Reframing Social Determinants of Health in Primary Care Clinical Education

Primary Care is evolving rapidly. Increasing patient complexity, widening health inequalities, and changing models of care are reshaping what it means to deliver effective, compassionate healthcare. The NHS 10-year Plan reflects this transformation, placing renewed emphasis on prevention as a key role of primary care. At the heart of these changes lies a growing recognition that health is determined by the social conditions in which people live. 

Terms like ‘social determinants of health’ (SDoH) are widely used across policy, education, and clinical practice. But what do we actually mean when we use them, and how are these ideas being communicated to those training and working in primary care?  

In a recent article I published in Education for Primary Care with Dr. Leonard Grant, we explored what the commonly used term ‘social determinants of health’ was used to mean in available literature and how it is framed in key documents shaping primary care clinical education. By examining how these concepts are described and used, we raised questions about how future clinicians are taught to understand and respond to health inequalities.  

What are Social Determinants of Health (SDOH)? 

Broadly speaking, SDoH  describe systematic differences in the health of people occupying different positions in society. The phrase Is usually understood as referring to the conditions in which people are born, grow, live, work and age - and how these conditions shape health outcomes across populations.  

These factors include things like education, employment, income level, housing, gender, and ethnicity. Together they help explain why some groups experience better health than others, and why these differences often follow clear social patterns. 

To understand how SDoH is being taught and learnt in primary care education, we analysed a number of key documents influential to Primary Care Clinical Education. These included sources from Royal College of General Practitioners (RCGP), the Royal College of Physicians (RCP), the British Medical Association (BMA), the General Medical Council (GMC), and gov.uk. We purposively selected documents relating to GP trainees at any stage of training about health inequalities, as well as documents outlining how GPs in practice should approach, consider or attempt to influence health inequalities. A full list of the documents included is shared below.  

Our analysis highlights three key themes.

Inequalities as changeable social problems

Some documents frame inequalities as produced through social interactions and thereby modifiable: framing health as determined by our social conditions and hence change as possible. However, within this, there are some problems to watch out for. First, responsibility can often be focused on the individual (including clinicians). Second, objective language e.g. ‘can be changed by society’ obscures who holds power to enact change. Third, mechanisms or approaches to faciliate change are rarely specified. This creates a sense of moral imperative to act, but avoids direct expectations or responsibilities for the clinician to engage with issues of structural power, political and resource distribution. This approach might therefore encourage learners to identify and acknowledge SDOH as part of their professional role, and look for opportunities to advocate for patients in relation to particular challenges. But might not help learners to attend to observed similarities or differences with their own lived experience.

Inequalities as variation without a cause

A common framing of SDOH presents inequalities as differences or ‘variations’ in health outcomes, without direct connection to their origins. For example: use of passive language (“people who may have health disadvantages”); descriptions of social circumstances as if they arise naturally or at random; and/or limited acknowledgement of structural or historical causes. These strategies depoliticise and minimise causality claims, making inequalities appear inevitable or difficult to challenge. Learners might therefore recognise their existence but not feel it is part of their professional duty or responsibility to explore or address identified issues.

Inequalities as risk factors

The third identified framing incorporates social determinants into clinical decision-making by treating them as risk factors for poor health outcomes. The focus for learners here is therefore on diseases and their management. SDOH are a means to highlight particular risks (e.g. smoking or damp housing) potentially associated with, or contributing to, a patient’s condition (e.g. asthma).

Why does this matter for clinical education?

How we frame SDOH shapes how learners:

• Understand causality of health and illness
• Perceive their professional agency and responsibilities
• Engage (or not) with inequalities in practice

In particular, the identified discourses tend to:

• Obscure power and causality
• Individualise structural problems
• Translate inequalities into technical risk

What might we change?

This analysis helps highlight additional or alternative ways to teach and learn about SDOH. For example:

Making structural causality explicit

Supporting learners to understand how poverty, policy decisions and priorities, and historical and institutional inequalities are not just correlated with but actively produce health outcomes.

Moving beyond risk-factor thinking

Professionalism in clinical education has the potential to extend students’ learning to include reflexivity about their own position and privileges within society. Education can help learners to critically examine how social factors are medicalised; recognise the limits of individual-level interventions; and engage with broader questions of justice and equity.

Embedding SDOH in clinical reasoning

Rather than positioning social context as ‘background’, curricula have potential to forefront SDOH as central to clinical practice. For example, integrating SDOH into diagnostic reasoning and care planning.

Supporting critical and reflective practice

These findings highlight the importance of philosophy of science within medical curricula to help learners situate their own values and familiar approaches alongside additional possible perspectives and ways of understanding their interactions, environment and available resources. Education has potential to help students question dominant narratives; recognise implicit assumptions in policy and practice; and reflect on their own role(s) within wider systems.

The paper highlights some key areas to strengthen student and practitioner future learning about SDOH. Primary Care is one important and rich context in which this learning can be supported reminding us of the importance of:

• Embedding structural and social perspectives in clinical education
• Designing curricula and content which reflect real-world complexity
• Integrating education, research and practice
• Developing clinicians who can engage with both medical and social dimensions of care.