Chris Easton and Nick Downham – Oct 2020 © Cressbrook Ltd 2020 – All Rights Reserved
The social determinants of health
We all know that the social determinants of health have a huge effect on health. In three studies cited by the Kings Fund the social determinants of health dwarf the healthcare determinants of health. NHS England themselves state that ‘only 20% of a persons health outcomes are attributed to the ability to access good quality healthcare’. In other words, the impact of £130 billion+ the UK spends on healthcare is dwarfed by the impact the social and environmental context has on the health of our population.
The NHS Long Term Plan and Primary Care Networks Service Specifications all point to more proactive, personalised care that moves towards population health and tackling neighbourhood inequalities. Designing services and interventions that improve the social determinants of health is now more prominent than ever.
This is healthcare 101. Clinicians know this stuff, lots of people have drawn attention to this, yet there is far less clarity about:
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- What this means for the work of general practice? In a practical sense?
- How many patients that a practice sees, that might currently be adversely influenced by social determinants? And what this means to the work of a GP?
To be clear on terminology, from this point onwards, we will refer to a person’s social determinants as their life or social context. Being under social contextual pressure, does not necessarily mean being part of the social services caseload. Those people are just the tip of the iceberg. There are all kinds of social pressure that influence health and wellbeing – way beyond that that meets the criteria of the statutory services. The work of Dahlgren and Whitehead (1993 and 2007), for the World Health Organisation Europe, illustrates the multiple influences on a person’s health. For example education, work environment, living and working conditions, unemployment, housing, social and community networks, individual lifestyle factors and general socioeconomic, cultural and environmental conditions.
Making this practical for general practice:
Our data systems predominantly capture activity history. This centres on who we did see rather than who we should have helped, and what we did do rather than what would have been most helpful. The detail collected is centred around a hugely detailed set of clinical codes that, for the vast majority, focus on documenting the bio-medical. Any detail on the context of the patient tends to be in free text. Taking an alternative view, there is plenty of information at neighbourhood level such as NS-SEC (National Statistics Socio Economic Classification) data. The gap between the two is understanding what this all means for a day in the life of a GP in a practical way that encourages decisions around changes to service model, and how we support the health and wellbeing people within our communities.
With these questions in mind, Tameside and Glossop’s Person and Community Centred Approaches team have been working with general practices to support them in understanding the practical implications of the social determinants of health to help practices consider new, person centred approaches. Part of this approach has been to create a simple three level lens through which to understand the work of general practice from a social determinants perspective. The intention of this work was to stimulate conversations around new models and bring to life what GPs have instinctively known for decades.
The table below features on of the outputs from a GP led study of over 2000 consultations (telephone and face to face). It details GP led segmentation from over ten practices, each looking at a week of consulting patterns. It details the proportion of patients likely to be under social contextual pressure.
The three context segments are:
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- Stable (default to if context not known)
- Under Pressure
- Turbulent
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This tells us that, in their GP’s view, 25% of all the patients* that attended in that week are under social contextual pressure. In other words life is not easy, at all.
In GP speak, these are ‘social stressors’. This means pressures such as caring duties, loneliness, relationships, housing, precarious employment and money. A small proportion of that 25% are turbulent in context. This means they are probably known to the statutory services and may regularly access the health, social or justice systems – the middle curve of the Dahlgren and Whitehead rainbow. It is important to say that this is not just about economic factors – you can be well off but be isolated or in a problematic relationship. It is also not just about health. You can have a significant health condition, but still be stable in your life context – clinical acuity does not always correlate directly with need.
While GPs may not have the data as above, they most certainly will have observed it in their everyday practice. But just because we know this, it does not mean we design services with this in mind. In fact, talking to GPs around the country, it seems that despite moves towards things like social prescribing, general practice often struggles to help people with needs outside bio-medical or those conditions that have a large life or lifestyle component (we call this relational work).
So what does this 25% mean for general practice services?
There are significant implications for the design of services regarding the 1 in 4 appointments that feature a patient who is under social context pressure.
It may well be that that particular appointment is not linked in anyway to context (for example a sprain or a cold), but the GPs who have undertaken this analysis state this is the exception rather than the rule. So for the majority this context means:
It is about life, not lifestyle.
As the Marmot Strategic Review of Health Inequalities report and Dahlgren and Whitehead suggest, life social context is much more than just lifestyle choices. It is about the ability to make lifestyle choices. For example, you may not be able to make better diet choices if you are under life context pressure. Diet classes may not help you are under severe life context pressure; perhaps lonely, in poor housing, a problematic relationship, precarious employment – or a mix of all of these pressures. It is much easier to make consistent better choices on things like diet if your life context is stable.
It limits the effectiveness of educational interventions
For conditions with a significant lifestyle component, such as Type 2 diabetes, GPs are often tasked with educating their patients by suggesting and guiding lifestyle changes. As above, the contextual pressure that these patients are under is likely to undermine educational advice. GPs know that patients need to be in the right ‘place’ to hear and act upon this advice. Life context makes that harder.
It puts pressure on the current model
There are two defining characteristics that make our current model of care less effective at helping people under contextual pressure. The first is that our services are hugely fragmented. Care is split into small chunks and delivered by countless professionals and services. This makes it hugely difficult to maintain a relationship with a patient (hold their context – Davis 2016) and meet the healing, caring and biographical domains of practice (Pratt 1995). The second is that the health system is predicated on a deficit model, rather than one that is asset based. In other words, as the Health Foundation states, we operate a model that concentrates on understanding what makes you ill, rather than what makes you healthy.
It is in a practice’s best interest to meet this need
Much can be debated about the definition of health and whether health services, such as a general practice should meet these, arguably social, demands. This is largely a fruitless argument because patients come anyway. Often a social need is presented as a health condition with a genuine medical presentation. General practice is also one of the last remaining places people can get help without significant barriers to entry. The second reason is that not helping with underlying contextual pressures makes health conditions worse. This is known as failure demand. People eventually present with conditions that are more complex and developed. Creating more work, not less. To illustrate this, when GPs applied the same segmentation to high attending patients within the same group of practices practice, the proportion grew to 50% of patients that were Under Pressure or Turbulent in context – as can be seen to the graphic below. It is worth noting that this group of 543 high attending patients, from 10+ practices, accounted for 12910 F2F or telephone consultations over the previous previous year.
Patients under life context pressure need a new service model:
The argument here is that the extent of social context pressure should have as much bearing on the service design as acuity or a specific health condition. It heavily shapes how we help people. Our services are predominantly designed around the bio-medical, even though at least one in four patients have broader needs that are likely to undermine health interventions.
People centred services:
This brings us to the ingredients of a new model. What might a new model for general practice look like? One that can improve health beyond the traditional bio-medical? Can general practices be the lynchpin of a place based, population health and wellbeing approach?
Careful use of social prescribing:
The introduction of social prescribing is a positive step forward, but there is more to it than just employing a social prescribing link worker (LSBU have a great report detailing the core principles of good social prescribing). It is important to ensure that social prescribing link workers don’t work in isolation from general practice, but at the same time have the flexibility to work in ways that wrap around the patient’s individual needs and circumstance.
We also need to be aware that our communities are rich with assets that can support people with their health and wellbeing – easily accessed without the need for referral to a link worker. A place based approach to health and wellbeing provides the opportunity to create a link between formal health and care services and these community assets.
Communities as assets:
Communities, rather than practices, are the only thing things that can give people the network and sense of purpose that enables them to help themselves. Practices have a place in connecting people and triggering further networks. If you look under the skin of one of the most celebrated general practice models in the UK, the Bromley By Bow Centre, it was a community centre before it became a general practice.
De-fragment services:
Multiple hand offs between services and professionals make understanding life context more difficult. Information, and trust, fall between the cracks of multiple services creating failure demand. It can become difficult for a patient to understand who holds the ring on the totality of their care. De-fragmenting (simplifying) the response to need is key. This requires much more than common integration activities of co-location, information sharing and single points of access.
Changes to the GP model:
General practice is, in many cases, one of the last remaining trusted institutions in many communities. This is a wonderful starting point for general practice to do something amazing. People come regardless of whether their need is health or social. Perhaps it should not be up to the public to try and work out if their need fits the correct box.
In some places, the changes are happening already. Changes to model such as longer and flexible appointment lengths, group based consultations, group based peer support groups, practice community champions, in house mental health provision, direct messaging, talking groups, links to schools, walking groups and lunch groups are all helping practices help their patients in different ways.
A broader challenge
This isn’t just about general practice though, and this is a challenge that often manifests in general practice but cannot be tackled by general practice alone. Person centred approaches are at their best where entire health and care systems consider these approaches a priority. This isn’t the delivery of new services within the existing system, but instead a fundamental paradigm shift that puts all the services delivered by health and care firmly in the frame of the life context of the person receiving them. We shouldn’t underestimate the scale of this challenge, but nor should we shy away from it.
As people working within health and care systems we need to become a little better at taking a walk in our patients’ shoes and seeing the services we are delivering through their context.
What does Covid 19 mean to this:
Health commentators have widely reported a large number of ‘innovations’ that have been triggered by the pandemic. Innovations such as greater use of telephone and video consultations, moves to electronic prescriptions, electronic / app based results communication and the use of pre-consultation and triage systems are all commonly mentioned.
Looking at these innovations, it is worth stepping back and considering which groups of patients this new, arguably more reactive, system benefits? How they are likely to impact upon health inequalities. Is it easier or harder to help people who are under life context pressure and if this demand is not currently presenting to general practice where has it gone? This risk of course being, as mentioned previously, that people present at a later date with a medical need which is caused or exacerbated by social context. Existing person centered services techniques will need to be rapidly re-modeled to suit distanced or virtual delivery – or risk being lost. This loss will be compounded by the likely extra demands the pandemic has created beyond those who have been directly affected by the virus. The early signs are that inequalities are likely to widen due to Covid 19, suggesting the proportion of people under life context pressure that general practices serve will increase.
What the COVID-19 pandemic has demonstrated though is the power of people and communities in driving health and wellbeing – 750,000 people have registered to volunteer through the NHS Volunteer Responder Programme and millions of people have come together within communities to help and support one another. As health and care systems we need to think about how we work with our communities to support this movement.
*Note some of the patients could be people coming in more than once in a week and show up in this analysis more than once.
Chris Easton is Head of Person and Community Centred Approaches at Tameside and Glossop Integrated Care Foundation Trust – Twitter @chris_easton1
Nick Downham is an independent improvement specialist – www.cressbrookltd.co.uk
Chris and Nick have a shared passion for designing systems that enable a wider view of health within the NHS.
Chris Easton and Nick Downham – Oct 2020 © Cressbrook Ltd 2020 – All Rights Reserved
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