Insights December 2013

Social Determinants – We Have Work to Do

North Perth Family Health Team and Hugh MacLeod

We start our conversation on the “balcony of personal reflection” with what goes on in busy ERs across the country. Suddenly, we are greeted by the Ghost of Healthcare Consciousness:

“Change the image … Imagine a patient seeing their family physician in the primary care setting for a periodic health review. The patient’s recent lab values show an increased risk for type II diabetes. The physician recommends changes in lifestyle including healthy eating and active living. This patient might be given counsel from the physician on what this means and may even leave the office with a handful of educational materials. Unfortunately, more times than not, this patient falls off of the radar and, with time, becomes just another statistic adding to the prevalence of chronic diseases such as type II diabetes in this province. This is a current reality.

“In an ideal health world, that same patient presents under the same circumstances and is counselled on healthy lifestyle by their physician, and the discussion also focuses on current financial status to support a healthier lifestyle, and on what personal and community supports are available. Imagine a system that considers this patient’s level of education, income, family structure and social support network in formulating a plan of action jointly with the patient and the provider. Imagine that this patient is linked with the appropriate resources and providers based on this information ensuring a coordinated, comprehensive approach to healthcare services.”

Unfortunately, healthcare is often fragmented, with care provided in an uncoordinated and often overlapping approach. We are in need of a system with a dynamic wholeness, that is cohesive, flexible, interconnected, cost-effective, orderly, and that values the patient voice. Hugh asks: “How do we achieve this?”

From primary care experience, we believe the system would be better served by a triangulated mode focusing not only on the clinical outcomes of health but also social and economic determinates of health. With each healthcare encounter, we look at the patient through three lenses: patient with health issues, a member of a family and a community, and a contributing member of society. There is abundant research that demonstrates the impact of social and economic factors on the health of the population. 

But there continues to be barriers that impede embedding these into health system planning initiatives. Keith Denny’s article, “Taking the social determinants of health seriously: A health services perspective,” articulates these obstacles which include such objections as health services are not mandated nor funded for population health and the claim that the focus of our system should be on treating illness. The article further explores that “the defining goal for the health system is to improve the health of the population”. If this is in fact the true goal of the health system, transformation is needed. If there is to be a transformation of our health system to support the delivery of comprehensive care across the continuum, there needs to be a combined effort to break down the impediments and begin to engage not only with health system partners but with new partners in community support, social services, health units and health promotion agencies, who together contribute to an integrated plan for health for each individual.

Set out below is a deceptively simple picture taken in part from Public Health Agency of Canada’s Web site. For us, the picture speaks to the complex set of factors or conditions that determine the level of health of every Canadian.

“Why is Jason in the hospital?

Because Jason has a bad leg infection.

But why does he have an infection?

Because he cut his leg and it’s now infected.

But why does he have a cut on his leg?

Because Jason was playing in the industrial lot near his home.

But why was he playing in the industrial lot?

Because Jason, young and unsupervised, was influenced by the other kids.

But why is he unsupervised?

Because both his parents are busily working trying to make ends meet and can’t afford to have someone look after him.

But why are his parents struggling to make ends meet?

Because Jason’s dad was unemployed for an extended period of time and his mom had been sick.

But why is his dad unemployed?

Because Jason’s dad has very little education and in this slowed economy can’t find any work.

But why …?”

Three recommendations for your consideration:

  1. Stop advocating for and planning around a picture of sickness model.
  2. Accept that we have huge equity issues that cannot be addressed through a sickness model and that we have an imbalance – a two tier at every determinant: Income and Social Status; Social Support Networks; Education and Literacy; Employment/Working Conditions; Social Environments; Physical Environments; Personal Health Practices and Coping Skills Health; Child Development Biology and Genetic Endowment; Health Services; Gender and Culture.
  3. Ask Government ministries and departments to talk to each other, in the right language, and to create a holistic conversation on the broader determinants of health.

We close with a comment posted by Dr. Peter D. Fry on the essay, “Empathy: A Foundation for New Conversations”:

“ … we can cover the costs of a $150,000 amputation but we cannot cover the $70 it costs for a podiatrist or a $300 pair of diabetic shoes. Many of these patients are seniors with limited resources while others are unemployed with even fewer resources. Who decides the fairness of this arrangement? Are there any ethics involved with this or is it simply a reflection of bureaucracy at work? Do I have the answers? No. But just a suggestion that a non partisan medical ombudsperson in every province and territory could go a long way to affecting some responsible changes that Canadians need and deserve.”

Why are we not focused? Join next week’s conversation titled: Are We Prepared to See and Leverage the Grey Zone?


About the Author(s)

North Perth Family Health Team Members: Mary Atkinson, Executive Director; Lindsay McGee, Quality Manager; Sarah Givens, Oncology Nurse Navigator … Primary Care Providers, Nurses, Mothers, Grandparents, Patients … Advocates for Change.
Hugh MacLeod, CEO Canadian Patient Safety Institute … Patient, Father, Husband, Brother, Grandparent … Concerned Citizen.


Denny, K. "Taking social determinants of health seriously: A health services perspective." Healthcare Management Forum Vol. 25, Issue 3, Pages 142-145, Fall 2012

Fry, P. 2013. Web site posting on essay: “Empathy: A Foundation for New Conversations.” Longwoods Ghost Busting Essays 


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