Social Prescribing Platform – Why I'm Building an SDoH Digital Infrastructure Platform for the UK
Dr. Jack Geiger. Of all the names that came across my lexicon while studying public health as an undergraduate student - John Snow, Paul Farmer, Kate Pickett, to name a few – Dr. Jack Geiger's name stuck with me the most.
I recently Googled Dr. Geiger's name to see how the internet memorialised the late civil rights activist, who passed in 2020 at age 94. Wikipedia describes him as "a leader in the field of social medicine, the philosophy that doctors had a responsibility to treat the social as well as medical conditions that adversely affected patients' health." As public health professionals, researchers, and academics, we're taught not to cite Wikipedia in our work. Well, believe it or not, Wikipedia has exceptionally captured the exact characteristic about Dr. Geiger that ignited my passion for the Social Drivers of Health (SDoH).
The Social Drivers of Health are – unlike much in academia – precisely what they sound like. They are social systems that drive and influence population, community, and individual-level health. Where and how we live, work, and play inform the health of ourselves and our communities. SDoH can be further parsed to provide us with a more robust understanding of what it means.
In public health, we often think of health interventions like we're trying to stop a flooding river. If the river is already flooded, emergency workers go downstream to save people from drowning. Saving people, however, doesn't stop the river from flooding, so we need policymakers, researchers, and community members to ask and answer the question, "How do we stop the river from flooding in the first place?" We call these interventions upstream interventions. SDoH work in the same way:
Upstream: Structural Drivers of Health – these are the systems and policies at play that drive health and, as a result, health inequities. One example is the UK Home Office's Hostile Environment policy programme. By deliberately making settlement in the UK difficult for immigrants and refugees, individuals struggle to find adequate housing, medical and mental health care, and family support, leading to poor health.
Middle of the Stream: Social Drivers of Health - these are community-level driving factors that influence the health of people living in a community. In the hostile environment, immigrants are more likely to be subjected to inadequate housing, which is overcrowded and poorly maintained, putting them at greater risk of infectious and chronic disease.
Most Downstream: Health-Related Social Needs – these are individual-level factors which drive an individual's health. For example, a refugee might have limited access to financial benefits, keeping their capital diminished and influencing their ability to access healthy food options, thus deteriorating their health.
How does my much-abbreviated outline of the social drivers of health connect to the legacy of Dr. Geiger? During the Civil Rights era, Dr. Geiger co-created the medical arm of the civil rights movement in Mississippi, building Community Health Centres for low-income, Black communities. His first Community Health Centre was in the Delta Region, which was one of the poorest parts of America. He recognised that children in the Delta were dying of chronic diarrhoea and severe malnutrition, much like the leading causes of mortality in children in low-and middle-income settings.
As a result, Dr. Geiger took a simple yet radical approach: he prescribed healthy food, charging it to the pharmacy. He looked at his patients and recognised that access to nutritious food – in this case a health-related social need – was the remedy for illness, When the pharmacists expressed outrage at the idea, Dr. Geiger leveraged his status as a medical doctor, confidently rebutting the outrage by saying, "The last time I looked at my textbooks, the most specific therapy for malnutrition was food" (Public Health Pioneer, 2016).
Dr. Geiger pioneered integrating health-related social needs into medical practice. His career was centred around advocating for medical professionals to be socially responsible, and that legacy lives on in many ways today. Despite the convolution of the American healthcare system, specific policy levers have been pulled to formally enable SDoH to be a strong consideration in medical practice. Pulling the policy lever opens up avenues for partnerships and new market opportunities. This blog post will demonstrate how the partnership and market opportunities have been addressed in the United States, and why they need to be tackled in the United Kingdom.
Dr. Geiger's Legacy Gets an Upgrade
In the modern world of healthcare digital transformation, entrepreneurs are seeking ways to improve healthcare through the promise of unique AI tools and rapid diagnostic testing innovations. These are great, but they often aim to address purely targeted issues while the rest of the sector waits for structural actions to catalyse systems-wide change. But the integration of health and social drivers of health does not necessarily need structural action and policy strategy to catalyse systems-wide change. Look at an example in the United States.
Unite Us – an American company - is a tech platform that enables health systems, social services, non-profits, and more to digitally send and receive referrals to each other, track outcomes of referrals, and gather robust data to inform programme delivery and policy change. Nationally, they've built local networks of healthcare and community partners that can work together through a unified platform to have visibility into health-related social needs outcomes. Unite Us has stayed ahead of the policy levers that enable integration, incorporating a system that allows community partners to invoice government agencies and health systems that pay them for their health-related social needs services. It is still in early stages – and currently facing severe political setbacks – but it's undoubtedly something Dr. Geiger would be proud of.
I worked for Unite Us, building and supporting provider networks in my local community. I watched as nationally, the deployment of a digital infrastructure uniting care sectors reduced hospital wait times, cut costs, and improved population health. Many of these partnerships already existed, but they lacked a comprehensive, user-friendly way of capturing the impact of their work until they started using Unite Us.
Now, imagine you are an NHS General Practitioner. You are seeing 20 patients in three hours at your GP office, and 10 of those patients have come to you three times in the last two months, with issues that you – medically – are only able to resolve with a paracetamol recommendation or ice and compression. System overuse has led to bottlenecks in care delivery; you are losing money as a GP practice, and specialist care waitlists pile up.
What if 5/10 of those recurring patients could resolve their issues with a simple social prescription to any of the diverse voluntary sector organisations in local boroughs, and you, as a GP or social prescriber, could see whether your patient received care? What if you see that voluntary sector organisations want to help your patients, but lack the funding to do so, and you work together to lobby the government for the comprehensive funding needed using referral data?
This type of blue-sky thinking is why I'm building the Social Prescribing Platform (SPP). Inspired by the vision of the Five Giants Foundation and the work of Unite Us, I am building a platform and community of providers who want to actually integrate health with the social drivers of health, not just include it as language in regional ICB reports.
The NHS and the entire UK health and social care infrastructure need this transformation. Wait times for specialist care are the longest they've been in 15 years. Doctors feel like they are constantly treating recurring issues, not preventing them. A&E is overcrowded, often with problems that should be treated elsewhere, and could be solved with community-level interventions. The UK has a robust voluntary sector that is eager to, and often does, work well with the statutory sector through formalised partnership. Still, the connective tissue between the voluntary sector, statutory sector, and the NHS is non-existent or scarred. Grant contracts are often the only thing anchoring cross-sector collaboration. Without the digital infrastructure, individuals and communities will continue to fall through the gaps, and the NHS will continue to bear the financial and labour-related burdens.
Now is the perfect time to tackle this journey to integrate health and social drivers of health. The NHS recently released their ten-year plan, and the focus of the plan is three-pronged:
1. Transitioning healthcare delivery from hospital settings to community settings.
2. Moving all health records systems from analogue to digital
3. Refocusing care from treatment to prevention
SPP will enable all of these as a preventive tactic, a digital referral platform that captures social drivers of health data, and catalyses care from hospital to community. Time and again, this kind of platform has proven that it can accomplish what the NHS needs. In the United States, several large health systems have reported astonishing outcomes. In Virginia, a health system reported a 24.8% average decrease in A&E visits for patients engaged by Community Health Workers in the six months following a referral on Unite Us. The health system also reported $825,000 in estimated annualised cost savings per 1,000 patients, or an estimated $68.8 per patient per month savings, based on reduced A&E utilisation. (Unite Us, Ballad Health)
A recent impact evaluation found that the Family Navigation partnership between a health system in Florida and Unite Us improved access to supportive services for families in Manatee, Sarasota, and DeSoto counties by 89%, leading to significant gains in parental mental health and stress reduction. Using the Unite Us platform, the program provided an average of more than three health-related social needs referrals per patient, with 79% accepted and 63% resolved, addressing needs from mental health to family support while potentially lowering participants' medical costs. Backed by over 90 partner organisations and local philanthropic funding. (Unite Us, First 1,000 Days Study)
What makes me even more confident in SPP's potential success is the tax-funded public system that powers the NHS. Unfettered access to healthcare is the glue that holds the NHS together. It is aligned with the goal of SPP, which strives to make it easier for all communities to access good health through social services equitably. Conceptually speaking, SPP is an exceptional business for a tax-funded health system like the NHS.
Provider payment models in the UK strongly cater to the use of SPP. In the US, providers are often paid on a fee-for-service model. That means that the more services providers give to a patient, the more money they can claim from an insurance company, incentivising overprovision of services for financial gain. It also encourages misdiagnoses and poor care quality, as providers want to see complex patients repeatedly to earn more money. That is not to say all providers in the US are consciously trying to overprovide to see recurring complex patients and not heal them. But it is worth saying that they are backed by a system that incentivises them to work this way. But in the UK, general practitioners are paid through risk-adjusted capitation. That means they get paid for every new patient they see, incentivising GPs to keep patients out of their office. These are backed by regulatory measures to ensure patients are not avoiding care because they don't need it, not because the system is blocking access to it.
Incorporating a tool like SPP across a wide range of sectors will not be easy, but there is a clear framework to do it. Following in the footsteps of Unite Us and learning from their mistakes, investing resources into SPP is a necessary investment to ensure the NHS accomplishes its goals, creating a concrete mechanism for it to implement the 10-year plan.
Dr. Geiger didn’t have the technological capacity that we have today, which undoubtedly would have made his work easier. However, modern health systems in the UK should channel Dr. Geiger’s motivations, blend them with technology to make life easier, happier, and healthier for all communities. The work of the Social Prescribing Platform will continue the legacy of Dr. Geiger, updated for the modern world, and applied to a new context.