Excerpts from a piece from the Nuffield Trust:
As our understanding of the effects of social circumstances on people’s health care needs increases, Nigel Edwards asks how the system should respond, drawing on findings from a Nuffield Trust seminar.
Our shared understanding of how health care should be delivered, both in the NHS and elsewhere, has traditionally been shaped by some underlying assumptions:
- that most health care is solely evidence based
- that it is delivered by those who understand medical science and technology to those who do not
- that health care is the principal contributor to the health and wellbeing of people and populations.
More recently, though, these assumptions have been challenged. A significant body of research tells us that patients’ preferences and levels of engagement can fundamentally change the way knowledge is applied and can influence the approaches that are used to prevent and co-manage illness. Furthermore, the circumstances in which people are ‘born, grow, live, work and age’ – and the effects of those circumstances on people’s behaviour – contribute far more to health and wellbeing across the life course than health care itself.
Significant research attention is now being devoted to these ‘social determinants’ of health: to adverse childhood experiences and the links between deprivation, austerity and mortality. This work tends to focus on the importance of life circumstances in creating good health and often concludes that health care makes a relatively modest contribution.
But these social determinants also have a significant impact on demand for health care. For example, socially deprived areas tend to have higher levels of multimorbidity, higher numbers and rates of admissions to hospital and extended stays once people are admitted. They also increase the level and complexity of the demand placed on primary care.
Social isolation is increasingly understood to be a major factor in determining demand for care, especially for the elderly. In a recent seminar convened by the Nuffield Trust on the social determinants of demand for health, a representative from one general practice reported that nearly half of all frequent users of that practice lived alone – compared to less than a quarter of the remainder of the practice population.
So if the determinants of health care demand are more complex than we have traditionally anticipated, are we responding in the right way? Is there a risk that our health systems are geared towards offering medical solutions that may not accurately reflect what is needed or what people want? Are there cases where needs can be met in less resource-intensive ways?
The time and skills that professionals have available for engaging patients in goal-setting, shared decision making and motivational interviewing are limited. The resulting failure rates, especially in supporting behaviour change, are often demoralisingly high. Opening up conversations about these issues could mean that a 10-minute consultation turns into half an hour, and a relatively straightforward transaction can become a challenging act of emotional labour.
For commissioners or integrated care organisations, the need to develop much richer linked data that can identify hot spots where loneliness, joblessness and other sources of deprivation are driving demand for health and other services is very important. For primary care and general practice, there is a need to build better responses to these social determinants of demand. Doing this could potentially take a lot of pressure off general practice. The growth of social prescribing, asset-based community development, more multidisciplinary models of general practice and, crucially, the inclusion of mental health in front-line primary care are all supported by a growing body of experience and research. In appropriate settings the inclusion of welfare, housing and other advice and support also makes a difference.
Many of the social causes of demand for health care are difficult to influence. But ensuring that there is a suitable response and that communities, patients and professionals have access to the service they need – rather than the one that is available – is a good first step.
Read the full article here: https://www.nuffieldtrust.org.uk/news-item/demanding-better-the-social-determinants-of-demand-for-health-care