Swimming 'upstream' to tackle the social determinants of health

Quality improvement interventions typically focus on how to improve the care delivered within healthcare organisations or by health systems. Rarely do efforts venture beyond the walls of clinics and hospitals to target the social determinants of health. Berkowitz et al remind us that swimming ‘upstream’ is essential if we want to improve health outcomes for vulnerable or disadvantaged patients. How can we begin to ‘swim upstream’ in quality improvement work? First, healthcare organisations should be deliberate in efforts to uncover social factors that influence health, even when engaging in clinical microsystem improvement. Second, we should listen carefully to patients’ experiences of self-care as these experiences may provide the most natural opportunity to identify social issues that are at the root of ill health and suboptimal disease management. Third, we can identify and address unmet resource needs within the clinical setting. Screening tools like those used by Berkowitz et al offer a structured approach to detecting resource needs. Alternatively, clinicians can be coached to probe patients for contextual factors that may influence care. Berkowitz et al described a model where clinicians address the social determinants of health for individual patients encountered in their clinic. But to truly improve health equity, we need to swim even further upstream and engage in advocacy for an entire population.