I met nine-year-old Jacob in clinic with his mum. He’d presented a few times to A&E with non-specific tummy pain. The results of his investigations were normal, and it was likely that his symptoms were the result of a poor diet.
His mum asked what they should do in the future, and my response was simple: ‘Eat healthily, drink plenty of water and do lots of exercise’.
At that moment, my assessment had established that Jacob lived at home with his two older siblings and his mother, in a small two-bedroom flat.
In a busy clinic, it’s difficult to delve into further detail. But if I’d had more time, I could have asked: ‘What’s preventing Jacob from eating well and exercising?’
If I had asked, I would have found out that Jacob’s mum works fourteen hours a day split between two cleaning jobs. She’s a good cook, but doesn’t have time to buy or prepare meals. Money is a significant problem, and often the quick, affordable food that her children resort to eating has low nutritional content. Jacob likes playing outside with his friends after school, but his mum doesn’t think it’s safe, so tells him and his siblings to stay in the flat while she’s at work.
Jacob’s family’s circumstances are shaping his opportunities to eat healthier food and be more active. These social, cultural, economic, commercial and environmental factors, the social determinants of health, shape the conditions in which people are born, grow, live, work and age.
Why should the NHS address the social determinants of health?
Access to good health care is important. However, it accounts for as little as 10% of a population’s health and wellbeing. The link between social determinants and inequities in health outcomes is not new, with numerous historical references in national policy.
A rising proportion of the UK population live with long-term conditions, and the NHS spends considerable time treating people with conditions that are a consequence of social determinants. As Professor Sir Michael Marmot stated: ‘Why treat people and send them back to the conditions that made them sick?’ There is an on-going mismatch between what our patients need to invest in their health and wellbeing, and what the NHS is designed to deliver.
And despite the fact that the role of the NHS in addressing social determinants has been proposed in several national policies over the past decade (including Tackling health inequalities in 2003, and more recently, the Five Year Forward View), it can be difficult for clinicians or commissioners to know what a prevention-focused service could look like in practice. This is compounded by lack of resources, time, and knowledge of the impact of social determinants on health outcomes.
What do possible interventions look like?
There are lots of promising examples of how health services are responding to the impact of social determinants on health. This includes work that the Health Foundation is supporting through our funded programmes. These projects are varied, targeting individual health professionals as well as whole organisational systems.
At an individual level, health professionals can make a difference by simply understanding the role social determinants have on health, and being able to signpost patients for support. For example, in Greenwich, Live Well Coaches work alongside GPs to help patients address specific issues around housing, employment and finances.
Some organisations are addressing health inequalities by identifying high-risk population groups, and embedding methods to address social determinants into clinical care pathways. For example, Pathway is an integrated approach to treating a highly vulnerable group of patients: homeless people. The service uses a hospital admission as a key moment to engage patients and work with a range of staff and services to ensure they receive the medical and wider social support they need.
In another example, the Advice on Prescription Project, led by Liverpool South Clinical Commissioning Group, allows GPs to refer patients at risk of health inequalities to Citizen Advice Bureau advisors in Liverpool. Plans are also now in place to embed ‘advice on prescription’ into respiratory care pathways. Thinking about social determinants in treatment protocols is a big step in the right direction, and there’s potential for this to be applied to many other care pathways.
Thinking back to Jacob, ideally I would refer the family to a service like the one in Greenwich, offering support from a Live Well Coach.
Without such a service more widely available, it’s likely that Jacob will present again to his GP or A&E with tummy pain, only to be offered further investigations and appointments. Meanwhile, he’s already started on a trajectory leading him to childhood obesity, adult obesity and long-term health problems.
From this perspective, it is clear that health professionals and services do have a role to play in understanding the context in which people live their lives, and the wider factors that are impacting on their health.
Dr Susannah Pye is a paediatrician and Clinical Fellow at the Health Foundation, @susannah_pye