"There are days I'd love to stay in bed but I can't. I get a phonecall or a text saying where are you," Terry Wilders says happily. He doesn't mind the nagging he gets from people in the F2 Centre in Dublin's Fatima district. Those reminders to get up and at it have transformed his health in the past two years.
Wilders spent 50 years sitting behind the wheel of a truck, getting up at 4am on work mornings and spending his day driving from one end of the country to the other. When he retired he felt like he’d been “thrown on the scrapheap”.
He passed whole days just sitting on the couch, talking to no one. Two years ago his health hit rock bottom and he went to his GP, Dr Martin Rourke (known fondly by his patients as Doc Martin), in the Rialto Medical Centre. Wilders had a range of health problems. He was overweight and worried that he was slipping into something like depression.
Rourke gave him something he didn't expect to get in a doctor's office. He'd had all the usual advice about looking after himself, taking exercise, getting out of the house. This time he got a social prescription. It was this that brought him to the Family Resource Centre in Rialto's F2. Social prescribing is an idea commonly used in the UK and now being piloted in Ireland.
The F2 is a friendly well-designed glass and brick building at the centre of the regenerated Fatima district in Dublin’s inner city. The building wasn’t far from where Wilders lives, but he says he wouldn’t have walked through the door “in a million years” without the referral from his GP. “He’s a young doctor. The younger doctors have different ideas.”
At the F2 he met community development worker Adrienne Dempsey, the social prescribing person who makes the connection between what someone arriving in with a social prescription needs and what the centre has to offer.
Now Wilders is here every day. “A few days ago I got me MOT, or NCT maybe in my case,” he says cheerfully as we chat in a meeting room in the F2. He got a clean bill of health. The retired truck driver swims every morning and later in the week he’s thinking of trying his first Pilates class. He’s an enthusiastic member of the Men on the Move group which comprises about a dozen similarly aged men. The slagging is dialed up to 11, he says, but they have great fun, travelling around the city and further afield on trips, walks and outings.
Wilders has lost weight, cut down dramatically on his drinking and is enjoying this new chapter.
More than 60 people from 170 referrals still take part in programmes in the community centre
The Dublin 8 Social Prescribing Project was set up in February 2017 and is funded by the HSE Social Inclusion Unit. An average of two people a week have walked into the F2 since then with a referral from their GP. Like Terry Wilders many of them have made a habit of their visits. More than 60 people from 170 referrals still take part in programmes in the community centre.
Community development worker Róisín Ryder and her colleague Adrienne Dempsey get the prescriptions by email from GPs. Ryder believes the project gives people a sense of connection and belonging and that can be of enormous benefit to their physical health. “One of the biggest factors as you get older is social isolation,” she says. Work is finished. You might have lost a spouse and suddenly days go by without talking to anyone. That changes when someone comes in for an appointment to see what courses, groups or activities they would like to join. “If you check in here, you can’t check out,” she jokes.
The F2 and Fatima are a world away from the 14-block flat complex that was Fatima Mansions where I sat in a resident’s flat 20 years ago reporting on a community whose extraordinary resilience was under siege from open drug dealing.
After years of battling for better housing and amenities, the regeneration of Fatima Mansions was one of the first public private partnerships embarked on by Dublin City Council. Its success was partly down to timing.The new buildings were finished just as the economic crash happened and, as a result, roughly half of the apartments became social housing and the other half were sold privately, making the area a model for integrating private and social housing.
Instead of a promised lump sum, the developer gave 13 of the privately built apartments to the trust set up by Fatima Groups United. The rent from the apartments funds some of the community activity. A patchwork of funding makes up the rest with Tusla, the Child and Family Support Agency providing a large plank of support. "Fatima regeneration was the biggest health project you could ask for," Ryder says.
The area still has its problems: stress, anxiety, debt and housing problems. “There are social determinants of health,” Ryder says. To put it bleakly “more people die in this area at a younger age”. More than a third of people in Rialto live alone, compared with 23.5 per cent national average; 16.9 per cent of residents are lone parents; 23 per cent are unemployed. Nearly 17 per cent of people are over the age of 55.
It's a system where the focus is on health rather than illness
Social prescribing allows for the expertise of people about their own lives, she believes. “There has to be a conversation as opposed to a diktat,” Ryder says. People become partners in maintaining their own health and that of their community, she says. It’s a system where the focus is on health rather than illness.
The first Irish social prescribing project started in Donegal. "For the project to work, it is essential for GP practices and other health professionals to refer participants who they think would benefit," Ryder says. And she believes the practitioners who use it best are the GPs who "respect and believe in people as equal partners in their own wellbeing".
It's a system that could work brilliantly in rural Ireland as well as inner city Dublin. An All Ireland Social Prescribing Network is in its infancy. Consultant geriatrician and co-chair David Robinson met Minister of State Catherine Byrne in February to discuss the potential.
Waterford started a similar service at the beginning of last year. There are smaller projects in Castlebar, Co Mayo, Listowel in Kerry, Dún Laoghaire, and Bray, Co Wicklow.
You think Google will tell me everything, but it's not that easy to find the services
As part of her masters in occupational therapy, Trinity postgraduate student Chloe O’Hara is piloting a social prescribing project for cancer patients in co-operation with the F2.
Thirteen patients have been referred through her project. She was the co-ordinator at the start and found it “very humbling”. “Finding the services was a bit more challenging than you’d expect. You think Google will tell me everything, but it’s not that easy to find the services.” The gold standard for social prescribing is London’s Bromley-by-Bow Centre, O’Hara says.
Cancer patients who go through her project with the F2 are “people living with and beyond cancer, some are in active treatment but most are a little past treatment stage. They might have a lot of time on their hands and this helps them get back to the new normal.”
Having the familiar face of someone like Adrienne Dempsey is a big help when a patient is starting a new activity. “In the F2 they’re great with the following up. They’re just so friendly, welcoming and so inclusive,” O’Hara says.
If you're suffering with low self-esteem or motivation or at the lowest ebb in your life, how would you have the organisational skills to research the number or to turn up to a class?
It’s a scenario familiar to most GPs. A patient comes with a health problem but the GP can see if they could just walk out of the surgery into an exercise class, a social group, addiction support or housing advice, they could get so much more than they would by filling a prescription at the nearest pharmacy. “Join a gym,” the GP might say. They might even have some leaflets in the waiting room, or posters on the noticeboard.
“The thing is if you’re suffering with low self-esteem or motivation or at the lowest ebb in your life, how would you have the organisational skills to research the number or to turn up to a class? Patients find that hard,” Rialto GP Martin Rourke explains. That’s where social prescribing comes into its own and it’s coming with the promise of impressive results.
If there was a medicine that could reduce hospital and GP visits by 25 per cent and shave another 25 per cent off unplanned hospital admissions, wouldn’t we jump at it, Rourke asks. “We live in a two-tier system. As a male if you’ve got a urology problem and you’re low to medium risk, I’ll refer you to James’s.” How long will a public patient be on a waiting list, he asks. At a guess? Six months. The reality is four years, Rourke says, while the patient with private health insurance will be seen within a month. “The two-tier system is very evident here [in Rialto] . People who need the most help have least access. People get sicker waiting.”
As we chat, Rourke says he has a patient downstairs and “I’m the only person he’ll have a meaningful discussion with today”. Many patients are “lonely, sad, in need of some more social interaction”. And this is why since July 2017 Rourke has been dispensing social prescriptions to patients he thinks might benefit from them.
“If it’s gardening, walking, reading, knitting, it doesn’t matter. I think it’s just all about the social connection, the actual people bit,” Rourke says. “That’s the resource that people can tap into.”
Connecting the dots between people and their community resources
Tallaght GP Darach O'Ciardha has been working with social prescribing for two years. "We have a social care co-ordinator in the practice with us. If I see a patient and there's a clear social or non-medical issue during attendance or they're in distress, I refer that person to Brenda Nolan" She will do a "45-minute to one-hour assessment", he says. "She has a really in-depth knowledge ."
If O’Ciardha had been asked to list the social groups and services in his area, it would have been a struggle to identify more than 20 organisations. Now his practice has a database of 350 resources compiled by Nolan, connecting the dots between people and their community resources.
Like many GPs, O’Ciardha found himself feeling helpless when faced with a patient who was experiencing social problems like addiction or housing difficulty. “That concept of a social network is really important to people’s health. We use the term social capital to refer to what’s available to us in our communities. A lot of people are unaware of what’s out there or just unable to tap into that social capital. Part of the revelation for us is how much is available, that we were just not aware of it.”
It has also been a revelation to the Tallaght GP to see the benefits to his patients’ health. “We have people who just have a very narrow circle, maybe one or two family members. So there’s no variety. Something as simple as going to a knitting group twice a week opens up a whole world to them.”
O'Ciardha has seen real results. About three-quarters of the patients whom Brenda Nolan interacts with will successfully engage with a resource in the community, he says. Initial figures suggest that those patients who have success with social prescribing reduce their GP visits by 25-30 per cent.
“It’s easier to open up a conversation about what’s getting to someone if you actually have something to offer. Before this I would be stumped when people start talking about housing, unemployment or isolation. But this has a really positive effect. It’s a wraparound service.”
[ oharac3@tcd.ie ]
