Health Inequalities and the Marmot Review: NHS Hot Topics for Medicine Interviews

Health inequalities are the unfair and avoidable differences in health between groups of people. In England, a boy born in the poorest tenth of neighbourhoods can expect to live 10.4 years less than a boy born in the richest tenth, and to spend around 19 fewer years of his life in good health.

I am Dr Akash Gandhi, an NHS GP and the founder of TheUKCATPeople, and I have been preparing applicants for medicine interviews since 2012. This is the topic where what I see in a surgery and what the national data says line up most plainly.

The patients who arrive sickest and youngest tend to come from the poorest streets in the practice area, and the ONS figures below say the same thing in numbers. Medical schools ask about it because they want you to see that health is made mostly outside the hospital.

What are health inequalities?

Systematic, avoidable and unfair differences in health between groups. They show up in how long people live, how many of those years are healthy, and how good their care is. They track four things:

• Socioeconomic position: income, education, occupation, area deprivation
• Protected characteristics: ethnicity, sex, disability, age
• Geography: where in the country you live
• Social exclusion: homelessness, Gypsy and Traveller communities, people in prison, known as inclusion health groups

Inequality or inequity?

• Inequality: any measurable difference. Older people have more heart disease than younger people, which is true but not unjust
• Inequity: a difference that is avoidable and unfair. A man in Blackpool dying a decade before a man in Kensington

UK policy says "health inequalities" but almost always means inequities, which connects straight to justice, the fourth pillar of medical ethics.

Key Takeaway: Define them as avoidable and unfair, then use the word inequity once. It takes five seconds and shows the distinction is deliberate.

Why does the social gradient matter more than poverty alone?

It is tempting to picture health inequality as a cliff edge, with poor people on one side and everyone else on the other. It is really a staircase. That is the social gradient: every step down carries worse health than the step above.

The evidence is the Whitehall study, which followed British civil servants from 1967, all of them employed and none of them destitute. It found:

• Men in the lowest grade had roughly three times the death rate of men in the highest
• It was not just top versus bottom. Every grade did worse than the grade above
• Smoking, cholesterol, blood pressure and diabetes explained only about a third of the gap
• The largest remaining factor was low control at work. Status and chronic stress were doing real physical damage

The causes of the causes

Marmot’s phrase, and a useful one. A patient has a heart attack. The cause is coronary artery disease. The cause of that is smoking, poor diet and stress. And the cause of those is insecure work, a cold damp home and a food environment where the cheapest calories are the worst.

Treat only the first layer and you send people back into what made them ill. Those upstream causes are the social determinants of health: the conditions in which people are born, grow, live, work and age.

Key Takeaway: Say staircase, not cliff edge. The gradient runs across every grade, which is why treating only the poorest never closes the gap.

What was the Marmot Review?

Sir Michael Marmot’s government-commissioned report, Fair Society, Healthy Lives, came out in February 2010 and is still the reference point. Its argument: health inequalities are avoidable, they are caused by social and economic conditions, and fixing them needs action across government, not the NHS alone. It set six objectives:

1. Give every child the best start in life
2. Enable people to maximise their capabilities and control their lives
3. Create fair employment and good work for all
4. Ensure a healthy standard of living for all
5. Create healthy and sustainable places and communities
6. Strengthen the role and impact of ill health prevention

Proportionate universalism

• Target only the poorest and you miss most of the gradient
• Offer everyone the same and the people who need it least take it up most
• Proportionate universalism: make it universal, but scale the intensity to the level of disadvantage

There are now eight principles, not six

This is where most interview material is out of date. Two were added to the original six:

• Tackle racism, discrimination and their outcomes
• Pursue environmental sustainability and health equity together

The first followed evidence on how the pandemic hit ethnic minority communities hardest, a theme running through racism and the experience of ethnic minority NHS staff. The second reflects that warmer homes and cleaner air cut carbon and narrow the gap at once.

Key Takeaway: Most interview material still says six. Say "six in 2010, now eight principles" and name the two additions, so your answer reflects where the thinking has moved.

What happened in the ten years after the Marmot Review?

The 2020 follow-up review found:

• Life expectancy stalled for the first time in more than a century
• It went backwards for women in the poorest tenth of neighbourhoods
• People spent more of their lives in poor health than in 2010
• The regional gap widened: biggest falls in the most deprived North East neighbourhoods, biggest gains in the least deprived parts of London

The review attributed much of this to a decade of austerity, with cuts falling hardest on deprived areas. You do not need to take a political position, but it helps to separate what the report found from how it interpreted it. A 2024 report estimated that around one million people in England lived shorter lives than they should have.

Key Takeaway: The honest summary is that the analysis was accepted and the gap still widened. Saying that plainly reads as judgement, not pessimism.

How big is the health gap in the UK right now?

The latest ONS figures for England, 2022 to 2024, compare the most and least deprived tenths of neighbourhoods:

The healthy life expectancy rows are the ones that tend to surprise people:

• The healthy life expectancy gap is roughly double the life expectancy gap. This is not mainly about dying earlier, it is about two extra decades in poor health
• Healthy life expectancy for the poorest men is now below 50, so the average man there reaches ill health long before the pension age he is working towards

It also fell in every decile compared with 2019 to 2021, with the largest falls in the more deprived areas.

Key Takeaway: Carry one figure into the room, not the table. "ONS, 2022 to 2024, a 10.4 year male gap" is enough.

What do health inequalities look like in a GP surgery?

Describing the mechanism is what makes an answer land, and this is where work experience becomes genuinely useful.

In my own practice the pattern turns up in the appointment book:

• Patients in their fifties with the multimorbidity I would expect twenty years later, after a lifetime of physical work, insecure income and poor housing
• Appointments missed by the people who most need them, because a shift cannot be dropped or the bus does not run
• Conditions presenting later and worse, because taking a morning off to get a lump checked is a real financial decision for some families and not others

There is a supply problem on top of that. The areas with the greatest need often have the fewest GPs per head, part of the wider GP shortage and visible as the 8am appointment scramble.

That pattern has a name: the inverse care law, described by the GP Julian Tudor Hart in 1971. Good care tends to be least available where it is most needed.

The same gradient runs through nearly every hot topic you will prepare: obesity, the sugar tax, the mental health crisis, waiting lists and the ageing population.

Panels assess values and insight, so link this to the NHS core values and to what you would do differently in a consultation.

Key Takeaway: One described mechanism does more work than three memorised statistics. A missed appointment is usually a bus timetable or a lost shift, not indifference.

Why does where you live change your health?

The north and south divide is real but it is shorthand. Deprivation does not stop at a line drawn across the Midlands:

• Coastal towns. Older populations, seasonal work, poor transport, hard to recruit clinicians. Severe deprivation often hides inside areas that look average
• Rural areas. Distance rather than density: longer journeys, thinner ambulance cover, isolation that is hard to measure

Disadvantages also multiply rather than add. A disabled woman from an ethnic minority background in a deprived coastal town does not face three separate problems, she faces a combined one that no single service is designed for.

This is related to, but not the same as, the NHS postcode lottery, which is about which treatments get funded rather than the causes. The four UK health systems add another layer.

Key Takeaway: Disadvantages compound rather than add up. Saying that out loud is what makes an answer about a specific group feel thought through.

What is the NHS doing about health inequalities?

Core20PLUS5

NHS England’s Core20PLUS5 framework is the single most useful thing to be able to name:

• Core20: the most deprived 20 per cent of the population, by Index of Multiple Deprivation
• PLUS: locally chosen groups such as ethnic minority communities, people with a learning disability, autistic people, people with multiple long term conditions, inclusion health groups and coastal communities
• 5: five clinical priorities. For adults these are hypertension, early cancer diagnosis, chronic respiratory disease, maternity and severe mental illness

There is a separate children and young people version, where the five are asthma, diabetes, epilepsy, oral health and mental health. Knowing it exists, and that the priorities differ, is worth a line if the conversation turns to children.

Marmot Places

Around forty local authorities have organised policy around the Marmot principles, starting with Coventry in 2013. Nationally, Lord Darzi’s investigation set out the scale of it, and social prescribing acts on the social determinants inside a consultation. Our guide to the structure of the NHS explains who does what.

Key Takeaway: Name Core20PLUS5 and say what the numbers stand for. It takes about fifteen seconds and it is the most concrete answer available on this topic.

What pushback should you be ready for?

"Is it not really personal responsibility?"

This one is worth taking seriously. Choices matter, but they are made inside constraints that are not shared out equally:

• Eating well is easier when fresh food is affordable and nearby
• Exercising is easier when the streets feel safe
• Stopping smoking is easier when you are not using it to manage stress

Whitehall is the strongest evidence here: a mortality gradient among employed civil servants that lifestyle could not explain.

"Has any of it worked?"

A fair challenge, and one worth meeting head on. The gap widened after 2010 and healthy life expectancy has since fallen across every decile. The defensible line is that the analysis is widely accepted, the funding to act on it was not, and Marmot Places show what implementation looks like.

Two quicker challenges

• Is this even the NHS’s job? Not alone. But it has three real roles: avoid worsening inequality through unequal access, find disease earlier in groups that present late, and use its weight as a big local employer
• Should we spend more on deprived areas? Resource allocation in disguise. Use proportionate universalism, and be honest that money spent in one place is not spent in another

That second one links to QALYs and justice; our medical ethics interview guide works through the frameworks properly.

Key Takeaway: Concede the strong version of the challenge first, then answer it. Agreeing that choices matter makes everything you say next sound considered.

What interview questions could come up on this?

Likely questions

1. What do you understand by the term health inequalities?
2. Why do people in the most deprived parts of England die around ten years earlier than those in the least deprived?
3. What was the Marmot Review, and has anything changed since it was published?
4. What do you think about the argument that poor health is mostly down to personal choices?
5. Should the NHS spend more money in deprived areas than in wealthy ones?
6. You are a medical student on placement at a GP surgery and a patient has missed three appointments in a row. What might be going on, and what should the practice consider?
7. Whose job is it to tackle health inequalities, doctors or politicians?

Less likely questions (harder, but worth knowing)

1. What is the social gradient in health, and why does it make targeting only the poorest an incomplete solution?
2. A friend tells you the NHS should stop worrying about housing and poverty and just treat sick people. How would you respond?
3. Healthy life expectancy for men in the poorest tenth of England is now under 50. What should that change about how services are designed?
4. If you had one billion pounds to narrow the health gap, where would you spend it, and how would you know it had worked?

Model answer: "Whose job is it to tackle health inequalities, doctors or politicians?"

I do not think it is really a choice between the two, and I would want to explain why before I land on an answer.

Most of what decides how long someone lives sits outside the hospital. That is Marmot’s central point. Income, housing, secure work, the air outside your front door. Those are levers politicians hold, not doctors. So if the question is who can move the biggest numbers, the honest answer is government.

But that does not let doctors off, because three things are genuinely ours. The first is not making it worse: the inverse care law, which Julian Tudor Hart described in 1971, says good care tends to be least available exactly where it is needed most, and that is something the health service does to itself.

The second is evidence, because doctors see the pattern first, and if we do not say it out loud nobody will. The third is what happens in the room, because asking whether someone can afford to heat their house changes what you can offer.

So my position is that the main levers are political, the evidence and the advocacy are medical, and neither works without the other. That is part of why I want this job. I would rather be the person who sees the consequences and says something than the one who treats the chest pain and stops.

Why this answer works:

• It refuses the false choice. It explains the division of labour instead of picking a team
• It gives the counter-argument first. Conceding that government holds the biggest levers makes the medical role sound considered, not defensive
• It names one dated source. One correctly dated reference carries more weight than five vague statistics
• It lands a position, then comes back to being a doctor. The last two sentences give a clear view and a reason for wanting the job, which is what the panel scores

More practice in our 360 MMI and medical school interview questions, with the NHS hot topics guide alongside it. To rehearse under pressure with feedback, we run one to one interview coaching.

Key Takeaway: Rehearse these out loud and to a clock. An answer you have never spoken takes twice as long as you think.

The one thing to remember

Health inequality is not a wall between the poor and everyone else. It is a staircase, and every step down carries worse health than the step above, all the way to the top. That one idea explains why Marmot argued for action across society, and why treating only the sickest and poorest will never be enough.