Health inequalities, smoking and alcohol

LTP Priority: Access to Primary Care

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: Health inequalities, smoking and alcohol. However, this intervention cuts across all priority areas, as it ensures access to healthcare to the most vulnerable groups of the population.

Major driver of health inequalities in your area of work

Everyone living in the UK is entitled to register and consult with a GP. However, people who are socially excluded are considerably less likely to do so. This leads to worse health outcomes among some of the most vulnerable population groups, which contributes considerably to health inequalities. This also leads to inappropriate use of services, and some of these groups have high rates of A&E use, leading to increased cost.

Low rates of registration and service use are a result of multiple barriers, such as lack of understanding of the system, negative previous experiences, communication and language issues, and stigma and discrimination. Socially excluded people usually experience several of these barriers at once. These barriers may be exacerbated by GP policies and practice, which can lead to incorrectly turning people away.

Target groups

Deprivation and inclusion health groups


Improving GP registration among socially excluded groups


To improve registration and use of primary care, GP practices must ensure their policies and practice are in line with NHS England guidance and considers the needs of potentially excluded members of their population. This will help create a welcoming environment and help to offer equitable service to all.

Research shows that GP practice staff often have poor awareness and understanding of NHS England registration guidance and good practice in relation to supporting socially excluded individuals. Therefore, GP practices need resources such as training to practice staff; support to create an inclusive registration policy; posters for waiting rooms; information leaflets for patients. There is a good toolkit that GP practices can use that brings all these resources together (links to the guidance below).

Access to these resources will mean that people who are frequently turned away from primary care will be able to access it and be referred to other services if needed. This will incentivise appropriate use of the system, therefore reducing costs. This is also key to improve health outcomes to some of the most excluded population groups. Improved health outcomes for people in such extreme circumstances can have a substantial impact on health inequalities.


Unpublished data has shown very positive results after implementation of the Doctors of the World Safe Surgeries toolkit (link available below). Among practices who have implemented the toolkit, 100% have strategiesi in place to register a patient with no address and 100% would recommend it to another practice. Practice staff felt the toolkit was particularly helpful for “Training for all staff, raising awareness of the issues (barriers, entitlements etc) among staff, making ourselves visible in the community as a practice that is welcoming and accessible to all (through posters and our website)” and to have a “positive endorsement of our caring approach, particularly with regard to those in vulnerable circumstances”.

Guidance for Commissioners

Doctors of the World Safe Surgeries Initiative (endorsed by the Royal College of GPs)

A Safe Surgery can be any GP practice which commits to taking steps to tackle the barriers faced by many migrants in accessing healthcare. At a minimum, this means declaring your practice a ‘Safe Surgery’ for everyone and ensuring that lack of ID or proof of address, immigration status or language are not barriers to patient registration.

Registering as a Safe Surgery means practices can receive a range of support, including resources to support practice staff, simple guides to NHS entitlement and translated patient-facing posters; training for clinical and non-clinical staff on migrants’ entitlement to NHS care common barriers and good practice. Being a safe surgery also has additional benefits, such as support to fulfil contract obligations and support successful CQC inspections by helping practices deliver an Effective, Responsive and Caring service.

The page contains information both for practices that want to become Safe Surgeries and for commissioners who want to help to build Safe Surgeries locally.

Inclusion health: improving primary care for socially excluded people (2010) – A practical guide to support the commissioning of improved primary care services for socially excluded people. Not in place anymore but may have some useful tips.

Homelessness and Inclusion Health Service Standards for Commissioners and Service Providers – Standards produced by The Faculty for Homeless and Inclusion Health as a framework for the commissioning and provision of health services for excluded people. They draw upon the latest evidence of best practice and provide quality assurance for supporting vulnerable and excluded patients with multiple and complex needs.

Homeless Health pages, Healthy London Partnership – Collection of pages with multiple resources to support healthcare professionals who deal with homeless patients, including commissioning guidance for primary care and e-learning for practice staff.

Migrant health – An online tool for GPs supporting new migrants in primary health care.

Homelessness: applying All Our Health – Guidance by Public Health England to help health and care staff use their trusted relationships with patients, families and communities to take action on homelessness.