Time to Look Upstream

Time to Look Upstream

Kaoru Ishikawa.

If that name doesn’t ring a bell that’s perfectly normal.

Ishikawa was a Japanese organizational theorist and inventor of the Ishikawa diagram or Fishbone diagram. It has been used worldwide as part of quality control processes to identify the possible causes of a certain effect. It can help with detecting to the root cause of why a certain event or issue arises.

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Having an engineering background myself I’ve used this type of root cause analysis tool in the past to detect the cause of software defects for example and prevent them from reoccurring. Identifying a defect might be easy, fixing it might be easy too… but making sure it doesn’t reoccur is not always that straightforward.

Root Cause Analysis of our Health Issues

Our healthcare system is especially specialized in fixing health issues. We spend most of our time and money on curation, an act which is located downstream the health continuum. We have brilliant, dedicated and passionate healthcare professionals without whom the damage of Covid would have been magnitudes larger. They’ve been on the front-lines, taking risks to save the lives of our family, neighbors and friends.

As a society we owe them and ourselves to think about how we can do things better in the future. Not only for the next pandemic but for the future of our health and care as a whole.

We need to reflect more profoundly on why health issues arise, we need to drill down to the root causes of why we get sick.

We need to make sure that all these highly motivated healthcare professionals can spend their energy on health issues that are hard to prevent.

While a root cause analysis won’t improve our healthcare system with a simple diagram, we should spend more time on reflecting and getting to the root cause of poor health. We need to look upstream to the causes of poor health and how we can prevent them.

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Social Determinants of Health

While I have no specific expertise in health policies or healthcare systems one seemly simple concept always struck me since I’ve learned about it about quite some time ago: the Social Determinants of Health.

It struck me that only 1/3rd of our health is related to our genetics and the medical care we receive.

66% of our health is influenced by other so called social determinants: our environment, our individual behavior and our social circumstances.

This means that when we would do a root cause analysis for the health issues we encounter, 2/3rd of these health issues would be due to non-medical or genetic causes. Fascinating numbers. Especially fascinating when you know that these causes are located more upstream in the healthcare continuum. They are located in spots where we spent less time and energy, or plainly said: less money as a society.

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The Social Determinants of Covid-19

Whereas the need to look more upstream was already present long before Covid-19 entered our world, Covid-19 exemplifies how the social determinants impact our health and wellbeing.

Covid-19 has further amplified already existing health inequities with more vulnerable communities being affected more heavily by the pandemic.

Social determinants such as poverty, poor housing conditions, low health literacy and social discrimination can all have a negative impact on someone’s health and contribute to the risk of being affected by Covid-19 or health issues in general.

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Addressing Health Locally

When you spend most of your money downstream (e.g. only 3% procent of the EU healthcare budget goes to prevention) it’s hard to fix issues upstream or to even incentivize people at all levels to reflect about these root causes and how to fix them.

So should we all lean back and blame policy that we don’t have the incentives to tackle our health issues in a more structural way? We could but we really shouldn’t.

We can move upstream by supporting healthcare and welfare professionals in addressing an individual’s social needs locally.

If we can increase the detection of social needs and make sure citizens with needs get the local support they need we take a big step upstream.

If at the same time policies are set out to create more favorable conditions supporting health for all people we can jointly make waves and move upstream towards more prevention.

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Social Prescribing

One way to better address health locally is through social prescribing. Social prescribing is a concept where health professionals refer patients to support in the community, in order to improve their health and wellbeing. It has gained support in the NHS and Canada and makes sure that the non-medical needs are as well detected and supported by healthcare professionals.

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In the NHS doctors refer their patients to a link worker who talks with the patient and perform a social needs assessment. Based on the social needs of the patient the link worker refers the patient to local wellbeing organizations, support organizations, community business and so on. In the UK there’s for example the concept of Arts on Prescription which implies that people, typically with mental health needs, are connected with local arts organizations to improve their wellbeing and health.

Social Prescribing in Belgium

With the support of the city of Antwerp I had the opportunity to build and launch a Social Prescribing platform named Zipster as a joint collaboration between Health Endeavour and NSX. Zipster can be used by healthcare professionals to perform a social needs screening and will, based on the detected social needs, suggest local organizations to which the patient can be referred. It facilitates the actual referral and follow-up between the healthcare and welfare professionals in a secure manner.

This year, in 2021, Zipster will be used in 15 Flemish Primary Care Areas (Eerstelijnszones) and we hope that, with the support of Zipster, the social needs of patients can be better detected and supported on a local level.

We believe that addressing the social needs of citizens is one element that can help us to look and move upstream in Belgium and beyond.

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Kaoru Ishikawa passed away in 1989 at the age of 73 due to a brain hemorrhage. While he might not have had severe social needs that impacted his health, his views on continuous improvement can inspire us all to look for the causes of health disparities and continuously improve our health(care) as part of a much larger societal system.