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Understanding of the social determinants of health and realistic ideas for action at individual, practice and system level.
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Define
Avoidable, unfair differences in health between groups — by deprivation, ethnicity, geography, disability, etc.
Evidence and causes
Social gradient (Marmot); social determinants: income, housing, education, work, environment; access and trust in services.
What doctors can do
Individual: ask about social circumstances, adapt communication, avoid bias. Practice: outreach, flexible access, social prescribing, interpreters. System: advocacy, research, data.
Limits and nuance
Most causes lie outside healthcare; doctors can't fix them alone but can influence.
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Health inequalities are avoidable, unfair differences1 in health between groups of people — for example, people in the most deprived areas of England live considerably shorter lives, and spend many more years in poor health, than people in the least deprived areas.
The Marmot reviews showed this isn't just a gap between the richest and poorest: health follows a gradient2 all the way down the social ladder. Most of the causes lie outside the NHS — income, housing, education, work and the environment people live in. But healthcare can widen or narrow the gap, depending on who finds it easy to access.
Doctors can act at several levels3. In the consultation, they can ask about social circumstances, use interpreters, adapt how they explain things, and be aware of their own biases. At practice level, they can make services easier to reach — outreach clinics, flexible appointments, social prescribing to link people with support for things like debt or isolation. And at a system level, doctors have a strong voice: they can collect data, do research and advocate for policies such as better housing or smoke-free legislation.
Doctors can't solve inequality on their own, and it would be naïve to suggest otherwise. But I think recognising it — and the idea of proportionate universalism, providing care for everyone but with more support where need is greater — changes how you practise.
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