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A framework for NHS action on social determinants of health

4 October 2022

About 10 mins to read

Contents

  1. Introduction
  2. A framework for addressing social needs in the NHS
  3. Where next?

Key points

  • Policymakers are increasingly emphasising the NHS’s role in addressing social and economic factors that shape health, but guidance on how this should be done in practice is limited.
  • In this long read, we outline a framework to understand potential approaches for NHS organisations seeking to address social factors that shape health, focusing on the role of local and regional action. We describe four categories of potential approaches, from more narrow interventions focused on improving care for individual patients, to broader partnerships to improve health of populations.
  • The most concrete policy action to address social needs in the NHS in England is the expansion of social prescribing for individual patients. But wider interventions and partnerships to improve social conditions across communities likely offer greater potential to improve health and reduce health inequalities.
  • There is limited evidence to guide the choice of health care interventions on social factors shaping health, and there is a risk of unintended consequences, such as medicalising social issues and widening inequities. Rigorous testing and evaluation are needed to learn more about what works, for who, in what context.
  • Ultimately, social and economic conditions that shape health are influenced by policy choices beyond the NHS’s control, such as government decisions on wider social spending. Health inequalities in England are widening and the current cost of living crisis will put even more pressure on people and public services.
 

Introduction

There is growing interest in the role of health care systems in influencing the social determinants of health.1,2 Social determinants include income, employment, housing and other social factors, which interact to shape the conditions in which people live.3,4,5 These factors play a major role in shaping health and health inequalities6,7 – and are influenced by local, regional and national policies.

Health care systems can take various approaches to addressing people’s social needs.8,9,10,11,12 Social prescribing approaches, for example – where staff identify patients’ unmet social needs, such as food insecurity, and make referrals to relevant social services – have been developed in some parts of the NHS for decades.2 Yet these approaches are often weakly defined, and there is little strong evidence and no clear national framework to guide the choice of health care-based social interventions.13,14,15,16

In England, a range of national strategies encourage NHS organisations to address social and economic factors that shape health, alongside some targeted policies (Table 1). For example, GP contracts include funding for social prescribing ‘link workers’ to address social needs.17 And newly established integrated care systems (ICSs) have been given objectives to improve health and contribute to social and economic development. From 2023, ICSs are required to develop local plans for improving health and reducing inequalities.18,19 To be successful, these plans will need to consider how local agencies can improve social conditions that shape health, and the role NHS organisations are expected to play.

In this long read, we outline a framework to understand potential approaches for NHS organisations seeking to address social factors that shape health, focusing on the role of local and regional action – for instance, in the new ICSs. We review existing frameworks, examples from NHS policy and practice, and evidence on interventions often promoted in the NHS in England. We highlight gaps in knowledge that must be addressed to clarify the role of the NHS in addressing social needs, and identify policy priorities for the future.

Table 1: Key national NHS policies on addressing social needs

Policy document NHS's role in addressing social needs
NHS Five Year Forward View (2014)20 The NHS is expected to collaborate with local government and others to plan and coordinate local services. NHS organisations are also expected to develop more integrated models of health and social care in the community, which may include social prescribing and should support more personalised and coordinated care.

NHS Long Term Plan (2019)17,21

 Integrated care systems will be developed between the NHS and local government to coordinate services and improve population health. The NHS will expand social prescribing, with more than 1,000 link workers in place in primary care networks by 2020/21. The role of the NHS as an ‘anchor institution’ is also introduced.

Planning guidance for COVID-19 recovery22,23

 

 The NHS is expected to work with local communities and others to protect the most vulnerable from COVID-19, restore NHS services for people living in deprived areas, and increase access to primary care. The NHS must also accelerate the delivery of personal health budgets, social prescribing referrals and personalised care plans. Collaboration and partnership working are required, and integrated care systems are asked to develop priorities that reflect the needs of their local populations.

The Health and Care Bill (2021–22) 24,25,26

 Supporting social and economic development is one of four objectives for integrated care systems. NHS, local government and other agencies must work together to make a plan for improving health in their area – including through addressing wider determinants. NHS integrated care boards will be expected to deliver more personalised care, and invest in local community organisations and infrastructure. ‘Place-based’ partnerships will be developed as local forums for addressing wider determinants.

 

 

A framework for addressing social needs in the NHS

The idea of health care systems intervening to improve social conditions is not new. In the US, various frameworks have been developed describing potential approaches for health care systems to address social and economic factors shaping health.3,8,9,10,11,27,28,29,30,31 For example, in 2019, a National Academies of Sciences, Engineering, and Medicine (NASEM) committee developed a five-part framework outlining potential actions for US health care systems to identify and address social needs (Box 1).8Yet there is no similar framework to help understand the various approaches being tested or encouraged in the NHS in England.

The US National Academies of Sciences, Engineering, and Medicine (NASEM) identified five complementary activities that could enable the integration of social services into health care:

Awareness: identifying the social risks, such as food insecurity or housing instability, and assets of defined patients and populations.

Adjustment: focusing on adapting clinical care depending on patients’ social circumstances.

Assistance: reducing social risk by connecting patients with relevant social supports.

Alignment: identifying the existing social services and supports in the community to facilitate synergies and partnerships.

Advocacy: promoting policies to address health and social needs – for example, advocating for increased investment in social security to help protect people’s health.

We suggest that NHS approaches to addressing social needs can be divided into four main categories (Figure 1). In each area, a mix of policy and system-level changes could support NHS action, such as better data on patients’ social needs and community involvement in decision making. Evaluation is also needed to understand the potential benefits and risks of NHS action. At all levels, NHS staff and organisations can use their power and resources to advocate for wider social policy change that could improve health and reduce inequities.

Table 2: A framework for understanding NHS approaches to addressing social needs

  Individual level Population level
Within the NHS

Adapt NHS care to account for patients’ social needs

Eg use data on patients' housing conditions to inform treatment and medication decisions

Use NHS resources to improve social conditions in the community

Eg widen access to high quality employment in the NHS for more deprived groups
NHS in partnership

Connect patients with resources to address social needs

Eg link patients to food banks or advice about benefits if they are experiencing food insecurity

Align local resources to improve population health

Eg joint planning between the NHS and local partners to identify and respond to local needs
Implementation depends on a mix of system-level changes, such as data collection on social needs, community involvement, staff capacity and training
Download the framework

Adapting NHS care to account for patients’ social needs

The first set of approaches focuses on adjustments to the way care is provided to account for patients’ social needs. More vulnerable groups often face greater barriers to accessing high quality care.32 Patients’ social circumstances – like work schedules and housing conditions – may make it harder to benefit from some kinds of treatment without additional support. More systematic understanding of patients’ social context may help reduce these barriers and improve clinical decision making. For example, information about housing or food insecurity may influence decisions about a patients’ treatment and medication.10

Making these decisions depends on clinicians having access to information about patients’ social circumstances (Box 2). Data on patients’ social needs are not routinely documented in NHS settings.33 In the US, health care systems are increasingly adopting social screening tools to understand potential social risks to health and identify appropriate services.34 Emerging evidence from the US suggests that social risk assessments in clinical settings are feasible and generally acceptable to patients and clincians.34,35,36,37 Yet there are also risks, including unintentionally exacerbating inequities38 – and some studies suggest that social risk screening can contribute to fear and discomfort for patients and concerns among clinicians about identifying social issues they lack tools to address.34

Data on patients’ social risks to health may help target interventions for individual patients, identify relevant social support, and help identify priorities for broader services in the community.27 One approach is to collect data directly from patients on their social needs, but it may also be possible to integrate social information from other sources.39

In the US, patients are increasingly being asked by their health care providers to complete structured social risks assessments, typically in the form of written questionnaires.40 For example, in 2018 the Centers for Medicare and Medicaid Services developed a 10‐item screening tool covering questions on housing instability, food insecurity, transport access, utility insecurity and interpersonal violence.41 Data from these surveys could be incorporated into a patient’s treatment plan or used to make referrals to relevant services in the community.41

Shared decision making is one approach that could help elicit and incorporate appropriate data about patients’ social needs into clinical practice.1,42 Shared decision making is based on the idea that an understanding of what matters in the context of a patients’ life – along with clear information about potential harms and benefits of treatment options – is needed to make high quality decisions about health care services.43,44 There is no single approach to shared decision making and there are a range of barriers to its implementation, such as staff having appropriate skills and training (box 3).45,46 But – if designed appropriately – shared decision making may help improve care for more disadvantaged groups.47

Health care staff need the right skills and training to understand social factors shaping health and their role in tackling them.8,27,48 Yet medical training on social determinants and health inequalities is often limited.27 Evidence suggests that providing health care professionals with continuing professional development (CPD) has positive effects on their knowledge and skills, and improves care delivery.49,50 Training on wider determinants of health could be incorporated into CPD programmes, focusing on how social factors shape health, and looking at strategies in the health care system that can help reduce inequalities.51 Greater awareness may also support staff to advocate for broader policy changes that could improve social and economic conditions in their communities.51,27

Connecting patients with resources to address social needs

NHS organisations can also address social needs by connecting patients with social services and support in the community.52 This is typically referred to as social prescribing, where clinical teams identify patients’ unmet social needs and help patients access relevant services to address them – for example, by helping patients experiencing food insecurity connect with food banks or advice about benefits.

Social prescribing has been practised in some parts of the NHS for decades.2 But since 2019, national NHS policymakers have committed to expanding social prescribing across England by investing in new social prescribing ‘link workers’ in primary care.27,53,54 GPs and other health care staff can identify patients who may benefit from non-medical support and refer them to a link worker. The link worker assesses the patient’s needs, develops a plan to meet those needs, and supports the patient to access relevant social services, such as job centres or legal supports.14,55 Some social prescribing models include co-location of health and social services (Box 4). For example, in Derbyshire, Citizens Advice Bureau advisors are placed in most GP surgeries to help patients with social and financial issues.56

Despite widespread policy support, evidence on the effectiveness of social prescribing in the UK is limited.14,57 The same is true in the US, where social prescribing is also growing in popularity among policymakers – though a handful of high quality studies in US settings suggest that social prescribing can help reduce some social needs and improve self-reported health.58,59,60,61

Evidence is growing on factors shaping the implementation of social prescribing, such as trust between patients and link workers, and relationships with social service providers.62,63 But, ultimately, the impact of social prescribing is linked to the resources available in the community to address social needs. Local government funding in England has been cut significantly over the last decade, with funding falling furthest in more deprived areas.64,65,66 As a result, social prescribing may increase pressure on already overstretched community services.67 There is also a risk of exacerbating inequities, if more disadvantaged patients face greater barriers to accessing support.38,68,64

Tackling social issues – such as poor housing, food insecurity, and unemployment – may require legal help. Evidence suggests that low-income families are disproportionately exposed to hardships related to unmet legal needs.69 Inability to access and use legal services can affect people’s health and wellbeing and exacerbate health inequalities.38,69

Medical-legal partnerships (MLPs) are one approach developed in the US and other countries to help identify and address unmet legal needs within the health care system.70, 71,72 In New York, a partnership between NYC Health + Hospitals and LegalHealth accepts referrals from hospital staff as well as self-referred patients.73 The most common legal issues faced by patients were related to public benefits, housing and immigration. In most cases, people were not aware of the benefits they were entitled to.

Using NHS resources to improve social conditions in the community

A third set of approaches focuses on using NHS resources to improve social conditions in the community – not just for individual patients. The size and reach of the NHS means it has the potential to act as an ‘anchor institution’, harnessing its role as an employer, purchaser of goods and services, and a powerful political institution, to benefit local communities.74,75,76

For example, NHS organisations can widen access to high quality education and employment.77,78 Barts Health NHS Trust in east London runs a programme that supports young people to build a career in the NHS.79 It also ringfences a proportion of roles for local candidates, particularly those from disadvantaged backgrounds.75 But the quality of work matters too. Rates of in-work poverty have been increasing in recent years, and the current cost-of-living crisis is expected to push more people into poverty.80 As the largest employer in the UK, the NHS has an important role in supporting existing staff by adopting policies that promote health and wellbeing and support people with the rising cost of living.81 This includes, for example, providing job security and opportunities for progression, paying fair wages, and offering fair and flexible working conditions.82,83 Other anchor approaches include procuring more services from local organisations and using NHS estates to benefit local communities. Despite growing policy attention, there is limited evidence on the impact of anchor strategies and little guidance on where NHS agencies should focus their attention to have the greatest impact.75 A UK-wide learning network has been established to share experiences and approaches between organisations developing ‘anchor’ approaches.84

NHS organisations can also actively consider social and economic drivers of health when commissioning services. Under the latest NHS reforms, integrated care systems are now responsible for planning and purchasing services to improve population health. Doing this effectively depends on having a systematic understanding of local health needs and their distribution – including data on social and economic factors shaping health and the perspectives of local communities (Box 5). For example, some NHS trusts are considering social and economic as well as medical needs in planning how to reduce waiting lists for elective care and target proactive support.85,86 Health care initiatives to develop more integrated services often focus on complex patients or those at high risk of hospital admission. But these approaches risk missing the underlying causes of ill health across the population – and could mean wider opportunities to improve health being missed.87

NHS organisations can benefit from community knowledge of local health needs and priorities by engaging them in planning and decision making.88 One approach is participatory budgeting, where residents are involved in deciding how and where funds are spent to help shape local services and their delivery.89 For example, North Tyneside CCG used this approach in 2015 to engage the local community in decisions about £5m of the CCG’s urgent care budget.90 Evidence suggests engaging local communities can increase confidence, empowerment and self-esteem of those involved, but can also lead to stress and exhaustion.91,92,93 Engagement also requires time and careful planning – and some people may be reluctant to share their views with public sector agencies.94,95

Aligning local resources to improve population health

A final set of approaches focuses on collaboration between the NHS, local government, and other sectors to improve social conditions for the local population. Resources for improving population health are spread widely across organisations and society – in local governments, social services agencies, schools, employers, health care systems, and beyond. Cross-sector partnerships have been developed as a way to coordinate resources and capabilities for improving health and reducing inequalities.

Partnerships to improve health are nothing new. In England, there is a long history of policies encouraging local collaboration to influence social factors that shape health, such as health action zones in the 2000s.96 Common approaches include joint planning, budget pooling and redesigning services. Pooled budgets are often used to support integration of health and social care services, but can also support broader interventions. For example, many areas report using budgets pooled via the Better Care Fund to support social prescribing.97,98 In Greater Manchester, public sector agencies have pooled spending and decision making to improve health and reduce inequalities in the region, including by prioritising interventions related to employment, school readiness and housing.99

New integrated care systems in England have been given broad aims to support local social and economic development.100 Yet mandatory partnerships do not necessarily lead to a greater focus on social interventions. Previous versions of integrated care systems were often dominated by NHS organisations and limited in their approaches to reducing health inequalities – with most local strategies adopting a narrow focus on individual-level approaches and few describing interventions on social and economic determinants of health.101,102,103 The governance and design of new integrated care systems risks local government and other non-medical services being sidelined by more powerful NHS bodies.104

There is limited evidence on the impact of local health partnerships on health and inequalities. A recent systematic review found little convincing evidence to suggest that collaboration between local health care and non-health care agencies improves health outcomes.96 Evidence of impact on health services and costs is also mixed. Despite this, various studies report on factors that could help or hinder collaboration efforts – such as the importance of trust, shared objectives and sufficient resources for local initiatives.

 

Where next?

Life expectancy in England is stalling and gaps in health between the richest and poorest are widening.105,106,107 The NHS can play an important role in reducing inequalities by providing equitable access to health care services.108,109,110 But policymakers are increasingly emphasising the NHS’s role in going beyond health care to address social and economic factors that shape health.24,26 The NHS lacks a clear conceptual framework for doing this. We have outlined four potential strategies – from more narrow interventions focused on improving care for individual patients to broader partnerships to improve health of populations. This framework can be used to help understand NHS interventions.

Currently, the most concrete policy action to address social needs in the NHS in England is the expansion of social prescribing at an individual level. But wider interventions to improve social and economic conditions across communities are likely to offer greater potential to improve health. There is strong support within the NHS to make progress in supporting broader social and economic development, but national guidance on how to do this is lacking.111 Policymakers will need to develop a clear framework setting out priorities, potential approaches and expectations to guide NHS organisations.

Overall, existing evidence to inform health care-led intervention is limited. NHS organisations are being encouraged to develop their own approaches, but experimentation is not risk-free. Interventions may unintentionally widen health inequities – for example, if they are not targeting patients or population groups facing the harshest social conditions.102 And there is a risk of social issues becoming defined and treated as medical problems, which may alienate community-based services that the NHS relies on to deliver social interventions. There is also a broader question about the most effective use of resources. Could NHS funding to hire link workers and develop social prescribing schemes deliver greater health impacts if invested directly in strengthening social supports outside the NHS? Rigorous testing and evaluation are needed to learn more about what works, for who, in what context.112,113

Ultimately, the structural, social and economic conditions that shape health and inequities are influenced by policy choices beyond the NHS’s control – such as government decisions on the level and distribution of spending on education, housing, public health, social security and other social services.1,114,115 Public health funding has been cut by 24% in real terms since 2015, and local government spending is on track to be smaller in 2024/25 than it was in 2010.116,117 The growing cost-of-living crisis is likely to increase pressure on low income families and public services that they rely on, and arrives on the back of a decade of low growth in household incomes and deepening poverty in the UK.118,119,120 Against this tide, the NHS is heading upstream with a small paddle.

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