Enabling health systems to take action to address local Social Determinants of Health – lessons from US health systems

Written By HALN

Guest long read

Authors:

  • Emily Hough, BSc (Hons): Senior Fellow, Brown University  

  • Matilda Allen, MSc: Public Health Specialty Registrar at Royal Free London NHS Foundation Trust; Honorary Research Fellow at the London School of Hygiene and Tropical Medicine 

  • Arielle Cohen Tanugi-Carresse MSc: Research Assistant, Brown University  

The NHS Anchors programme was inspired by the anchor movement that has been growing in the United States (U.S.) since the 2000s.

This paper sets out some of the lessons from over 50 interviews with US health systems leaders working to improve the health of their community using anchor principles.

It recognizes the importance of leadership, shared language, strong and active community partnerships and flexibility in using available resources to drive action that will benefit the community. Whilst there are clear differences between the NHS and the US healthcare systems, these enablers are equally as applicable for those in the UK that are working to improve health and tackle inequities.   

Background

Healthcare services are expected to improve health. However, clinical care is not the primary driver of overall health outcomes, contributing as little as 20 percent to individual health outcomes; social and economic factors and physical environments play a much larger role. Unequal exposure to these factors, also known as social determinants of health (SDOH), drives inequity in health outcomes within and between communities.

In recent years there has been an increased focus on addressing inequities (including work on racial equity) in all sectors. However, addressing these issues is complex, there is no silver bullet.  Improving health and reducing health inequities requires a coordinated effort across multiple sectors, and healthcare has an important role to play in that. The NHS Long Term Plan recognized that the NHS can address SDOH as a partner with others in a community, but also as an ‘anchor institution’ that is often the largest employer and public sector spender in a local community.

The concept of healthcare organisations as anchors in their communities was established in the US back in the 2000.  Over 70 US health systems have committed to being anchor institutions, participating in the Healthcare Anchor Network.  These institutions are working to build more inclusive and sustainable local economies, taking action to have greater impact in their employment, purchasing and investments, address racism in their communities and working to address social determinants of health including access to food, healthy and affordable housing and employment.

We used our time as Harkness Fellows in Health Care Policy and Practice to learn from some of the US health systems that have committed to being anchor institutions, or share similar goals.  Using insights gained from over 50 interviews with US experts and health system leaders, this article proposes a set of enablers that can help the NHS establish their role as an effective partner in addressing SDOH, with a focus on how they use their existing resources to improve community health as an anchor institution.

Five enablers for healthcare systems looking to addressing SDOH

Here we outline five enablers for those looking to successfully establish and deliver work on the SDOH, thereby ensuring health systems provide a greater contribution to health and equity in local communities.

1. Leadership support  

Executive or Board Level leadership support – at the system and hospital level – is critical to translate a mission to serve and improve the health of the local community into action.  Executive leadership can maintain focus on the agenda, secure funding and commit resource to enable delivery.  Some leaders interviewed were driven by the – often faith-based – mission of their organisation, while others told us that work to address SDOH was simply ‘the right thing to do’. However, most had multiple motivations, including business or financial reasons – many mentioned that this work will become more important as hospitals are increasingly held accountable for improving broader health outcomes.

In addition, having support at all organisational levels is key, including those working in the ‘middle’, who have the power to drive action and partner with internal and external stakeholders to identify and act on local community needs. As one interviewee described, you need a leader to decide the hospital will do this work; then you need someone to actually do it.

2. Shared language and definitions

The language we use matters. If definitions are not clear, assumptions can arise, and a lack of shared understanding can cause confusion. 

One example from our interviews was a confusion between ‘population health’ (generally used in the US to describe the healthcare outcomes of a specific group of people or patients, often with a shared condition or insurance health plan) and ‘community health’ (a broader term that refers to the health outcomes of all the people living in a geographical area or ‘place’).

Population health programs tend to focus on clinical services, healthcare activities or individual patient behaviours, while community health programs usually look beyond healthcare to SDOH. However, in some cases, hospitals are using population and community health interchangeably, or the understanding varies between teams or individuals.

Having a shared understanding of definitions and aims makes it easier to get buy-in and support for work.  In recognition of this, organisations in both the US and the UK are working to create clear definitions in this space, which could help hospitals as they develop and deliver projects.

3. Strong and active community partnerships 

Interviewees consistently reflected that partnerships are essential for work on SDOH, recognizing that hospitals are unlikely to be the expert on non-clinical issues.  Partnerships vary in membership, purpose and length, and there is no ‘one size fits all’ model.

One of the most critical partners is the community itself.  Not-for-profit hospitals in the US are required to develop a Community Health Needs Assessment (CHNA) every three years, as part of their tax-exempt status.

Many hospitals are partnering with community-based organisations to ensure their CHNA reflects community priorities. In developing such local partnerships, it is critical that partners are representative of local diversity, and historically excluded or marginalised groups are involved in all forms of work to address local SDOH.     

Interviewees described how their partnerships bring different skills and experience together to help find creative, flexible solutions that suit the community – which healthcare alone can find challenging – and felt that community involvement increased the impact of interventions and helped to avoid unintended negative consequences. 

4. Addressing SDOH as part of core business

Some interviewees reflected that community health programs had historically been seen as ‘charity’ work or a PR activity. For many the focus of this work is starting to shift from a ‘nice to have’ to ‘core business’. 

As well as exposing and increasing health inequities, COVID-19 also demonstrated the importance of community partnerships, and hospitals increasingly worked with community based organisations to reach and engage community members in health and healthcare services.  This evolution strengthens the view that improving community health is an essential component of a health system’s mission to improve health and reduce health inequity and help the NHS support broader social and economic development, one of the core requirements of Integrated Care Systems (ICSs).

5. Flexible use of available resources

Funding work to address local SDOH remains a challenge.  This is a particular challenge for US hospitals that are income driven and do not get specific income from community health work. However, the NHS can face similar challenges in how it uses available funding sources to improve community health, including funding staff to lead on anchor and SDOH work.

Many hospitals in both the UK and the US have a range of non-financial assets which those working to tackle local SDOH can use creatively. Capacity and expertise from hospital staff can be used to provide project management support, offer pro-bono technical support and training or build capability within community partners. In the US, land and buildings can be sold to community partners at a lower price, loaned or shared through mechanisms such as community land trusts, or simply made available for community partners to use (see recent guidance from NHS England on how to use NHS estates to reduce health inequalities and Building Health: How the NHS can use estates to combat inequality). Community level data can be shared at an aggregate level with community partners to inform their service provision, and hospital research and data capacity can support community SDOH projects. Finally, we heard how hospitals are using their social and political capital for policy advocacy – locally and through membership of national networks such as the Healthcare Anchor Network.

Discussion

The enablers described here are intended to help health systems as they take on new roles tackling SDOH in their local communities. Whether a system has a well-established program of work, or a single champion working to drive change for the local community, reflecting and acting on these enablers can help ensure the work succeeds. 

The NHS in England benefits from having a national health system which has a clear commitment to anchor principles, and support is available for hospitals seeking to enhance anchor work (for example, through the Health Anchors Learning Network).  The role of the NHS in supporting broader social and economic development, particularly through how it spends its money and hires its staff as an anchor, has been further reinforced by ICS partnership role.   

ICSs are required to report oversight metrics that include indicators relevant to anchor activity (for example, the proportion of staff in senior leadership roles who are from a BME background or are women); and are currently developing plans that set out how they will meet their four fundamental purposes, one of which is to support broader social and economic development. NHS Trusts are required to assign, at minimum, a 10% weighting to social value and Net Zero carbon targets when procuring goods and services.  

 The enablers listed here are based on research undertaken in the US, but we believe they are relevant to those working to increase the role of the NHS as an effective partner in addressing SDOH.  This needs to be supported by understanding the needs in the local community, local approaches to population health management and engagement in any local Joint Strategic Needs Assessment and integrated care strategy.

It is clear there is much health anchors can do, and are currently doing, to go beyond delivery of core healthcare services and consider how they can positively impact on community health, reduce health inequities and act as an anchor in their local community.   

Additional HALN Resources

HALN
Previous

Social value in Procurement: Learning from East London NHS Foundation Trust
Next

Two Years of Learning