Mulligan's paper makes an important and persuasive case that social prescribing should be understood as strategic infrastructure rather than as a marginal program. However, for that claim to hold in practice, the argument needs to be more clearly grounded in three operational conditions. The first one is that community action must be recognized upstream of healthcare access. Secondly, primary care must be repositioned as a local clinical infrastructure responsible for a population. Finally, the model requires an explicit territorial architecture of governance, financing and accountability.

Introduction

In her 2026 lead paper, Mulligan convincingly argues that social prescribing can help reorient health systems toward community capacity (Mulligan 2026). We agree with her that the current pressures on Canadian healthcare systems should not be understood solely as a problem of rising demand, but rather as the manifestation of a deeper structural mismatch between what the system has historically been designed to fund and what increasingly shapes needs in care settings. As others have noted, Canadian medicare remains largely organized around a relatively narrow basket of hospital and physician services (Martin et al. 2018), while many of the inequities that continue to structure morbidity and access to care are rooted upstream, in the social determinants of health.

This tension is particularly salient in the Canadian context, where many of the needs now surfacing in care settings are not reducible to biomedical issues alone, but relate to social isolation, food and housing insecurity, weak social support and other non-medical needs that shape people's health trajectories (Gautier et al. 2023). Recent municipal-level analyses in Canada further show life expectancy gaps of approximately 13–14 years across localities, with these differences strongly associated with social and educational conditions (Quick et al. 2025).

In that respect, Mulligan's intervention is an important one. Social prescribing is convincingly framed not as a peripheral add-on to clinical care, but as a possible lever for reorienting health systems toward community capacity, relational care and more upstream forms of action. Our argument is that neither fragmentation alone nor the “wrong pocket” problem fully captures the nature of the barrier at stake. What appears to be missing, more fundamentally, is a shared territorial architecture through which healthcare organizations, municipalities and community actors take ownership of the health system, for example, by assuming responsibility for a defined population, sharing relevant data and participating in decision making on a common basis. Research on integrated care and place-based governance suggests that such transformation depends not only on stronger referral pathways, but on collaborative, inter-sectoral, multi-level governance and geographically anchored forms of coordination (Doré et al. 2024; Klepac et al. 2023; Valentijn et al. 2015).

In this commentary, we argue that to realize the promise of social prescribing as envisioned by Mulligan, the model must move beyond referral logic and be grounded in three operational realities: community capacity must be recognized upstream of healthcare access, primary care must function as a territorial clinical infrastructure rather than a simple gateway and integration must rest on a shared territorial architecture of governance, financing and accountability.

1. Looking upstream – communities cannot appear only after entry into the health system

   One key issue with social prescribing as Mulligan frames it, is that if the community sector enters the picture only once a person has already reached the healthcare system, then social prescribing remains largely downstream. For instance, Mulligan argues, citing (Muhl et al. 2023), that “Social prescribing connects people with non-medical community resources to address the social determinants of health.” But in many places in Canada – and elsewhere in the world – non-medical community resources are actually much more accessible and in fact, more used by diverse population groups, than medical services (Jackson et al. 2025; Onuegbu et al. 2021; Ridde et al. 2020). In these situations, community-based actors are not peripheral to care trajectories: they are the first, most accessible, approachable and trusted point of contact. Recent work that we led with refugees and asylum seekers shows that “front-line intermediaries” from the community sector are trusted to provide holistic forms of support – psychosocial, food-related, social and administrative – well before any formal healthcare encounter takes place (Gautier et al. 2025). Likewise, Torres and colleagues' Canadian case study shows that community-based organizations can facilitate culturally responsive access not only to healthcare but also to a broader range of social services, precisely because they are embedded in people's everyday realities rather than accessed only through institutional referral (Torres et al. 2014). Other works carried out in Montreal during the pandemic also highlighted the crucial importance of place-based vaccination-outreach strategies, engaging with imams as trusted intermediates (Schinazi et al. 2022). For marginalized groups, the issue is often not that “community” is missing until the clinician activates it, but rather that formal healthcare remains less accessible, less navigable or less trusted than community-based support structures. Despite their significance being highlighted during the COVID-19 pandemic, community organizations' role in policymaking remained largely marginalized, in Canada and elsewhere (Luba et al. 2026).

   Learning from the Global South is also fundamental. In a survey conducted in two urban slums in Nigeria, scholars found that most respondents (83.7%) consulted lay network members during illness and that these networks influenced whether people turned to informal or formal healthcare (Onuegbu et al. 2023). In other words, community and social networks were not downstream complements to medical care; they were part of the pathway that preceded and shaped treatment-seeking itself.

   The community sector already exists upstream of healthcare use; it should be framed as part of the health-producing infrastructure, not merely as a destination after clinical contact. To do this, though, we must avoid conceiving communities only through identity-based categories (e.g., newcomer communities or lesbian, gay, bisexual, transgender, queer, Two-Spirit, intersex and asexual and other sexual and gender minority communities). We should also – and perhaps primarily – define them through territory and proximity. Place-based and integrated community care scholarship indeed insists that local area, proximity and embeddedness in living environments are not incidental features (Klepac et al. 2023; Thiam et al. 2021). They are what make community action capable of operating upstream on the social determinants of health. Identity-based solidarities clearly matter, but if social prescribing is to become genuinely upstream, community must be understood as part of a territorial infrastructure of everyday support. Without that shift, social prescribing risks reproducing the very institutional bias it seeks to correct.

2. Primary care should be framed not as a gateway, but as territorial clinical infrastructure

   A second implication follows from this upstream understanding of community capacity: primary care itself should not be conceptualized primarily as a gateway into the health system. The gateway metaphor has been central to many health policy discussions because it appears to offer a simple solution to fragmentation: patients enter through a single access point, are assessed, and are then directed toward the appropriate service (Milakovic et al. 2021). Yet this framing remains too narrow. It reduces primary care to an access-management function, whereas the challenges currently facing health systems require something more structurally ambitious. Primary care must be understood as a territorial clinical infrastructure: a stable, locally anchored set of clinical, social, public health and community relationships through which a defined population can be known, supported, followed and reached over time (Starfield et al. 2005).

   This distinction matters. A gateway is activated when an individual presents with a need. An infrastructure, by contrast, exists before, during and after that encounter. It creates the conditions for continuity, prevention, outreach, population health management and inter-sectoral coordination. In contexts marked by chronic disease, aging, mental health needs, housing insecurity, social isolation and unequal access to services, the problem is not only whether people can enter the system (WHO 2023). It is whether the system has the local capacity to understand the distribution of needs, mobilize the right actors and organize a coherent response across clinical and community settings. Referral pathways alone cannot achieve this (Valentijn et al. 2013).

   The history of Québec's local community service centres, the Centres locaux de services communautaires (CLSCs), is instructive in this regard. Created in the early 1970s, CLSCs were not designed simply as points of entry into medical care (Plourde 2019). They were public, territorial, community-oriented institutions intended to combine health services, social services, prevention, community engagement and local responsiveness. Their original promise lay precisely in their capacity to connect clinical practice with population needs and community resources within a defined territory (Plourde 2019). Although successive reforms progressively integrated CLSCs into larger and more centralized administrative structures, the underlying territorial logic remains highly relevant today (Gouvernement du Québec 2026; Ministère de la Santé et des Services sociaux 2025).

   This is also why the Québec government's current policy direction is significant. The proposal to re-anchor first-line services around CLSC territories formally attaches every person to a CLSC territory and strengthens local responsibility for planning and coordination. The policy implicitly moves beyond a narrow access model (Ministère de la Santé et des Services sociaux 2026). It recognizes that first-line care cannot depend solely on individual attachment to a physician, nor on the capacity of isolated clinics to absorb demand. Instead, it requires collective responsibility for a population, shared across interdisciplinary teams, public institutions, community organizations, municipalities and other local partners (Ministère de la Santé et des Services sociaux 2026).

   For social prescribing, this shift is crucial. If primary care is treated only as a gateway, social prescribing risks becoming another referral mechanism layered onto an already fragmented system (WHO 2022). But if primary care functions as territorial infrastructure, social prescribing can become part of a broader architecture of shared responsibility: one that identifies needs upstream, links clinical teams with community capacity, supports vulnerable populations proactively and allows local actors to co-produce responses adapted to their territory (Morris et. al. 2022). In this sense, the task is not simply to improve navigation after entry into healthcare, it is to build the territorial conditions through which healthcare, social care, public health and community actors can jointly take responsibility for health.

3. Without territorial governance, social prescribing risks remaining aspirational

   A final implication is that social prescribing cannot be sustained by referral pathways alone. Mulligan rightly points to fragmentation and siloed budgets, but the deeper problem is the absence of a shared territorial architecture through which responsibility, data, financing and decision-making power are organized on a common basis. Without such an architecture, social prescribing risks remaining a well-intentioned aspiration: clinicians may identify social needs, community organizations may receive referrals and policy makers may celebrate connection, but no actor is structurally accountable for whether the local system has the capacity, resources and authority to respond (Layani 2026).

   This is where territory becomes operationally decisive. “Community” cannot remain an abstract category or a long inventory of identity-based groups and disconnected programs (Klepac et al. 2023). It must also be understood as lived territory: the concrete geography in which people seek help, build trust, encounter barriers and access support (Kononovich et al. 2025). Proximity is not merely logistical; it is a condition for coordination, accountability and legitimacy.

   This also requires a clear political boundary. The community sector should not be treated as a low-cost workforce, a substitute for missing physicians or a residual safety net for an overloaded healthcare system (Morris et. al. 2022). If social prescribing is to contribute to health equity, community organizations must be recognized as co-producers of health, with stable funding, shared data and a meaningful role in governance ((Morris et. al. 2022; Mulligan et al. 2024). Otherwise, social prescribing may reproduce the very asymmetries it aims to overcome.

Conclusion

Ultimately, social prescribing will only fulfill its promise if it is embedded in a broader territorial reconfiguration of care. Rather than treating community organizations as downstream referral destinations, health systems must recognize them as upstream co-producers of health. This requires primary care to function as a territorial infrastructure, supported by shared governance, stable financing, data-sharing and accountability. Without these conditions, social prescribing risks remaining an aspirational response to fragmentation rather than a transformative lever for equity, prevention and community-based health system renewal.

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