayes explains, “and we know that mental health difficulties are increasing in prevalence and young people from socially disadvantaged backgrounds are more likely to suffer.” It’s not a replacement for talking therapies, but something to be used in conjunction. “We want to test how social prescribing may work for this group and what benefits it has, as well as looking at how the NHS and other providers can make social prescribing work.”

However, social prescribing for mental health is contentious. In a recent article published in Nursing Times, Liam Stowell, a registered mental health nurse, says: “The current move towards social prescribing is just another plaster on the gaping wound that is the current state of children’s mental health”. Stowell argues that social prescribing “centres the difficulty within the individual rather than external, systemic factors such as poverty, education and trauma, to name a few”. In other word, if you do not feel better after engaging in the particular intervention offered, it can feel as though the fault lies with you, rather than the breakdown of society.

Stowell also points out that certain interventions might be out of reach for people, such as a young person who wants to try surfing but does not live near the sea. In addition to this, prescribing a depressed person surfing could come across as less proactive, more provocative, or worse: patronising. Professor of Philosophy Kimberley Brownlee, writing in 2018 when social prescribing began in the UK, questioned the ethics of such schemes. “One danger is that social prescriptions are dismissive and paternalistic towards people,” she wrote.

Ironically, Brownlee, in taking the principle to its conclusion, actually anticipated Alexandra Rose’s scheme: “Being given a social prescription might feel like being prescribed broccoli on the NHS,” she wrote. “It might seem to trivialise the pain of loneliness as something easily solved with some chat, the social equivalent of eating more greens.” When time with doctors is increasingly precious, a social prescription could be a bitter pill to swallow. “If a GP gives someone a social prescription,” she wrote, “he might leave her office feeling more disheartened and incompetent than when he walked in.”

Perhaps, then, schemes that bypass the GP’s office entirely are more effective, a novel approach that boosts traditional healthcare rather than replaces it. Many such projects are in the works and on the fringes; Pauling references the AT Beacon Project led by GPs and nurses, taking health services out into the community and offering check-ups in local food banks and – most creatively – a nearby barbershop.

“They’re a really innovative model taking healthcare out into the community,” he says. “It stops people waiting until something’s going really wrong and has them engaged…I think that’s exactly what social prescribing is all about. It builds resilience and enables people to take more ownership and control of their health and their wider life.” This sense of agency, of making the patient active, is the real strength of social prescribing, something that complements medicine rather than trying to wean us off it. It’s positive, too, to see social prescribing as a way of not just focusing on curing serious illness but actively preventing it in the long run.

The issue with Universal Personalised Care, though, lies within its name: can a personalised system truly become universal without losing its case-by-case basis? Or, vice-versa, can a universal system actually be personal (or, even, personable)? While social prescribing’s power lies in its localised, individualised approach, with every pilot taking a totally different approach in the way it engages the patient, GP and local authorities, it’s too difficult to evaluate how the concept works as a whole right now. As schemes homogenise and the data becomes more numerous, it’ll become clearer as to how fruitful it can be: for now, though, it’s a little like comparing apples to oranges.

Follow Kyle Macneill on Twitter. 

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