• Quality improvement
• Healthcare quality improvement
• Patient safety

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 al1 remind us that swimming ‘upstream’ is essential if we want to improve health outcomes for vulnerable or disadvantaged patients. The authors conducted a cross-sectional study of a Health Leads intervention in two urban adult primary care practices. Social needs were identified and then addressed by advocates based in the practices. They found that 15% of patients seen had an unmet resource need, most commonly food insecurity or a health resource need such as difficulty obtaining health insurance or affording medications. Patients with unmet resource needs were less healthy, had more ‘no-show’ appointments, more emergency department visits and were less likely to meet care targets.

The association between social factors and health outcomes is well documented.2 To take just one of the chronic conditions discussed by Berkowitz et al, having or developing diabetes is more common in patients living in low income neighbourhoods.3–5 Living with a low income is a key determinant of being food insecure, a factor independently related to diabetes prevalence.6 The physical environment where one lives is strongly determined by one's income and is also associated with the occurrence of diabetes, likely through access to active transportation and healthy food sources.7 Patients with a low income are less likely to meet targets for cholesterol, blood pressure and glycaemic control8 and are more likely …