This BMJ Leader blog series has been produced in collaboration with the Health Equity Evidence Centre (HEEC). HEEC are dedicated to generating solid and reliable evidence about what works to address health and care inequalities. By adopting innovative methodologies, they efficiently map successful strategies for reducing health and care inequalities, and subsequently empower policymakers and practitioners to make evidence-informed decisions for all.

The blog below has been written by Dr Helena Painter, clinical academic researcher at HEEC.  

Identifying unmet social needs  

As general practitioners (GPs) we spend approximately 1 in 5 appointments talking to patients about problems that are related to their life circumstances and require non-medical support, but we often feel ill-equipped or lack time to deal with them. We know that social determinants of health such as inadequate housing, low levels of education and low income lead to poor health outcomes and drive health inequalities, but navigating community and social services can be challenging for even the most knowledgeable and engaged patients and professionals. To remedy this, social prescribers are non-medical professionals embedded in GP practices who can signpost patients to a range of community services. Most commonly patients are referred to social prescribing by a clinician after discussing a social problem with them in a consultation. This approach excludes many people who would likely benefit from social prescribing as many people will not come to the GP with non-medical issues and the most marginalised groups face additional barriers to accessing healthcare. Researchers and clinicians are trying to find more effective ways to connect patients to the professionals and services they need, but in order to do this we need to know who needs help and what kind of help they need.

Innovative healthcare leaders in primary and secondary care across the country have started to ask social needs questions more routinely, but without guidance about how to do this the approach varies significantly.

What is social needs screening?

Social needs screening is a systematic, individualised and proactive way of identifying unmet social need, triggering a referral to social support. Patients are invited to answer a series of questions about needs such as housing, finances and literacy during routine or emergency healthcare visits. This is recorded in the electronic health record. If an unmet need is identified they are referred to onward support; in the UK usually via social prescribing. As well as linking individuals to appropriate services this can provide valuable information about the needs of the population that can be used to guide policy and planning.

There is great hope for the potential of social needs screening in healthcare settings, however implementing it at scale poses real challenges. There will be additional workload placed on healthcare providers and in a context of already overburdened community services, additional referrals via social needs screening might mean services are unable to offer meaningful support, making the process disappointing and even distressing for patients. While local innovation is essential in driving change and providing examples to build on, having multiple, disconnected programmes collecting different data risks duplication of work and limits the value of screening at a population level.

What can we learn from the USA?

 Recommendations for collecting social needs information in the electronic health record and a range of standardised tools have been widely used in the USA since 2014. This has led to an evidence base that broadly demonstrates the potential for social needs screening to improve the lives and health of the most disadvantaged people.

Crucially, patients are happy being asked questions about their social needs and this is effective in identifying unmet need. In the USA Social needs screening can increase referral rates to interventions or community-based services, and can result in resolution of social problems ^{2 3}. Social needs screening has been linked to improvements in health as well as social issues including child health, smoking cessation, depression, blood pressure and lipid control³. It can also improve quality of consultations as clinicians can use the social needs information to deliver more personalised care, offer longer appointment times where needed and be mindful of potential barriers to healthcare such as prescription costs⁴. There may also be benefits for the healthcare system as some studies have shown it can reduce emergency department attendance and hospital readmissions^{2 3}.

As expected, the most commonly described barrier to implementing social needs screening is time, but the burden on staff can be reduced by standardising tools and workflow, working with community health workers and using technology. Another challenge noted is the great variation in the screening tools in use and how different clinics ask patients the questions, with little consensus on what the best approach is.

Our healthcare system is vastly different to that in the USA but many of these principles can be applied to the NHS. There are teams in the UK conducting research into the best way to implement social needs screening, including work ongoing at Keele University to design and validate an evidence based social needs screening tool for a UK setting, which would be valuable in standardising data collection.

What could healthcare leaders do now?

We need more evidence to develop robust national guidance, but there are common principles that are useful for those organisations already thinking about social need screening. The Health Equity Evidence Centre has developed some recommendations to support teams in providing effective, impactful and efficient social needs screening:

• Develop a multi-disciplinary, multi-agency leadership team to guide development (e.g. social prescribers, clinicians, community organisations, patients)
• Map community resources and capacity and work within this
• Use a standardised data collection tool with local, regional or even national agreement
• Provide training to all staff involved, not just clinicians
• Share strategies, tools and learning
• Conduct and share evaluations

Conclusion:

Social needs screening in healthcare settings has the potential to significantly benefit people and communities but there are challenges and uncertainty. To have any chance of success we will need effective systems supporting implementation. This includes collaboration between healthcare and community services, realistic workflows, effective referral pathways, regional or ideally national agreement on the data collected and evaluation of programmes that have been implemented. One of the most valuable things we can do as healthcare leaders is to share strategies and learning between organisations to ensure we make the most of the opportunity social needs screening offers.

References:

1. Brcic V, Eberdt C, Kaczorowski J. Development of a tool to identify poverty in a family practice setting: a pilot study. Int J Family Med 2011;2011:812182. doi: 10.1155/2011/812182 [published Online First: 20110526]
2. Gottlieb LM, Wing H, Adler NE. A Systematic Review of Interventions on Patients’ Social and Economic Needs. Am J Prev Med 2017;53(5):719-29. doi: 10.1016/j.amepre.2017.05.011 [published Online First: 20170705]
3. Yan AF, Chen Z, Wang Y, et al. Effectiveness of Social Needs Screening and Interventions in Clinical Settings on Utilization, Cost, and Clinical Outcomes: A Systematic Review. Health Equity 2022;6(1):454-75. doi: 10.1089/heq.2022.0010 [published Online First: 20220624]
4. Tong ST, Liaw WR, Kashiri PL, et al. Clinician Experiences with Screening for Social Needs in Primary Care. J Am Board Fam Med 2018;31(3):351-63. doi: 10.3122/jabfm.2018.03.170419

Declaration of interests

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