Leveraging primary care to address social determinants
Authors: Luke Allen
Journal: The Lancet Public Health (2018)

Our health systems are not fit for purpose. Although social determinants play a substantial part in health outcomes,1McGovern L Miller G Hughes-Cromwick P Health Policy Brief: the relative contribution of multiple determinants to health outcomes.https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf415185Date: Aug 21, 2014Date accessed: August 13, 2018Google Scholar countries like England allocate less than 5% of staff and health spending to public health.2NHS DigitalNHS workforce statistics January 2018.https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/nhs-workforce-statistics---january-2018Date: April 24, 2018Date accessed: September 5, 2018Google Scholar, 3Office for National StatisticsUK Health Accounts 2016.https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystemDate: April 25, 2018Date accessed: August 13, 2018Google Scholar The illness-focused biomedical model has delivered substantial gains; however, in the era of preventable chronic multimorbidity, this calculus is less convincing. Boosting public health investment is important but recalibrating primary care systems to shift emphasis from reactive management to proactive prevention could also make a huge difference. At a meeting held on July 2, 2018, in Oxford, UK, we explored barriers to and opportunities for integrating public health and primary care. Primary care professionals work in neighbourhoods and communities where social determinants manifest.4Kawachi I Berkman LF Neighbourhoods and health. Oxford University Press, New York2003Crossref Scopus (520) Google Scholar In many countries (ie, England, the Netherlands, and Belgium) they are responsible for health outcomes of listed populations, and the introduction of capitated payment incentivises keeping people well. Primary care teams have unparalleled data and good ethnographic knowledge of local disease, trends, and social drivers. Primary care professionals are well placed to support public health teams in assessing and addressing causes of disease. In England, public health teams have insufficient resources to operate at the neighbourhood level, and austerity has led to many teams prioritising high-risk programmes over population-level interventions. Although family physicians have listed populations and capitated payment schemes, activity remains focused on managing individuals in the waiting room. Primary care teams have insufficient skills, time, training, and incentives, and the wrong mindset to address social determinants. Even when staff or commissioners understand that prevention can reduce demand of health-care services, improve outcomes, and save money, financial and workforce pressures5Baird B Charles A Honeyman M Maguire D Das P Understanding pressures in general practice. King's Fund, London2016Google Scholar inhibit experimentation with new ways of working. Local health intelligence generated by public health teams is rarely used by primary care teams because of absent or inadequate handover mechanisms. Several reforms would help to integrate specialties. The most fundamental conditions for integration are aligned system-level incentives: dedicated time, money, staff, training, targets, and technical support. Placing emphasis on social determinants of health during medical school and speciality training schemes and joint continued professional development sessions for working practitioners would build relationships and imbue a shared population mindset from the outset. Specialties could be formally linked through shared budgets and responsibility for population health outcomes, as well as interoperable information systems. Like safeguarding leads, each medical practice or local network of doctors should have a named professional who is responsible for assessing local drivers of disease (by analysing practice data and gathering peer feedback) and liaising with public health colleagues to develop interventions aimed at local social determinants. This work requires commissioners to make additional resources available for primary care and to see beyond the next 3–5 years. Cities such as Ghent and Glasgow already provide multiple examples of practices hosting in-house community health workers.6Deep End GroupDeep End Report 32: 8 years of the Deep End Project.https://www.gla.ac.uk/media/media_557259_en.pdfDate: October 2017Date accessed: August 13, 2018Google Scholar The original signatories of the Alma-Ata Declaration understood that primary care is strategically positioned to assess and address local social determinants of health. 40 years later, misaligned incentives have stopped primary care from reaching its potential in England. Although reform isn't cheap or easy, leveraging primary care to address community-level primary prevention could save money, reduce demand, and improve health outcomes. Futureproofing health systems begins with reorienting primary care. For more on the PrimaPrev Network see www.primaprev.comFor the Alma-Ata Declaration see http://www.who.int/publications/almaata_declaration_en.pdf For more on the PrimaPrev Network see www.primaprev.com For the Alma-Ata Declaration see http://www.who.int/publications/almaata_declaration_en.pdf I report funding from the Global Challenges Research Fund. The NHS at 70 and Alma-Ata at 402018 welcomes two important anniversaries for health. In the UK, the National Health Service (NHS) will be 70 years old in July, and the global health community will mark the 40th anniversary of the Alma-Ata Declaration at a conference on Oct 25–26 in Almaty, Kazakhstan. Common to both anniversaries will be recognition of universal health coverage (UHC) as a goal, and the place of primary health care in achieving that goal. Full-Text PDF