The social determinants of health
Expanding the health ecosystem to encompass where people live, work and play
Whether you are a payor, provider or government entity, social determinants have become a more critical component of the health ecosystem in the twenty-first century. In the Dutch health ecosystem we also acknowledge the rising importance of social determinants in increasing as well as ensuring quality of life and affordability of care.
PwC lays out five steps for bold action that organisations in the health ecosystem can take to lead in a world in which social determinants assume a more prominent role. These five steps are based on the results from a global survey conducted by PwC’s Health Research Institute, along with expert opinions of healthcare leaders. On this page we explain these five steps in more detail by taking a look at different (cross-domain) initiatives with a focus on the social determinants of health by illustrating the impact of four Dutch showcases (in the social domain) in order to inspire all players in the health ecosystem.
The importance of social determinants
Countries have been spending more on healthcare every year — 8.4tn US dollar across the globe in 2019. Yet after decades of increasing life expectancy and improving health outcomes, a health crisis is escalating. For all the investments being made in healthcare, countries have not been able to affect the social determinants that also significantly influence someone’s health status. At this rate, the increase in illnesses caused, at least in part, by people’s behaviours and other social determinants of health could suffocate public and private budgets in both wealthy and poor countries. In the Netherlands, the expenditure on total health, social care and welfare increased from 92bn euro to over 106.2bn euro between 2014 and 20191, growing at over two per cent every year. Despite the rise in expenditure, there has been no decrease in the number of people with one or more chronic conditions. In fact, the percentage of people with more than one chronic condition in the Netherlands is expected to increase from circa fifty per cent (8,5 mn) in 2015 to circa 54 per cent (9,8 mn) in 20402.
1CBS Statline
2RIVM, 2018
Therefore, social determinants have become increasingly important for the Dutch health ecosystem. Factors such as employment status, someone’s social network and educational attainment have a stronger impact on the health of the population, than some traditional healthcare metrics. Curing diseases may seem more within reach than curing these underlying societal challenges but the increase in illnesses caused by people’s behaviours and the way people are not always able to cope with their diseases put our healthcare system under further pressure. In fact, research suggests that clinical care, while vital, is responsible for only twenty per cent of a person’s health. The other eighty per cent is attributable to behaviour i.e. the way people cope with their decreasing health status, the physical environment and socioeconomic conditions. As governments, payors and communities are looking in to ways to guarantee the quality, accessibility and affordability of the Dutch healthcare system in a sustainable way, social determinants of health will take centre stage in developing successful healthcare approaches with better outcomes for all.
The urgency of addressing social determinants of health
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Generating meaningful impact with social approaches
Five steps can help health systems finally deliver a meaningful impact on the social determinants of health. Since traditionally our health systems have not been created with a focus on these social determinants of health, many organisations lack the partnerships, experience and/or infrastructure needed to make social approaches to health a success.
Build collective will
This necessitates going back to the basics – start with building the collective will. This is crucial, since ownership and responsibility will only be clear when true costs of care are understood. It will take a coalition of partners who may need to stretch their roles, but leaders must find ways to show prospective partners how their goals meaningfully align.
Develop standard but adaptable frameworks
Despite building strong coalitions, the merging of disparate workplaces with different missions, incentives and perspectives will be inherently challenging. Even if all the partners come from one sector, such as the healthcare sector, they may still follow different protocols and procedures that could inhibit efforts to work together. Coalition leaders must be sure all partners are invested in, and agree on, the common purpose. They should set clear expectations and establish a common language, standards and adaptable frameworks, because the terminology used for social determinants of health intervention measurements can differ within and outside an organisation.
Generate data insights to inform decision making
When it comes to execution, generating data insights to inform decision making can guide the path for organisations taking this approach for the first time. If coalitions do not have the data needed for such analysis, they can fill in gaps with non-traditional sources, such as consumer marketing data, data from wearable monitors, social interaction websites and survey data that entail the needed data. Partners will need to integrate platforms to make the information available and usable to all partners.
Engage and reflect the community
Building the collective will, designing an effective framework and deploying data are all necessary steps — but they are not sufficient. The success of any social determinant of health strategy ultimately depends on the targeted community’s response. Those carrying out the intervention must have the credibility and knowledge to work in the area so they can build trust in the population.
Measure and redeploy
Only after these steps are carefully considered and followed, can the social approaches be deployed successfully. However, it does not end there. Partners must use evidence to fine-tune and grow social determinants of health efforts and to keep partners accountable. Successful social determinants of health intervention campaigns are exercises in continual improvement, in which experience, data and insights are gathered and fed back into the system.
Illustrating the social determinants approach
Over the last few years, PwC has been actively incorporating the approach based on social determinants of health in solving important problems for the Dutch healthcare sector. The following showcases demonstrate how taking an approach based on the principles of the social determinants of health, does not only improve quality of life but also generates better health outcomes and a higher return on healthcare investments in the Dutch healthcare system.
'Social Trials' for dementia care
Dementia is one of the most common causes of disability and mortality among the elderly, affecting more than 10.5 million people in Europe. The Netherlands also faces a high prevalence of dementia, at 16.8 persons per thousand. Moreover, these numbers are rising. By the year 2050, dementia prevalence in the Netherlands is expected to almost double and reach 32.8 persons per thousand. This not only implies a huge economic cost, but also leads to massive social costs. How do people with dementia stay a “part of things”? How do they and their (informal) care givers cope with the constantly changing possibilities and limitations? And what do these increasing numbers imply for our Dutch healthcare system?
'Lifestyle monitoring' for elderly care
Around 74 per cent of people with dementia live at home and receive support from an informal care provider and around thirty per cent of people with dementia live alone at home3. While this is not necessarily an issue and might actually be the preferred option for most clients with dementia, this situation becomes challenging for those clients with a more severe need for intensive care. As a consequence of the growing shortage of resident caregivers or informal care providers in the house, the deployment of more intensive care or admission to a nursing home is more likely to be addressed by this specific group of elderly. In addition, it is difficult to deliver tailored care to this group of clients at home in a timely and safe manner, because the insight into the health status of these clients and supervision of their well-being is limited.
'Disability and employment' in mental healthcare
Considering the scale of people not able to work as a consequence of psychological problems and the associated economic burdens, there is a need for better ways to integrate people into societal life. One of the primary areas to focus on is employment, since not only does having stable jobs ensure participation in society, but also helps lower the need for continuous care and ensures a better quality of life.
'Waiting times initiatives' in mental healthcare
The average waiting times for mental healthcare have been on the rise ever since in recent years. For many patient groups, the waiting times for registration can be as high as the waiting time for treatment itself, or even higher. This is particularly of concern, for those patient groups in high risk situations and whom lack the support necessary to get them urgent assistance. While this might be an issue of high demand for mental healthcare services, there are many interventions possible that can help reduce the waiting times for mental healthcare.
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