The Institute of Health Equity in London, led by Sir Michael Marmot, has published a major report on what the health sector can do to address health inequities and their roots in social determinants of health. Working for Health Equity: the Role of Health Professionals notes that “those in the health sector regularly bear witness to, and must deal with, the effects of the social determinants of health on people.” The report argues that there is much that health professionals and the system can do to influence social determinants and calls for action in six core areas:
- Improve workforce training and professional education so that providers can act on social determinants. They highlighted taking patient’s social as well as medical histories to be able to provide care that better responds to the full context of their lives. They also called for student placements, especially in social service settings in disadvantaged areas.
- Working with individuals and communities in different ways. They highlighted that building relationships of trust with all patients is especially important for those facing the harshest social and economic challenges. They argued that collecting better information is important at both individual and social levels: to understand how social circumstances are shaping a patient’s health situation, and to take aggregate population level data into account in service planning and commissioning. I would go further here (for my Roadmap for Delivering health equity):
- taking adverse social circumstances and living conditions into account is crucial to customizing care for disadvantaged people;
- systemic access barriers must be addressed – language through comprehensive interpretation, racism and discrimination through cultural competence and diversity programs, inadequate planning through proactive engagement with populations whose voices and interests are often excluded;
- building equity into system drivers such as quality improvement and chronic disease prevention and management;
- embedding equity deliverables into the requirements, targets, incentives, funding and accountability regimes that drive the health care system. For example a common hospital priority is to reduce the rate of avoidable admissions; the equity adaptation is to reduce the disparities in rates between poorer and richer neighbourhoods, women and men, language groups, etc.
- Building on the huge size and potential of the health care sector as major employers and purchasers of services. They emphasize that health care employers should always provide good quality work, as the nature of jobs is a key determinant of health. Similarly, purchasing power can be deployed to support employment and economic activities in organizations’ areas.
- Working in partnerships with sectors well beyond health care to address determinants and deliver integrated and coordinated services. They emphasize the potential of early child development as one key area. We have written about building equity into childhood obesity strategies and Canada’s National Collaborating Centre for Determinants of Health as published a report on ‘what works’ in inter-sectoral action.
- Health professionals can be powerful advocates. They argue that providers can use their position as experts and as trusted and respected professionals to identify and push for changes in wider policy spheres that affect health and well-being.
- Addressing systemic inequities should be built into health care organization’s priorities and plans. They particularly emphasized the need to line this goal up with the funding and other incentives that drive organisational action – for example, the shift in many jurisdictions to outcomes-based funding.
It also has an interesting collection of statements from 18 physician, midwife, nurse, psychiatrist and other professional colleges on role of that profession in tackling social determinants, actions the particular professionals can take and illustrative case studies (for example, Inclusion Healthcare is a social enterprise run by a doctor and nurse to provide services to homeless and other excluded people; a multidisciplinary health promotion program that reduced disparities in infant mortality in a deprived area; social work after hospital programs designed to reintegrate people into social networks; a mobile tuberculosis service visits people at several hundred London hostels, drug treatment programs, day centres and other locations – going to people often excluded from services, rather than expecting them to come in to the providers).