Factors such as enabling health promoting behaviours and preventing social isolation are more important for the health of the elderly than just clinical care. ST PHOTO: KUA CHEE SIONG
Instead of just giving patients medical treatment, imagine being able to improve their lifestyles or address their emotional needs. It's called social prescription.
After one fall too many, the 70-year-old's hip bone, ravaged by decades of unhealthy lifestyle and poor nutrition, finally broke.
More than bones were broken. The familiar rhythms of her life were shattered as simple activities, such as getting out of bed, going to the toilet and going downstairs to her favourite coffee shop for breakfast, were now impossible without another person's help. Family members had to reorganise their lives to care for this once happy and independent person, who became demoralised, helpess and trapped within her flat.
Our healthcare system prevented an untimely death and broken bones were healed with state-of-the-art surgery, but there were so many regrets and "what-ifs" before and after the fall.
Social cost of ill health
The question that looms largest is: Could a different form of care or advice have prevented the fall altogether or at least made the 70-year-old's bones less brittle?
The answer, it so happens, is "yes" – if the elderly woman had been in touch with a doctor who did not merely prescribe medication but addressed her lifestyle and the social fabric of her life. Or if not a doctor, then some other professional. The good news is that such a system is on the cards and could make life easier for Singapore's elderly.
Every month, there are more than 40,000 admissions to Singapore's public sector acute hospitals. The proportion of patients aged 65 and older admitted to public healthcare institutions has climbed from 28.6 per cent in 2006 to 39 per cent in 2020. By 2030, the elderly group is expected to make up 58 per cent of all hospital admissions.
Older people with multiple health problems are more likely to experience disease complications and functional failure, thereby consuming more healthcare resources. This, combined with a shrinking demographic base of economically active person, is why an ageing population can place a disproportionate burden on a country.
We often measure the impact of ill health through direct healthcare costs.
In a report on the cost of healthcare for Asia-Pacific's elderly by March & McLennan Companies, the healthcare expenditure per elderly person is projected to increase 4.6 times, from US$8,200 (S$11,000) in 2015 to US$37,400 in 2030.
These numbers do not even take into account the indirect, social cost of ill health – such as the informal care by family members with potential loss of income, and the pain, suggering nd isolation on the part of the elderly.
Going beyond clinical care
Given our population trends, we need to urgently re-examine our model of care in Singapore. We can even see the direction it may take.
In his Committee of Supply speeches in 2022 and 2023, Health Minister Ong Ye Kung mentioned the term "social prescription". He highlighted that "doctors are saying social prescriptions are more important than drug prescriptions". And that there is "community support to make social prescription possible".
So what exactly is this novel approach and is it going to help us alleviate Singapore's healthcare burden over time?
A landmark study published in the American Journal of Preventive Medicine in 2016 evaluated the impact of four factors – clinical care, healthy behaviours, physical environment and socio-economic conditions – on health outcomes (length and quality of life). It found that clinical care only accounted for 20 per cent of health outcomes. Social determinants of health accounted for the remaining 80 per cent.
This means that, in developed countries such as Singapore, factors such as enabling health-promoting behaviours and preventing social isolation are more important for the health of the elderly than just clinical care.
This is what "social prescription" is about.
A new health equation
In the 1980s, the local community in Tower Hamlets in north-east London set up a community services facility known as the Bromley by Bow Centre. This was to address the health inequality and socio-economic challenges faced by the people living in one of the most deprived areas in England.
Bromley by Bow Centre brought together general practice with community services in childcare, adult learning and social enterprise, among others.
This concept is premised upon the observation that many people often visit their doctor for social issues as they do not know where and how to access such support. Now a globally renowned centre, it has seamlessly connected people to non-medical resources and improved their well-being while reducing the burden on healthcare resources.
This approach is also catching on form the United States and Europe, to the Asia-Pacific.
The World Health Organisation defines social prescribing as a means of connecting patients to a range of non-clinical services in the community to improve their health and well-being.
In this paradigm, doctors do not just order tests, dispense pills or perform surgery, but also look at the social factors affecting a patient's well-being.
For example, in the case of an elderly person who suffers from frailty and recurrent falls, social risk factors such as loneliness and difficulty accessing transportation options may be uncovered during the medical consultation.
This will prompt the doctor to refer the patient to a community link worker, who can connect the patient to community support agencies such as a befriending service. Apart from reducing the elderly person's loneliness, befrienders will also be able to facilitate and accompany the patient for medical appointments.
Social prescription may also include linking the patient to financial assistance or to specific programmes such as art therapy.
What's more, the concept seems to work. In one study in Britain, an investment of £1 (S$1.70) in social prescription yielded a return of £3.42. Another study showed that healthcare cost was 27 per cent lower in patients who received social prescription. Such patients also had better mental health.
Singapore's game changer
This approach has been gaining traction in Singapore since just before the turn of the decade. With the pivot to empower Singaporeans to take proactive steps to manage their health (Healthier SG), social prescription may well prove to be the game changer.
The question is: Who will helm this system in Singapore?
It may not be ideal to assign healthcare professionals as community link workers, given the shortage of healthcare workers we face and the workload they are already bearing.
We have to look at other options. For example, in SingHealth Community Hospitals, non-clinical staff known as well-being coordinators are trained to administer social prescriptions for patients, connecting them to a range of resources in the community based on personalised needs to support health living, better social connections and active ageing. These may seem to be small, non-medical interventions, but they may well hold the power to rewrite the narrative of illness.
Plans are under way to support general practitioners (GPs) with social prescriptions, which can be included in the health plans for patients under Healthier SG. These can be shared with well-being coordinators, who will administer them.
From healthcare to health
Social prescription fits well with the Healthier SG initiative, which recognises that preventive care and community engagement enable good health.
Returning to the case of our 70-year-old patient who broke her hip bone, early enrolment in Healthier SG would have enabled her to receive regular health checks and subsidised screening tests. An early diagnosis of osteoporosis (low bone mineral density) and high fall risk would prompt the GP to prescribe both medical and social interventions, potentially preventing serious medical events such as fractures.
From the health system perspective, social prescription can help bend the cost curve in the medium to long term. It also empowers the individual to take action and achieve better outcomes in health and well-being.
In this changing paradigm, health interventions are no longer restricted to medical prescriptions and surgery.
A big component will be the ability to identify frail and lonely seniors and connect them to a community activated to support them; or to help a struggling family access resources that can tide them over their difficulties and enable them to bounce back.
Social prescription has the power to prevent illness before it takes root, and to make our healthcare system sustainable. It is not a fad, but the missing piece of the puzzle that will transform our healthcare landscape. It is an investment in our collective well-being.
