How doctors can close the gap

Transcription

1 RCP policy statement 2010 How doctors can close te gap Tackling te social determinants of ealt troug culture cange, advocacy and education

2 Acknowledgements We would like to tank te Department of Healt for funding te Social Determinants of Healt project. Te work was led by a small steering group, comprised of representatives from partner organisations, to wom we are very grateful. We would like to tank all tose wo took part in te policy dialogues and contributed teir ideas and expertise. Tis statement as been written and compiled by Ben Cottam and Karisma Candaria. Te Royal College of Pysicians Contents Foreword 1 1 Introduction 2 2 Canging perspectives 4 3 Canging systems 6 4 Canging education 8 5 Moving forward 11 Appendix 12 References 13 Te Royal College of Pysicians is a registered carity tat aims to ensure ig quality care for patients by promoting te igest standards of medical practice. It provides and sets standards in clinical practice and education and training, conducts assessments and examinations, quality assures external audit programmes, supports doctors in teir practice of medicine, and advises te Government, public and te profession on ealtcare issues. Copyrigt All rigts reserved. No part of tis publication may be reproduced in any form (including potocopying or storing it in any medium by electronic means and weter or not transiently or incidentally to some oter use of tis publication) witout te written permission of te copyrigt owner. Applications for te copyrigt owner s written permission to reproduce any part of tis publication sould be addressed to te publiser. Copyrigt Royal College of Pysicians 2010 ISBN Designed and typeset by te Publications Unit of te Royal College of Pysicians Royal College of Pysicians 11 St Andrews Place Regent s Park London NW1 4LE Registered Carity No Printed in te UK by Te Lavenam Press Ltd, Suffolk +6A21.:?<02= -<:1?0> 4<:?; 8/9/421 3:<2=>= /91 :>52< 0:9><:7721 3=0 :<4 (2<> 9:.*. (,(!!#&%$ B "''% ):<2=>.>2@/<1=56; (:?9067 ii How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010

3 Foreword Te inequalities in ealt tat persist today in te UK are not inevitable. All sectors ave a role to play in reducing te gap in ealt between te ricest and te poorest in our society. Doctors are one of te lincpins in tis endeavour and, witin an enabling policy framework, must initiate, involve temselves in and advocate for programmes of action to tackle te social determinants of ealt and reduce ealt inequality. Tis policy statement and te recommendations contained witin it are a syntesis of te ideas and proposals tat emerged from a series of policy dialogues organised by te Royal College of Pysicians (RCP). Te aims of tese dialogues were to identify wat role doctors can play in reducing ealt inequality in te UK by acting on te social determinants of ealt, and ow tey can best be trained to do tis. Te statement contains recommendations tat cover te need for cange in doctors attitudes towards te social determinants of ealt, a cange in ealtcare and social systems, and a cange in te education of doctors. Te proposals are aimed at a broad range of actors, from individual doctors and teir teams to te ealt departments of all UK administrations and oter public and tird sector organisations. Tis reflects te necessity for cross-sectoral programmes working at bot te macro and micro scale. Tere is a growing movement to confront social inequity and I believe tis statement to be a timely contribution to tis endeavour. It is set against te background of te recent report on ealt inequalities carried out by Sir Micael Marmot Fair society, ealty lives 1 and focuses more specifically on te roles of doctors, medical scools and te ealt service. It is my ope tat tese proposals are read and acted on by doctors and policy makers of all levels and disciplines and tat togeter we can strive to close te gap. June 2010 Ian Gilmore President, Royal College of Pysicians How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans

4 1 Introduction Te social determinants of ealt can loosely be defined as ow te circumstances in wic people develop and live affect teir mental and pysical well-being and life expectancy, and ave been caracterised as te causes of te causes 2 of ealt (or ill ealt). As well as age, sex and biological caracteristics tat are largely fixed, individuals are part of society and terefore te debates around ealt policy and ealtcare provision must reflect te influence of societal, economic, environmental and cultural factors on a person s lifestyle, as well as teir interactions wit familial, social and community networks. Tese interactions and layers of influence affecting ealt are represented in te well-known diagram devised by Dalgren and Witeead in te early 1990s (Fig 1). A ealty life relies eavily on te pysical and social infrastructure of communities access to and uptake of ealtcare and social support, te quality of services and amenities, and environmental factors suc as pollution and access to green spaces. Climate cange is increasingly being recognised as a (social) determinant of ealt, and socially disadvantaged groups, wo lack adequate environmental protection, resources and insurance, and are more prone to its effects on ealt. 6 Reflecting tis, tere is a growing movement in te ealt service towards te development of sustainable buildings and care patways and also te promotion of programmes tat ave co-benefits for te pysical and mental well-being of socially disadvantaged groups and te environment. Tere is muc evidence tat social disadvantage and inequity can result in vast gaps in ealt in te UK for te years , in Canning Town, a deprived district in te East End of London, te average male life expectancy was 73 years, compared wit 79 years in te affluent boroug of Westminster (Office for National Statistics) (Fig 2). Individuals and communities need te support of te ealt system, ealt programmes, social services and local and national Fig 1. Layers of conditions affecting ealt. (From G Dalgren and M Witeead. Policies and strategies to promote social equity in ealt. Stockolm: Institute for Futures Studies, 1991.) 5 Education Agriculture and food production Work environment General socio-economic, Social and Individual cultural and Living and working conditions community lifestyle Age, sex and constitutional factors environmental conditions networks factors Unemployment Water and sanitation Healt care services Housing 2 How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010

5 governments to create te enabling conditions for tem to take effective ealt action. Doctors also need an enabling policy framework and te finances and capacity to adapt teir practice in order to effectively tackle te social determinants of ealt. It is important to combine topdown policies wit grassroots actions. Te distinct principles of equality (parity in ealt) and equity (fairness in ealt) must syntesise to promote good ealt for all. Te Black report 3 publised in 1980 represented te first example of a robust strategy to draw attention to ealt disparities over te life course. Te report also looked at actions tat were needed beyond te ealt system and te need to agree measures and targets to bring about population cange in terms of lifestyle factors. Most recently, Sir Micael Marmot s report, Fair society, ealty lives, 1 as set te problems of ealt inequalities in te widest possible context; wit policy proposals aimed across te government, public and private sector organisations. In 2006/7 only 4% of te NHS budget was spent on prevention 4 and wile tis level ad increased during te decade before tis, it is still considered by many to be inadequate. Some doctors remain entirely focussed on te medical interventions tat tey make, wereas all medical professionals need to adopt a population ealt perspective tat looks beyond te immediate needs of individual patients and work to actively promote ealt and well-being. Public ealt interventions need to be made long before a patient presents wit teir symptoms, and preferably in teir early-years development, in order to reap te most benefits for ealt and well-being in te long term. Doctors and oter ealtcare workers ave a crucial stewardsip role and can use teir position as leaders witin te ealt system and respected voices in teir communities to influence, advocate, inform and build partnersips wit oter sectors to promote ealt equality. Fig 2. Jubilee Line of ealt inequality. Travelling east from Westminster, eac tube stop represents up to one year of male life expectancy lost at birt (2002 6). Source: Analysis by London Healt Observatory using Office for National Statistics data revised for Diagram produced by te Department of Healt. (Reproduced under te terms of te Click-Use Licence.) Male life expectancy 78.6 (Cl ) Female life expectancy 84.6 (Cl ) Westminster Waterloo London Bridge Canada Water Bermondsey Canary Warf Canning Town Nort Greenwic Male life expectancy 72.8 (Cl ) Female life expectancy 81.4 (Cl ) Soutwark How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans

6 2 Canging perspectives To tackle effectively te social determinants of ealt a olistic approac to te issues is required, wit doctors not only taking a lead in promoting and protecting ealt, and preventing ill ealt, but also working collaboratively across all sectors to develop systems to reduce ealt inequalities. Tere needs to be a iger degree of solidarity between professionals concerned wit different facets of ealtcare, enabling tem to act to address te social determinants of ealt in a far more effective and targeted manner. An increased interaction between public ealt teams and researcers, clinicians, social care services and local government, and a better flow of information between tese groups, will elp to establis wic ealt promotion initiatives are most effective or wic population groups are under-utilising various ealtcare services. Information-saring on te best practice in te UK on ow to tackle te social determinants of ealt sould be encouraged and centralised. Many doctors ave long seen teir role as curing illness and ave paid insufficient attention to teir responsibilities in promoting and protecting ealt, preventing ill ealt and reducing inequalities in ealt or access to ealtcare. To deal wit te social determinants of ealt, more effort and funding sould be focussed earlier in people s life-course to prevent disease and injury. Healt professionals must act to instigate and/or guide tese initiatives. It is important to promote ealt literacy and to tackle ill ealt, bot before and after it becomes manifest. It is also commonly recognised tat doctors are some of te most trusted and respected professionals in society and tis goodwill needs to be cannelled into programmes tackling ealt inequalities. Doctors at all levels need to join forces to advocate ealt equality from impassioned medical students to influential deans and directors. Te entire profession can use teir powerful voices, weter on a personal, community or national level, to promote action on te social determinants of ealt. All doctors sould recognise and understand te effects of climate cange on ealt and ow ealtcare systems will need to adapt in te face of sifting pressures, wilst reducing greeenouse gas emissions. It is important to pay attention to social and environmental issues wen allocating funds and resources. Tose wit management responsibility in te ealt sector need to be informed as to te breakdown of te carbon footprint in teir working environment, to enable tem to identify areas for improvement. Doctors can also advocate directly to patients and encourage or refer tem to take up activities tat positively affect bot teir ealt and environment. 4 How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010

7 Recommendations All doctors sould consider te impact on ealt inequalities of teir day-to-day practice. Key actors: All doctors Senior medical figures and medical educators sould legitimise, encourage and arness te power of student advocacy and action on te social determinants of ealt. Key actors: Deans, course directors, undergraduate and postgraduate deans, royal medical colleges Information-saring on best practice in te NHS and beyond concerning te social determinants of ealt sould be encouraged and centralised. Key actors: Department of Healt, Academy of Medical Royal Colleges (AoMRC) Medical professionals sould igligt and advocate policies and programmes tat bot ave benefits for te pysical and mental ealt of socially disadvantaged groups and result in reductions in greenouse gas emissions. Key actors: All doctors, NHS Sustainable Development Unit (NHS SDU), AoMRC All medical professionals sould be educated and informed about te implications of teir ealtcare decisions on greenouse gas emissions. Key actors: NHS SDU, strategic ealt autorities (SHAs), primary care trusts (PCTs), medical royal colleges, AoMRC Clinical doctors and public ealt specialist teams sould work togeter more closely in saping services and developing programmes to promote and protect people s ealt, prevent ill ealt and tackle ealt inequalities. Key actors: All doctors, local public ealt teams, local commissioning and planning teams. How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans

8 3 Canging systems A key callenge in addressing ealt inequalities is tat te most disadvantaged and marginalised are often te last in society to seek medical elp. Tis can result from pysical or mental impediment, logistical issues, language barriers or even a stoic attitude towards ealt and a general acceptance of ill ealt as inevitable. All ealtcare professionals need to engage wit teir local communities and work to widen access to services and connect wit ard-to-reac sections of society. Healtcare programmes sould be designed to empower te public and take increased control of teir ealt. It is vital to provide user-friendly and accessible information and advice on ealt issues to socially disadvantaged groups, and in particular younger people. Engagement programmes sould go and-in-and wit a broader restructuring of primary care services, were ealtcare providers are more closely integrated wit social services, education and cildcare provision and employment services. 7 Te incentives system witin te NHS also needs to be examined wit a view to promoting action on te social determinants of ealt. During te consultation between a clinician and te patient tere are opportunities to address te factors affecting teir ealt beyond te formulaic approac of te social istory (Fig 3). Tere are roles for clinicians at all levels and in all clinical settings, from GPs to tose working in secondary care, to igligt te ealt risks of a patient s beaviour and environmental circumstances. 8 Clinicians can discuss wit patients te impact of wider social determinants on teir ealt, identifying areas tat may ave a significant ealt impact and signposting towards appropriate support and services, inside and outside te ealt sector. Tis could be troug elping tem to access ealt information, screening, ealt promotion and prevention services and treatment. Doctors can also elp and encourage patients to act to modify teir environment. A useful framework for considering tese various approaces is provided by te tree E s of engagement, empowerment and environment. Fig 3. GP on a visit. During visits doctors get to see first and te social and pysicial environment of teir patients. Using consultations to address wider social issues could reap benefits for te long-term care of te patient, and also prompt tem to act as expert patients and advocate for ealt issues wit teir family, friends, colleagues and te wider communities in wic tey live. BSIP, LECA / SCIENCE PHOTO LIBRARY 6 How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010

9 Doctors can involve temselves in te development of scemes in socially deprived areas tat create more efficient ousing and activity-friendly and green environments: tese ave te co-benefits of bot reducing greenouse gas emissions and boosting a population s pysical and mental well-being (Fig 4). 9 Te sustainability of ealt services is becoming an increasingly prominent issue, and new ealtcare facilities need to be planned wit sustainability and patient access as two of te most important factors in teir design. Existing facilities can also be greened as muc as finances and patient care will allow. 10 Healt professionals and policy makers in tis country could learn from resource-poor countries wen designing new protocols and approaces, including increasing te amount of recycling and reusing of equipment and resources and reduction of waste. Te reorganisation of ealtcare and ill-ealt prevention services outlined above could also ave te dual role of reducing patient miles and te overall carbon footprint of a service, as well as giving te opportunity to reac out to disadvantaged and marginalised groups in society. Fig 4. Active travel suc as cycling can be promoted by doctors to bot boost ealt and cut greenouse gas emissions. MICHAEL DONNE / SCIENCE PHOTO LIBRARY Recommendations Doctors need to work innovatively and collaboratively to develop systems to reduce ealt inequalities and must be given adequate resources, including finances, information and time, to do tis. Key actors: All doctors, SHAs, PCTs, acute trusts Tere sould be adequate medical input into decisions taken witin non-ealt sectors to ensure tat te initiatives do not exacerbate ealt inequalities and simultaneously maximise potential ealt gains. Key actors: All doctors, national and local government Healtcare services sould be better integrated into te community to reac out to disadvantaged and marginalised groups in society and reduce te many barriers impeding access to advice, prevention, diagnosis and treatment. Key actors: All doctors, PCTs, SHAs, Department of Communities and Local Government How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans

10 In te course of all doctor patient consultations tere needs to be more scope to discuss te root causes of ill ealt and signpost patients towards appropriate support and services, inside and outside te ealt sector. Key actors: All doctors All providers of ealtcare sould be encouraged and given incentives to implement sustainable care patways and working environments. Key actors: PCTs, SHAs, NHS SDU, acute trusts 4 Canging education We must give medical students and trainees te encouragement and support to act on social determinants of ealt and to promote ealt trougout te population, rater tan exclusively concentrating on treating individual patients. It is important to impress on students early in teir medical careers tat learning about te social determinants of ealt really will elp tem to make a difference to te ealt of society. As well as being taugt explicitly, public ealt issues relating to ealt inequalities and te social determinants of ealt sould be embedded as a vertical tread running trougout all parts of te curriculum and training. Students need strong and active role-models trougout teir training; not only medical practitioners but also representatives from oter sectors including social workers, tird sector workers and cildcare specialists. Role-modelling provides students wit opportunities to gain skills, as well as driving entusiasm. It is important to properly train te trainers, and good trainers need to be encouraged to pursue programmes tat tackle te determinants of ealt. Te majority of medical students embark on teir education wit an idealistic and optimistic outlook and undergraduate courses need to be designed to arness and structure tis passion. Despite te fact tat tere are many individuals and groups wo develop an interest in issues around ealt inequalities during teir time at university, tis is usually not driven by te courses tey participate in, but by te non-taugt curriculum and advocacy activities (Fig 5). Current teacing in public ealt is often seen as dry and uninspiring and needs to be modified in order to grab students attention on issues of ealt inequality. It is acknowledged tat te context of learning is as important as te content and tere are opportunities for establising a more ands-on approac to learning by te development of exciting and engaging experiential courses in social ealt issues. A two-pronged approac, coupling academic courses wit experiential training, is important and placements wit community groups, carities and social care networks allow students to see ow a variety of social situations affect te ealt of te people living witin tem. Suc placements can be life-canging experiences for students. Innovative student-selected components (SSC) and socially oriented electives are perfect opportunities for furtering students interest in particular social ealt topics and will allow students to emerge from teir education wit a more rounded view of ealtcare. 8 How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010

11 Experiential learning programmes can make population-based medicine visible troug individual people and elp te social determinants of ealt agenda come alive. However, suc programmes need to be backed up by engaging academic courses tat inform students of te broader picture and te ard facts beind population ealt. It must be recognised tat public ealt and ealt inequalities affect all disciplines and need to be taugt across te curriculum, not just explicitly as stand-alone modules. Tis can be done by linking specific diseases to teir causes and getting students to discuss te causes of tese causes for example wen learning about respiratory disease, students need to understand ow a person s family and social networks, and living and working conditions, can impact on suc factors as smoking, and wat measures can be taken to reduce te impact. Tis practice can be mirrored in te ospital setting, were public ealt specialists do ward rounds wit te students and discuss individual cases from a sociocultural perspective. Medical students also need to develop a broad range of transferable skills to better tackle te social determinants of ealt and tis can be done not wit bland lecture courses but troug experiential management and communications programmes. Doctors at all levels ave a role to play in addressing te social determinants of ealt and to enable tis tere need to be canges made to bot te foundation and specialty training of all doctors. Te inclusion of an element of primary care and/or public ealt in te foundation training of all junior doctors will allow tem to work more directly wit ealt inequalities issues and develop first and te skills and understanding to tackle te social determinants of ealt. Te structure of postgraduate medical training needs to be examined, to create more opportunities for trainees to be exposed to social issues outside te clinical setting. Tis, in turn, will give trainees te skills and knowledge to better structure teir systems and practices in te future to engage most effectively wit socially deprived and marginalised groups. Tere is also a need to ave more flexibility in te professional development of clinical specialists. Tis could come from encouraging trainees to take accredited public ealt modules as part of clinical specialty training or undertaking dual accreditation (a combined public ealt Fig 5. Medical students can be powerful advocates for cange. JONAHHPHOTOGRAPHY.COM How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans

12 and clinical training programme leading to accreditation in bot specialties). Many doctors ave a strong interest in public ealt but are reluctant to give up clinical practice entirely (and vice versa) and a transformation of te system would give doctors te opportunity not to ave to make suc a stark coice on teir career pat at an early stage, allowing for a more diverse medical workforce tat is well equipped to tackle ealt inequalities. Tere are also opportunities for te inclusion of more public ealt and social determinants material in te examinations of all medical colleges. Recommendations Learning on ealt promotion, ealt inequalities, disease prevention and te social determinants of ealt sould be made more engaging, be embedded as a vertical strand trougout medical education and be considered a key outcome of te process. Key actors: Deans of medical scools, course directors, postgraduate deans, medical royal colleges Experiential and researc-based student selected components in te social determinants of ealt sould be offered at every medical scool in te UK. Key actors: Deans of medical scools, course directors Dynamic trainers and teacers sould be fostered, encouraged and trained to devise and implement innovative programmes in te social determinants of ealt. Key actors: Deans of medical scools, course directors, postgraduate deans, medical royal colleges Te training of all foundation year 2 doctors sould contain an element of primary care or public ealt. Key actors: Medical Education England (MEE), postgraduate deans Te structure of postgraduate medical training of all doctors must be examined, to see ow opportunities to engage wit te social determinants of ealt can be better incorporated troug practice, researc and secondments. Key actors: All doctors, General Medical Council (GMC), AoMRC and postgraduate deans Innovative and flexible options for certification and continuing professional development need to be instigated to give clinical doctors te opportunity to remain involved wit public ealt issues and vice versa. Key actors: GMC Te examinations of all te royal medical colleges and faculties sould include an element of public ealt and social determinants. Key actors: AoRMC, all royal medical colleges and faculties 10 How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010

13 5 Moving forward Doctors are integral to te society-wide and cross-sectoral responsibility in tackling te root causes of ill ealt across te social gradient and especially amongst te most disadvantaged sections of our society. A olistic approac needs to be taken and te profession sould contribute its knowledge, leadersip and influence to strategies and programmes tat lessen inequalities and inequities. At te very least, doctors sould work to transform te NHS into an organisation wit muc more of an empasis on promotion of ealt and te prevention of ill ealt, wilst continually stressing te need for ig-quality care for all patients. Policy makers and ealtcare trusts need to develop te capacity witin medical practice to allow tis to appen. Individuals and organisations tat work directly wit ealtcare provision must also engage wit tose wose work indirectly affects te ealt of a population. Te main sections of tis statement canging perspectives, canging systems and canging education contain recommendations wic are aimed at a wide variety of delivery agents; from individual doctors, ealt trusts and tose involved in te education and training of doctors. Programmes need to be developed tat reac out to te marginalised members of society and tose wose social circumstances inibit tem from presenting teir symptoms. Doctors sould better use teir position and influence to elp mitigate or remove some of te many social and environmental barriers to better ealt and well-being, and all delivery agents are called upon to embed te principles of social inclusion and ill-ealt prevention into teir work. In tis era of increased concern for our environment, all of tese recommendations must be implemented wit sustainability at teir core and bearing in mind te direct effects of climate cange on vulnerable groups. We urge delivery agencies to adopt te co-benefits approac, were programmes to create greener environments and active transport in deprived neigbouroods can work to boost a community s pysical and mental well-being, wilst reducing greenouse gas emissions. Training in te social determinants of ealt and broader public ealt needs to be troug a variety of media and embedded as a vertical tread troug te curriculum from te first few weeks of medical scool, troug to royal college and faculty examinations. Te recommendations relating to education and training are predominantly aimed at course directors and te deans of medical scools. However, students and junior doctors must be extensively consulted in te formulation and implementation of canges to te curriculum. Te RCP will continue to work on tackling te social determinants of ealt in coordination wit te Royal College of General Practitioners (RCGP), Royal College of Psyciatrists (RCPsyc), National Heart Forum (NHF), Faculty of Public Healt (FPH) and NHS Sustainable Development Unit (NHS SDU). Several of te recommendations tat ave been made in tis statement apply directly to te RCP and we will endeavour to carry forward te agenda, wile encouraging oter delivery agencies in teir work. We call upon all doctors to embed te social determinants of ealt into teir day-to-day practice and work to increase awareness amongst How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans

14 teir colleagues, policy makers and te wider public of te factors contributing to inequity and inequality in ealt. Appendix Te Royal College of Pysicians, wit te support of te RCGP, RCPsyc, FPH, NHF, NHS SDU and te Department of Healt (DH), ran a series of policy dialogues for doctors and policy makers to discuss te issues outlined above. Te dialogues aimed to establis te avenues and opportunities for medical professionals to become more engaged in te social determinants of ealt and work to lessen ealt inequality in te UK. Tree of te meetings were attended by senior doctors and ealtcare managers and policy makers, and centred on avoidable cronic disease, climate cange and te training of doctors. A fourt dialogue was organised for medical students. On eac occasion a need for stronger advocacy from doctors and students on tese issues, a transformation of ealtcare systems wit engagement, prevention and sustainability at teir core, and an increased focus on social issues in te education and training of all doctors arose as te prominent temes and tese are reflected in tis document. Details of policy dialogues referenced in te policy statement 14 July 2009 Te social determinants of ealt and avoidable cronic disease: implications for te role of te doctor 14 October 2009 Te social determinants of ealt and climate cange: implications for te role of te doctor 14 January 2010 Te social determinants of ealt: implications for te training and education of doctors 12 April 2010 Te social determinants of ealt: students dialogue 12 How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010

15 References 1 Marmot M (Cairman). Fair society, ealty lives strategic review of ealt inequalities in England post London: Te Marmot Review, Rose G. Strategy of preventive medicine. Oxford: Oxford University Press, Black D. Inequalities in ealt: report of a Researc Working Group. London: Department of Healt and Social Services, Healt England. Public ealt and prevention expenditure report no. 4. London: Healt England, Dalgren G, Witeead M. Policies and strategies to promote social equity in ealt. Stockolm: Institute for Futures Studies, Stern N. Te economics of climate cange: te Stern review. London: HM Treasury, Te Bromley by Bow Centre. 8 McKee M. Wat can ealt services contribute to te reduction of inequalities in ealt? Scand J Public Healt 2002;30(suppl 59):54. 9 Roberts I. Te ealt co-benefits of climate cange policies: doctors ave a responsibility to future generations. Clin Med 2009;9(3): Recel B, Wrigt S, Edwards N, Dowdeswell N, McKee M (eds). Investing in ospitals of te future. Brussels: European Observatory of Healt Systems and Policies, How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans

16 Partner organisations Royal College of General Practitioners 14 Princes Gate Hyde Park London SW7 1PU Tel: ttp:// NHS Sustainable Development Unit East of England Strategic Healt Autority Victoria House Capital Park, Fulbourn Cambridge CB21 5XB Tel: ttp:// Royal College of Psyciatrists 17 Belgrave Square London SW1X 8PG Tel: ttp:// Faculty of Public Healt 4 St Andrews Place London NW1 4LB Tel: ttp:// National Heart Forum Entrance D Tavistock House Sout Tavistock Square London WC1H 9LG Tel: ttp:// 14 How doctors can close te gap Tackling te social determinants of ealt Royal College of Pysicans 2010