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 lives 10.4 years less than one born in the richest, and spends around 19 fewer years in good health. Medicine interviews use this topic to see whether you understand what actually makes people ill.

I'm Dr Akash Gandhi, an NHS GP and the founder of TheUKCATPeople, and I've been preparing applicants for medicine interviews since 2012. This guide covers what the term actually means and what you can usefully say about it, alongside our wider NHS hot topics guide.

What are health inequalities?

Health inequalities are systematic, avoidable and unfair differences in health between groups of people. They show up in how long people live, in how many of those years are spent in good health, and in the quality of care people get when they need it. The drivers fall into three groups.

• Socioeconomic position: income, education, occupation and area deprivation
• Protected characteristics: ethnicity, sex, disability and age
• Excluded groups: homelessness, Gypsy and Traveller communities and people in prison, the inclusion health groups

Inequality or inequity?

• Inequality: older people have more heart disease than younger people. True, but not unjust
• Inequity: a man in Blackpool dying a decade before a man in Kensington. Avoidable, and unfair

UK policy tends to say 'health inequalities' when it really means inequities, and that connects straight to justice, the fourth pillar of medical ethics.

Key Takeaway: Define them as avoidable and unfair, then use the word inequity once to show you know the difference.

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

About ten years of life for men, and roughly twice that again in years of good health, which is the figure most people find surprising. These are the latest ONS figures for England, 2022 to 2024. The table below is most of what you need.

• The healthy life expectancy gap is the bigger one: roughly double the gap in years lived, so this is about two decades in poor health
• Below 50 for the poorest men: they reach ill health long before the pension age they are working towards

The north and south divide is useful shorthand, but the pattern is really about specific kinds of place rather than a line across the map.

• Coastal towns: older populations, seasonal work, poor transport and hard-to-recruit clinicians

Disadvantages multiply rather than simply add up, so someone who is poor and disabled and living somewhere remote fares worse than any one of those would predict. None of this is the NHS postcode lottery, which is about which treatments get funded, and the four UK health systems add another layer.

Key Takeaway: Carry one figure into the room rather than the whole table. 'ONS, 2022 to 2024, a 10.4 year male gap' is plenty.

Why does the social gradient matter more than poverty alone?

Because health steps down a little at every rung of the social ladder rather than only at the bottom, which means you can't close the gap by helping the poorest alone. That's the social gradient: a staircase rather than a cliff edge.

The evidence comes from the Whitehall study of British civil servants, begun in 1967, and what makes it so useful is that everyone in it was employed and nobody in it was destitute.

• Men in the lowest grade had roughly three times the death rate of the highest, and every grade did worse than the one above
• Smoking, cholesterol, blood pressure and diabetes explained only about a third of the gap
• The largest remaining factor was low control at work, so status and stress were doing real damage

Marmot calls the layer sitting behind the diagnosis the causes of the causes. A heart attack is caused by coronary artery disease, which is caused in turn by smoking, poor diet and stress, and those come from insecure work, a cold damp home and food that's cheap because it's bad for you.

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

Is this not just about poor people making bad choices?

No, and the Whitehall data is the reason why. The gradient runs all the way to the top, so a civil servant in a secure job on a decent salary still had worse health than the grade above him. People make choices inside constraints, and those constraints aren't shared out equally.

Key Takeaway: Say staircase rather than cliff edge, because treating only the poorest never closes the gap.

What was the Marmot Review, and has anything changed since?

A government-commissioned report on health inequalities in England, published in February 2010 as Fair Society, Healthy Lives, led by Sir Michael Marmot. It argued that health inequalities are avoidable, that social and economic conditions cause them, and that fixing them needs action across government, not the NHS alone.

It set out six objectives, and they're worth skimming because they're all about life outside a hospital:

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

Two more were added later, so the current framing is eight principles rather than the original six:

• Tackle racism, discrimination and their outcomes: added after the pandemic hit ethnic minority communities hardest, as in racism and the experience of ethnic minority NHS staff
• Pursue environmental sustainability and health equity together: warmer homes and cleaner air cut carbon and narrow the gap at once

What is proportionate universalism?

It means offering something to everyone while scaling the effort to the level of disadvantage. Target only the poorest and you miss most of the gradient, but offer everyone exactly the same and the people who need it least are the ones who take it up.

The 2020 follow-up review found that progress had stalled badly. Life expectancy flattened for the first time in more than a century, went backwards for women in the poorest tenth of neighbourhoods, and the regional gap widened.

The review attributed that to a decade of austerity, with the cuts falling hardest on the most deprived areas. A 2024 report estimated that around a million people in England had lived shorter lives than they should have.

Key Takeaway: Say 'six in 2010, now eight principles' and name the two additions.

What do health inequalities look like in a GP surgery?

They look like people arriving sicker and younger than their age would suggest, and like the patients who most need an appointment being the ones least able to keep it.

• Multimorbidity twenty years early: patients in their fifties with conditions I would expect much later, after a lifetime of physical work and poor housing
• Missed appointments: missed by those who most need them, because a shift cannot be dropped or the bus does not run
• Later presentation: taking a morning off to get a lump checked is a real financial decision for some families

The areas with the greatest need often have the fewest GPs per head, part of the GP shortage and visible as the 8am appointment scramble.

That pattern is well enough recognised to have a name. The inverse care law, described by the GP Julian Tudor Hart in 1971, says good care is least available where it is most needed.

The same gradient runs through obesity, the sugar tax, the mental health crisis, waiting lists and the ageing population.

Key Takeaway: A missed appointment is usually a bus timetable or a lost shift rather than indifference.

What is the NHS doing about health inequalities?

The main national programme is Core20PLUS5, NHS England’s framework for reducing healthcare inequalities, and the 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, autistic people and inclusion health groups
• 5: five clinical priorities, which for adults are hypertension, early cancer diagnosis, chronic respiratory disease, maternity and severe mental illness

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

Key Takeaway: Name Core20PLUS5 and say what the numbers stand for, which takes about fifteen seconds.

What pushback should you be ready for?

A handful of challenges come up again and again, and they're all easier to handle if you've thought about them beforehand.

Is it not really personal responsibility?

Partly, and conceding that straight away makes the rest of your answer sound more considered. People do make choices, but they make them inside constraints that aren't 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

Has any of it worked?

Not at a national scale, and saying so is more honest than claiming otherwise. The analysis was widely accepted while the funding to act on it never really followed, and the Marmot Places are where you can see what proper implementation looks like.

Is this even the job of the NHS?

Not on its own, though it has real roles here: making sure its own access is even, finding disease earlier in the groups who tend to present late, and using its considerable weight as a large local employer.

Should deprived areas get more money?

This is really a resource allocation question, and proportionate universalism is the principle to reach for. Money spent in one place can't also be spent in another, which links straight to QALYs, and our medical ethics interview guide works through the frameworks.

Key Takeaway: Concede the strongest version of the challenge first, then answer it.

How can I talk about health inequalities in my medicine interview?

Start from something you've actually seen rather than from the statistics, and then explain the mechanism sitting behind it. In the mock interviews I run, that's consistently what makes an answer land.

• A placement or volunteering: what had happened to people before they arrived
• Your own school or town: transport, green space, what food is sold near the school gates
• A family member’s access to care: how long it took to be seen, how far they travelled, whether time off was possible

Then give the answer a shape:

1. Define health inequalities in one sentence, as avoidable and unfair differences
2. Give one figure and attribute it. The ONS male gap of 10.4 years is plenty
3. Explain one mechanism in your own words, identifying nobody
4. Say what it means for you as a doctor, including what a doctor cannot fix

Here's what interviewers are listening for:

• That the gradient is not just poverty: that health steps down at every rung
• That you do not blame patients: that you hold behaviour and circumstance together
• That you know this is bigger than the NHS alone: housing, income and work decide much of its workload

Do I need to have seen deprivation myself to talk about this?

No. Interviewers are listening for whether you understand the mechanism and can describe it with respect, rather than for any particular background. One local example is plenty.

Key Takeaway: Anchor this to something you've actually seen, because that's far easier to reach for under pressure.

What interview questions could come up on this?

You are unlikely to be asked any of these word for word, and you do not need a prepared answer to each one. Use them to check your understanding: if you could speak for a minute on most of them, you know this topic well enough for whatever the interviewer actually asks.

Questions to get you thinking

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?
3. Is poor health mostly down to personal choices?
4. Should the NHS spend more money in deprived areas than in wealthy ones?
5. A patient has missed three GP appointments in a row. What might be going on?
6. Whose job is it to tackle health inequalities, doctors or politicians?

Harder questions to stretch you

1. What is the social gradient, and why does targeting only the poorest leave the gap open?
2. A friend says the NHS should stop worrying about housing and just treat sick people. How do you respond?
3. Healthy life expectancy for the poorest men is 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?

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 giving an answer.

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

That does not let doctors off, because some of this is genuinely ours. The first part is making sure we do not add to the problem. The inverse care law, which Julian Tudor Hart described in 1971, says good care is least available exactly where it is needed most, and that is something the health service does to itself.

The second part is evidence, because doctors see the pattern before anyone else does, and if we do not describe it then nobody else is well placed to.

The third part is the consultation itself, where asking whether someone can afford to heat their home changes what you can sensibly offer them.

So my position is that the biggest levers are political, the evidence and advocacy are medical, and neither works without the other. I say that as an applicant rather than someone who has had to do it.

Why this answer works:

• It refuses the false choice: it explains the division of labour instead of picking a side
• It concedes the counter-argument first: agreeing that government holds the biggest levers makes the medical role sound considered, not defensive
• It is honest about its limits: saying what you have not yet experienced is a strength in an interview

Rehearsing out loud matters far more than reading does. To practise under pressure with feedback, we run one to one interview coaching.

Key Takeaway: Rehearse these against a clock, because an answer you've never said out loud takes about twice as long as you'd expect.

The one thing to take into the room

Health inequality is a staircase rather than a wall between the poor and everyone else. Every step down carries worse health than the step above it, and that holds all the way to the top.

Related reading: the NHS core values guide, and more scenarios in our medical school practice interview questions.

Key Takeaway: Health is made mostly outside the hospital, so treating only the sickest will never close the gap.