As our understanding of health has developed over the years, the importance of wider determinants of health in the community has become clear.
Person-centred care: the bigger picture
The role of the patient has changed greatly over the years. Patients were once mostly ignorant of their ailments and heavily dependent on the advice of a doctor; they were considered passive in the doctor–patient relationship and the healthcare system. Now, however, patient autonomy and the importance of the patient perspective has changed this dynamic: patients are more empowered, able to make informed decisions about their care, and can take on a more active role.
Alongside this change, our understanding of health has transformed, from aiming to balance the four humours to a realisation that there are wider determinants of health. It seems natural, therefore, that to support person-centred care we must address these wider determinants and acknowledge that healthcare does not comprise only hospitals, healthcare professionals, patients and governments. The role of communities is equally important.
The community and its role in health
The community is made up of networks that provide individuals with the social capital that is essential for health. Social capital has been defined as those resources which accrue to an individual when they are in a network of relationships based on mutual recognition and acquaintance. Such networks are depicted in the health determinants model, originally established by Dahlgren and Whitehead in 1991. The model demonstrates the layers that influence one’s health, from general socioeconomic, cultural and environmental conditions, through living/working conditions and community networks, to individual lifestyle factors and elements such as age, sex and genetic makeup. The resources that social capital produces for health include the building of resilience, improvement in mental health and wellbeing, and encouragement of health-seeking behaviours.
Engaging with the community can empower individuals to seek help and change behaviours. Ultimately, they gain more control of their own health. In a strong community, individuals can manage chronic illness more easily through the support of others. This may also encourage patients to communicate more confidently about their ailments with healthcare professionals, as they feel they have the support of the community behind them.
Improving health outcomes is, naturally, a goal of healthcare systems, which are constantly experiencing a push and pull between containing costs and improving quality of care. However, a study carried out by the Robert Wood Johnson Foundation supports the view that social determinants of health are of equal importance to clinical care. It reveals that only 20% of the factors that influence a person’s health are related to access and quality of healthcare, the other 80% being determined by socioeconomic, environmental or behavioural factors. There are many examples of this: homelessness drives up emergency-room visits, poverty is associated with an increased prevalence of asthma, and urban areas devoid of affordable fresh foods have an increased incidence of type 2 diabetes.
Adopting a community approach to healthcare will likely see a shift from traditional fee-for-service models towards pay-for-performance models, encouraging a focus on value, not volume, and on prevention, not cure. There is an economic argument, then, for keeping people healthy by addressing social determinants of health. There is also the sustainability perspective, with one study utilising cluster analysis to predict the sustainability and positive changes brought about by community health programmes after implementation. And then there are moral arguments for strengthening the social fabric of our society, reminding clinicians, patients, families and communities what we owe one another, and how we respect and take care of each other.
The challenge and the future
Community health services are widely recognised as a key component in providing patient-centred care. Organisations are willing to collaborate, and health systems are keen to engage in prevention, but they are let down by a lack of rigorous and comparable universal indicators that can be used to measure performance of such services. Datasets through which comparisons can be made only offer limited information on quality of community services and/or social strengthening.
National policy should focus on patient outcomes, a community-based approach to health, and comparable, robust metrics to evaluate performance. Collaborations between different services in the health system, community outreach projects, patient organisations and local councils will need to focus on improving social capital in a sustainable and efficient way.
To read more about this topic:
Read HPP’s 2015 report on The state of play in person-centred care.