‘How are things?’ I ask Lucas. He has a history of severe depression, also suffering from post-traumatic stress disorder following a series of adverse life events. He is still on the waiting list for psychological therapy after four months, but with regular catch-ups with the same GP and a change in medication, he had recently begun to improve.

‘Not good’. He responds. ‘I’m being evicted and there’s no other housing in the borough. I’m going to be homeless; I’m getting more anxious and I’m starting to feel like I did when things were really bad.’ My heart sinks. This is not something that I can fix with a monthly 10-minute GP appointment or a different medication.

This is not a unique or even unusual consultation. It will not be surprising to anyone working within the NHS or people who use health or social services. Healthcare providers across primary and secondary care will recognise the story and the associated sense of frustration and helplessness. General Practitioners (GPs) in particular, find themselves faced with patients’ social issues on a daily basis. One survey found that 1 in 5 primary care consultations were for problems not primarily related to health. Working in parts of the country with high levels of socioeconomic deprivation, this means struggling to provide care for patients who are living in poverty, in insecure, overcrowded or damp housing or who have low levels of health literacy. GPs pride themselves on delivering holistic and person-centred care, but there are some things that we have little influence over, and it is these things that can often be the biggest barriers to care. These are the social determinants of health.

We know that these factors such as housing, employment, education and socioeconomic status are fundamental in shaping health and are arguably more influential on health outcomes than anything we as healthcare professionals do. We know that people living in socially disadvantaged areas have significantly higher rates of disease, poorer access to both health and care services and ultimately higher morbidity and mortality. Nevertheless the gap between the health of the rich and poor has widened in recent years. The Labour party manifesto commits to halving this gap in healthy life expectancy by addressing the social determinants of health. This will require cross-departmental collaboration to focus on upstream causes of poverty and discrimination and will be influenced by policy in housing, education, immigration, employment, welfare and many more. Some question the role of healthcare when it comes to social determinants of health; that it is it ‘not our job’. While clinicians may not be able to solve the root cause of social problems, we have a role to play in identifying those in need, signposting effectively and working with social care and voluntary sector colleagues to make support accessible.

The new NHS 10-year plan, due in March 2025, represents an opportunity to work towards reducing health inequalities and to reconsider how we approach the social determinants of health in the NHS. One of the proposed changes is a move to a ‘Neighbourhood Health Service’ where the majority of care is shifted into the community with a focus on prevention. They describe plans to form Neighbourhood Health Centres by bringing together existing services such as GPs, district nurses, care workers, physiotherapists, palliative care and mental health specialists under one roof. Despite their manifesto pledge, currently absent from this list are any services that directly address social determinants of health.

There is strong evidence to support co-locating wider, non-health services, such as welfare and legal advice in primary care to provide wider social support ^{1 2}. Studies in the UK and internationally found that access to these services improved with co-location and there were measurable improvements in social determinants of health as well as improvements in mental health and wellbeing. Similarly, housing primary and secondary health care services, such as mental health, in one place can reduce waiting times for appointments, improve treatment engagement and improve outcomes^{3 4}. My patient, Lucas, struggles to travel beyond his immediate surroundings due to his mental health, is mistrustful of authorities but is in desperate need of co-ordinated health and social support. I refer him to our social prescriber but worry he will struggle to follow their signposting advice. Co-locating multi-sector services in the community can particularly benefit disadvantaged groups as they reduce barriers to access such as stigma, distance, cost and agency^{1 2}. Co-locating services also supports a more collaborative and integrated way of working, known to be important for people living with multi-morbidity and complex social circumstances⁵.

The biggest challenge to creation of Neighbourhood Health Centres is likely to be physical space. A Royal College of General Practitioners report last year found that 9 in 10 practices did not have enough consulting rooms to support their current services. Perhaps the implication of this is that in order to deliver neighbourhood health centres, new premises will be built or alternate-use buildings will be renovated. Given the potential benefits to disadvantaged communities, if funding is made available to support new development, Neighbourhood Health Centres should be preferentially built in communities where need is greatest; where health outcomes and access to care are worst.

Co-locating multi-sector services in primary care holds great potential benefits for disadvantaged populations. If the government decides to go ahead with plans to create Neighbourhood Health Centres, they must consider social determinants of health and health inequalities to maximise this. Firstly, in order to directly address the social determinants of health, wider services such as welfare and legal advice should be housed within the centres. Secondly, areas of socioeconomic disadvantage should be prioritised as locations to provide accessible support where it is most needed.

Addressing unequal social determinants of health requires much more than restructuring of healthcare delivery, but in the case of my patient a shorter waiting list for mental health support and easier access to housing advice would be a good start.

References

1. Reece S, Sheldon TA, Dickerson J, et al. A review of the effectiveness and experiences of welfare advice services co-located in health settings: A critical narrative systematic review. Social Science and Medicine 2022;296:114746. doi: https://dx.doi.org/10.1016/j.socscimed.2022.114746
2. Beardon S, Woodhead C, Cooper S, et al. International Evidence on the Impact of Health-Justice Partnerships: A Systematic Scoping Review. Public Health Reviews 2021;42 doi: 10.3389/phrs.2021.1603976
3. Platt RE, Spencer AE, Burkey MD, et al. What’s known about implementing co-located paediatric integrated care: a scoping review. International Review of Psychiatry 2018;30(6):242-71. doi: https://dx.doi.org/10.1080/09540261.2018.1563530
4. Elrashidi MY, Mohammed K, Bora PR, et al. Co-located specialty care within primary care practice settings: A systematic review and meta-analysis. Healthcare 2018;6(1):52-66. doi: https://dx.doi.org/10.1016/j.hjdsi.2017.09.001
5. Øvretveit J. Does clinical coordination improve quality and save money?: The Health Foundation, 2011.

Author

Dr Helena Painter

Helena Painter is an academic GP trainee with an interest in health inequalities. She works in a GP surgery in an urban and diverse area of East London. Her academic work is based at Queen Mary University of London and is focused on ways of delivering primary care that address health inequalities including social determinants of health.

Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.