Personal responsibility Vs Social determinants of health: How us GPs can avoid shaming our patients when trying to help.

I’ve enjoyed The BMJ’s focus on societal causes of ill health recently and Dr Lucinda Hiam (et al)’s article this week deeply resonated with me.

Mainly as I’ve always been troubled by my colleagues often well meaning but equally tone deaf rhetoric of “personal responsibility” with regard to health promotion.

“To lose weight, feel great and reduce the burden on the health system, just eat 5 veg/fruit a day. Healthy fats. Enough protein. No UPFs. Get your zone 2, 5 and strength training in. Meditate. Sunlight in your eyes. It’s free!”

For an upper-middle class family without historic trauma or current adversity this might be useful.

But let’s take the case of a patient I spoke to in clinic yesterday. 

She was a young single mum, early school leaver, on universal credit, her child has chronic health issues and she presented with anxiety, exhaustion and insomnia. 

Her council flat is covered in black mould that is poisoning both her and her child, meaning she can’t work from the stress. She’s overweight, low income, and uses food banks. 

Yes she may benefit from lifestyle advice to detox the mould and manage her sleep, weight and stress.

But what she really needs is good quality housing, enough money to buy food, a job market that can work around her skills and passions. 

She needed more support as a child, not years of austerity.

She doesn’t need a clinician to tell her to pull her socks up and take responsibility for her health.

She needs investment now to compensate for what she didn’t have for the last 14 years of cuts.

And she needs empathy and support in this process. Not blame and shame.

Nationwide some figures are shocking. In 2022, 3.8 million people including one million children were destitute (doing without two or more of six essential items: housing, heat, light, food, clothing and toiletries.)

The number of children food poverty doubled between 2022 and 2023.

Health inequalities have been growing over the last decade due to poor investment and the political ideology of (vulgar) individualism and accusations of nanny state.

It results in blaming people for succumbing to poor health as a way of deflecting from lack of investment.

So as clinicians we need to take a moment before we tell people to just ‘take more responsibility’.

We need to get into their shoes. We need to appreciate their barriers.

No, we shouldn’t hold back from giving important lifestyle advice. 

But we need to avoid hidden blaming and shaming in the process.

And together, we need to push for huge investment in social determinants of health to avoid worsening the already catastrophic demand for healthcare we are facing in GP and OP clinics, A&Es, hospitals and social placements.

As Dr Hiam writes. “A common response is that we can’t afford such action - we argue, we cannot afford inaction.”

What do you think?