Social prescribing: The next step for equitable healthcare
The data are in: people living with racism, low incomes and crowded housing are most affected by the COVID-19 pandemic. The attention it has drawn to these inequities has healthcare providers re-examining their practices with respect to virtual care, active outreach and health equity.
However, many are not sure what to do next. In addition to structural and policy changes, patients and healthcare practitioners need a straightforward, practice-based solution to help them take immediate action that can address health and social needs in real time. They need supportive structures that enable them to use both COVID-19 testing and routine healthcare visits as opportunities to collect vital sociodemographic data and to screen and refer people for access to food, housing, income supports, culturally safe supports and community connection. They need social prescribing, a way to integrate health care with community and social services to support people’s immediate social needs.
In February, the Alliance for Healthier Communities and the Association of Family Health Teams of Ontario argued that it was time for healthcare practitioners to take on social prescribing, a strengths-based referral program that empowers patients and healthcare providers to use health appointments as opportunities to connect with the community. When patients experience social isolation or other social needs, healthcare practitioners can use social prescriptions to connect them to a link worker, who then works hand in hand with patients to connect them with the appropriate supports and services.
In March, the Alliance released the early results of Ontario’s first major social prescribing intervention study that demonstrated a 49 per cent reduction in loneliness amongst participants and more than 80 per cent support amongst healthcare providers engaged in taking action on the social determinants of health. We were hopeful that the provincial government would invest in social prescribing in its March 2020 budget.
A month later, we were locked down under COVID-19. Mainstream populations encountered firsthand the health impacts of social isolation while disparities in Canada’s COVID-19 cases and the global Black Lives Matter movement made intersecting social determinants of health front-page news. More people saw that we can only protect everyone when everyone is protected: seniors in long-term care, retirement homes and at home whose health worsened under isolation; women and children at risk of gender-based violence who found themselves cut off from social supports; working people removed from meaningful, income-generating livelihoods; those already pushed to the margins and living without adequate food or safe and secure housing; Black, Indigenous and racialized people who experience discrimination in healthcare and beyond.
In Canada, governments at all levels responded to the disruptive isolation of COVID-19 lockdowns with a range of measures ranging from income supports to efforts to bridge the digital divide for students disconnected from their schools. The federal government’s allocation of $350 million for community responses to COVID-19 and similar initiatives by provincial and local governments demonstrated the recognition that it is community, as much as any infection control measure or economic support, that gets us through. At the same time, grassroots “care-mongering” and neighbourhood-level mutual aid provided heartening examples of the capacity people and communities possess to keep one another healthy and well.
But there has been something missing from the Canadian “community support” response: a direct connection to healthcare and a direct goal of improving health equity. In particular, government investments in community supports were disconnected from healthcare, with no structured way of receiving input from the primary healthcare teams that have built trusted relationships with nearly every person in the province – including those who are uninsured, those who have reasons to mistrust healthcare providers because of stigma and discrimination and those in communities underserved by acute care services. Healthcare responses focused on shoring up acute care and failed to leverage the capacity in communities to identify and deliver on local needs for COVID-19 testing and supports, even though we know that as a person’s medical and social complexity increase, so does the need for social connectedness and support.
Throughout the pandemic, many Community Health Centres (CHCs) and Family Health Teams stayed open to meet the ongoing healthcare and social needs of their communities and clients. With little additional support, they maintained the comprehensive care, rooted in relationships, that has been proven to improve the health of people and communities. They reallocated staff and volunteer resources to identify vulnerable clients and made proactive check-in calls to screen for and support health and social needs. They dropped off food, medication and even craft supplies to housebound seniors and others in need of support. They created online spaces for health promotion and social connections, from fitness, cooking and language classes to diabetes education and coffee socials.
They also tailored supports to specific communities at high risk of COVID-19 or of the side effects of lockdown. TAIBU CHC created a “TAIBU Together” helpline for Toronto’s African, Caribbean and Black communities; Humber River family health team (FHT) conducted telephone outreach to assess social determinants of health and domestic safety; NorWest CHC created emergency boxes to deliver harm reduction kits for isolated clients who use drugs; Niagara CHC’s Queer Youth Collective used Instagram to create a safe online gathering space; Central Lambton and Delhi FHTs worked directly with migrant workers to deliver trusted health and social care; Anishnawbe Health brought out a Mobile Healing RV to provide health and social support to Indigenous people experiencing homelessness in Toronto.
It is now time to scale up and measure the impacts of these diverse local interventions. We need to integrate health and social care to make this work straightforward and commonplace. We need to act on what we know: that 80 per cent to 90 per cent of our health and wellbeing is determined by factors outside the mainstream health system and that there is a role for healthcare in reorienting health services to address health equity and the social determinants of health.
Social prescribing and data alone are not substitutes for healthy public policy. But these practice changes are important steps toward addressing and tracking people’s social needs in real time. Together, they are simple, effective, plug-and-play next steps for healthcare providers ready to take action and measure those impacts on health outcomes and health systems. They provide an architecture for action and improvement that makes us all accountable for closing health equity gaps.
We need to act before the windows of opportunity and transparency offered by COVID-19 close behind us. The openness of policy makers and healthcare providers to make a change that addresses health equity and the social determinants of health, and the willingness of communities to step up to meet social needs, creates a once-in-a-lifetime opportunity to take this important step.
Kate Mulligan is the Director of Policy and Communications at the Alliance for Healthier Communities. She is also an Assistant Professor in the Dalla Lana School of Public Health at the University of Toronto and sits on the Toronto Board of Health.