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Perspective Comparative Health Systems Social determinants of health
Laura M. Gottlieb
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Both England and the United States have long recognized that social determinants of health play a major role in shaping population health and health equity.1,2 The World Health Organization (WHO) defines the social determinants of health as “the conditions in which people are born, grow, live, and age,” which are “shaped by the distribution of money, power and resources.”3 Social determinants include income, employment, education, neighborhood conditions, social and community context, and other social and economic factors.4 In fact, research suggests that social determinants and related health behaviors may have a bigger impact on health outcomes than clinical care does.5-10 This research has also contributed to new initiatives in the health care sector that involve assessing and addressing patients’ social needs, such as food insecurity, housing instability, and social isolation, alongside the delivery of medical services.11
Forms of “social prescribing” have emerged as a common strategy for weaving attention to social conditions into the delivery of health care in both England and the United States. Broadly speaking, social prescribing refers to identifying patients’ social needs and connecting patients with relevant nonmedical services to improve their health and well-being.12 In England, social prescribing is typically used to describe efforts by general practitioners (GPs) to identify and refer patients who may benefit from nonmedical supports to a social prescribing “link worker.” Link workers assess patients’ needs and develop a “social prescription” to relevant services in the community.13 Social prescriptions may include referrals to exercise programs, nature activities, employment assistance, and a range of social services (e.g., welfare support and debt advice).14 Although little robust evidence exists regarding the effectiveness of social prescribing in England,15 recent reviews describe existing gaps in knowledge and factors that may influence the implementation16 and impact of interventions.17,18
Social prescribing programs in the United States are more commonly called “social needs” or “social care” interventions. These programs usually involve a social risk assessment or screening followed by efforts to connect patients with relevant social services or other resources. These resources may be on or off site and include health care–sponsored (e.g., on-site food pantries), government-sponsored (e.g., Medicaid-covered meal delivery programs), or community-based programs (e.g., Meals on Wheels).19 The staff for these types of activities varies across settings and may include traditional health care staff (e.g., physicians, nurses, and medical assistants) or nonmedical staff (e.g., social workers, community health workers, and volunteer navigators).20 Although the majority of studies evaluating social prescribing in the United States have focused on process measures and do not include comparison groups, a handful of randomized, controlled trials and strong quasi-experimental studies suggest that some social prescribing interventions can help reduce social needs, improve some health indicators, and, in some cases, reduce hospital utilization.21-24
The available evidence shows that the scope of services offered to patients in social prescribing schemes in the two countries have some similarities but also some notable differences (Figure 1).14,25-27 Programs in the United States typically concentrate on connecting patients to resources that help meet basic material needs, such as food insecurity and housing instability.28 Services in England also help address patients’ basic social needs, as well as enabling social prescribing practitioners to refer patients to other types of services, such as arts and crafts and volunteering programs, whose purpose is to improve the patient’s overall well-being and quality of life. The processes for identifying social needs and relevant services for community linkages also vary. Whereas interventions in the United States often use social risk screening tools, in England, interventions place less emphasis on standardized screening.29,30 As more social prescribing interventions are integrated into clinical care, policymakers in England and the United States are developing and testing a mix of policies to support adoption and scaling. Both countries are exploring how policy supports should be used to maximize programs’ uptake and effectiveness, by asking about which intervention components are most likely to affect health outcomes, core training and deployment strategies for the social prescribing workforce, the appropriate use of data and technology, sustainable financing models, and more.31
In this paper, we describe how public-financing approaches have progressed in both countries to support social prescribing. We highlight three models: (1) traditional health care and social service funding, which provides limited or no dedicated financial support for social prescribing activities; (2) flexible funding models that may encourage, but rarely directly finance, social prescribing; and (3) direct financing mechanisms for social prescribing (Table 1). Understanding the evolution of these governmental approaches to financing and ongoing challenges in England and the United States may advance the adoption of social prescribing in both countries and globally.
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