Social Determinants of A&E

foundation crack

As we enter the winter months, there has been much debate about the capacity of A&E services to respond to the demand safely and with the expected quality standard.

 I was reading through twitter news a short while ago and read an excellent blog written by @Roylilley on A&E, there followed a really thought provoking tweet exchange with @RobWebster_LCH which led me to write this blog…

 My interest comes from being a Foundation Trust Governor, a citizen living with a long term condition and having worked for over 18 years with communities around improving well-being.

To start with an analogy, when a house has a cavernous diagonal crack across its brickwork, how do we respond? We can cover up the crack, add a little filling which might work for a bit, but it doesn’t tackle the root cause so will just get worse. The best solution which might take a little longer is to look to the foundations, check for subsidence and investigate why this might have happened and resolve that problem.

Whichever way you look at it A&E problems are a symptom of a deeper complex issue in our society and our communities.

 It might be helpful to look to the well researched ‘social determinants of health’ as spelled out in the seminal Marmot Review of Health Inequalities.

Where we live, the state of our housing, our level of income, how friendly we are with our neighbours, how connected and active our community is, the level of our literacy and education, how safe we feel, our level of self-esteem and mental well-being are all important factors in our health and subsequently linked to A&E admissions. For example if loneliness is as harmful for our health as smoking 15 cigarettes a day and is scientifically proven to impact on our immune system (check the ‘Campaign to end loneliness’ research resource how does this play out for the most vulnerable older people in the winter months. And if loneliness is the root cause, what could be the resolution and whose responsibility is it?

On my street, there are many different types of households, some new young families, some students, some older people living alone who have lived in the street for most of their lives. We don’t have street parties at Jubilee and the houses are terraces with only a foot wide front gardens and no driveways but we are adjoined and can see into each others kitchens and over the back fence. There are about 100 households in total, I know about 25% well and about 50% a little.

When we first moved in, three doors up there was an older lady, living alone since her husband had died. We didn’t see much of her but had quick chats when we met. One Christmas I said to my husband shall we invite Mrs x over for lunch on Christmas Eve, we didn’t get around to it, something I will always regret. A few days after that Christmas, she died. After not seeing any movement for a couple of days, on Boxing Day her next door neighbour alerted the police and she was found unconscious, rushed to hospital and died not long after.

From then on my husband and I made a resolution to keep an eye out for our other older neighbours and I have really begun to notice the connections and social capital across our street e.g. the children all go to the same school, there are at least 5 NHS workers on our street and we have this great Bike Shop at the top which is a bit like Desmond’s Hairdressers they serve good chat and free croissants on a Saturday morning! So to give some examples of how we are helping reduce A&E admissions and inpatient bed days. The gasman who lives on our street left his wife wrapping presents to fix our boiler on a very cold, snowy Christmas Eve when I was 8 months pregnant, he also made safe the antique gas fire which an older neighbour was using as a sole source of heat. A Dad of 3 young children cleared a path along the whole street of really slippery ice. The GP across the road on more than one occasion has been our ‘out of hours’ service. We took another older neighbour who lives alone, a toothbrush and PJ’s to hospital when he got knocked over and brought him home, whilst others providing him with meals and filled his cupboards, we were his ‘care plan’. That’s just a few stories of many.

So how can we enhance this feeling of community and create more resilience, ‘the capacity of a system, enterprise or a person to maintain its core purpose and integrity in the face of dramatically changed circumstances’ (taken from amazing book @resilience)

Well, there are some excellent tried and tested ‘evidence based’ approaches, for example

Theses approaches take time, a little money, collaboration and a big change of culture!

There are some key principles involved which have to be not simply paid lip service too but taken to heart, e.g.

  • Public services and institutions must change their role from paternalistic to facilitation
  • We need to move from a one dimensional deficit model to also recognising the wealth of resource in our people, our connections and our place
  • Actions must be driven by what citizens and communities think are important not what ‘outsiders’ think should happen. This has to happen in each  community/neighbourhood.
  • Each community has to experience the process of building connections for themselves, it is this process as much as the final outcomes which creates value.
  • Community facilitators and connectors are an invaluable part of change
  • Building relationships and trust across communities is key
  • People need to feel valued, and when they do, amazing things happen.
  • Digital can enhance although not replace offline connections
  • And finally Margaret Mead puts this one better than anyone… ‘Never doubt that a small group of committed citizens can change the world, indeed it is the only thing that ever has’.

So here are some ideas which might help resolve the A&E crisis…

  1. Foundations Trusts and others could identify the geographical communities which are attending A&E the most and work with Community Organisations and fund a Community Builder in those areas to work on how the community can help itself.
  2. CCGs could look at the idea of engaging with people ‘Care Connectors’ who would be interested keeping an eye out for older or vulnerable people, bring groups/neighbours together when needed, e.g. Shopping rota’s when it is snowing and who can signpost people to services and community activities. People who could have a direct link and relationship with the Foundation Trusts.
  3. ‘We Care’ app which can be used by a street to build a contacts list of neighbours and what they offer and who to ‘look out for’ e.g. keep an eye on Eric’s curtains to make sure he is ok, or ‘I have a spade and brush and happy to clear up snow for others’.
  4. Engage people who are attending A&E the most and work with them on potential solutions. Check out Dr Hotspot for hard evidence of reduction of admissions and costs!

 And here are some existing examples..

 Living Well Champions in Sheffield

 Casserole Club

 Forever Manchester


Experience led commissioning

Connecting Communities C2

Street Associations


Jersey Post Community Service –


The answer and the responsibility for the ‘A&E’ crisis doesn’t just lie in the place where the cracks show, actually the answers are at the root foundations, in communities. It lies in connected communities where people know and care about each other and feel confident and able to ask for help and give help, sharing what they have.

Please do post any excellent examples of building connected communities and tackling the social determinants of A&E.


11 thoughts on “Social Determinants of A&E

  1. I love this and want to know more. Incidentally I worked on a social marketing project to look at behaviours of whose turning up to A&E who could have been cared for elsewhere. Happy to share. Blogged earlier in year topic
    Thank you

  2. Hi,

    A really excellent and well thought out piece – you describe the day by day activities of friends, neighbours and family in caring for vulnerable members of our community. There is however, just one problem, you fail to recognise the individuals providing this care as ‘unpaid carers’ of whom there are some 6.5m in our population. They save the NHS some £119billion a year and often go unrecognised in our community.

    For some carers their help is as you described, occasional, emergency and non threatening. For others it is 24 hours a day, 7 days a week, 365 days a year. It threatens their employment, their family life, their own health and wellbeing and causes poverty, illness, social isolation and emotional difficulties.

    Without the input and support of carers our whole health and social care system would collapse.

  3. Thanks for this. Really helpful. I’ve been putting together a bid to the Health and Social Care Volunteering Fund, with the Voluntary and Community Sector, the CCG and Public Health in West Kent. If we get it through we will fund some “community connectors” posts and 200 local volunteers, anchored in general practices in the most deprived communities (there are some in Kent, not everywhere is well off!); then helping create the kind of community capital, you mention, in the neighbourhoods around the practices. We want to try and have some clear evidence that this kind of peer support to older people is the “have to do” stuff, not just about being nice to the local voluntary sector. Would be good to keep in touch. Where are you?
    Graham Shaw

  4. Doctors badly over worked. Nurses on low pay and Health Care Assistants treated like skivvies on minimum wage.
    NHS Admins on 5 figure sums
    Politicians on private health care
    Health tourists and abusers of our system
    Criminalisation of alcohol and tobacco might be a good start with a health tax levy on our fast food outlets and pile it high sell it cheap crap sold in some of our supermarkets
    Go to some of these places & see the trollies full of crisps and fizzy drinks.
    Obesity and ill health are becoming endemic in our failing society so A & Es pick up the burden for a lot of bad stuff which is so avoidable if our Governments were smart which is a non starter with the Tories, Labour and that other party whatever they are called??

  5. We have a great innovation at Newham University Hospital (part of @nhsbartshealth). One of the diabetologists setup Skype clinics 3 years ago. Mostly aimed at non attending teenagers with diabetes to start with now much wider. Intervention reduces DNAs to zero – everyone attends their Skype appointment. Additional benefits include reduced admissions via A&E and reduced ketotic episodes. Highly values by patients, families and docs. On line diabetes community rocks in East London.

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