Intended for healthcare professionals

Rapid response to:


If social determinants of health are so important, shouldn’t we ask patients about them?

BMJ 2020; 371 doi: (Published 24 November 2020) Cite this as: BMJ 2020;371:m4150

Rapid Response:

Recording individual patient socioeconomic status in GP records

Dear Editor

We write in support of Moscrop et al.1 The Townsend Score and Index of Material Deprivation (IMD) have been important tools but lack high resolution at an individual level because they are averaged over 150 households. This is particularly true in urban environments where the affluent often rub shoulders with council estates, multioccupancy dwellings, hostels and the homeless (who don’t get a look-in). This considerably ‘dilutes’ the resulting social gradients.

In 2019 Hackney Council commissioned face-to face interviews using a stratified random locational sampling approach, with interviews completed at pre-selected sampling points across Hackney. This included 1,024 Hackney residents aged 16 years and over, during February and March 2019. Participants were asked the Canadian question “Do you ever have difficulty making ends meet at the end of the month?" in the categories Always (5%), Sometimes (33%), Rarely/ Never (60%) preferred not to say (2%).2 3 This was contrasted with the IMD score based upon their postcode of residence.

The further questions included smoking status, the Short Warwick-Edinburgh Mental Wellbeing Scale and whether the respondents had physical, mental or cognitive impairment, or disability.
Individual self-reported economic circumstance was associated with significantly greater discrimination of outcome than area based IMD scores. These descriptive figures can be viewed at

This simple question is a very powerful tool for examining equity, comparable to our existing general practitioner collected data on ethnic group which we have successfully pioneered on self-reported ethnic group throughout east London for over 30 years with completion in over 90% of adults.4

Ethnicity recording was achieved (in the face of some scepticism at all levels) through educational programmes in conjunction with standard data entry templates and initial financial incentives to promote the approach. Self-reported ethnic group is now viewed as an essential descriptor of health service usage and is collected routinely without incentives, across an entire population of 2 million in NE London. A similar approach could be taken to recording the Canadian question, which would transform knowledge about individual patient socioeconomic circumstance.

Unlike ethnic group, self-reported economic circumstance would require periodic updating. The current IMD is based on 10 yearly Census information with partial updating 4-5 yearly. General practice might do at least as well. GPs are easily able to text 5 yearly patient questionnaires that the majority can complete, or set-up systems relating to practice appointments where this is a better method.

It would be worthwhile supporting the piloting and evaluation of this across a variety of differing geographies and if successful, to support scaling.

Yours sincerely

Alexander Miller1, Jayne Taylor1, Carol Dezateux2, Kambiz Boomla2 , Sally Hull2, John Robson2.
1. City of London Corporation and Hackney Council, London. E8 1DY
2. Institute of Population Health Science, Queen Mary University of London. E1 2AT

1. Moscrop A, Ziebland S, Bloch G, et al. If social determinants of health are so important, shouldn't we ask patients about them? BMJ 2020;371:m4150.
2. Miller A.J. WL, Taylor J. and Robson J,. Testing an individual level instrument of self-reported socio-economic deprivation in Hackney. . Public Health England Annual Conference. Warwick University, 2019.
3. Hackney Council. Health and Wellbeing Survey 2019 2019 [Available from: accessed 30/11/2020].
4. Hull SA, Mathur R, Badrick E, et al. Recording ethnicity in primary care: assessing the methods and impact. Br J Gen Pract 2011;61:e290-4.

Competing interests: No competing interests

03 December 2020
John Robson
Alexander Miller, Jayne Taylor, Carol Dezateux, Kambiz Boomla, Sally Hull
Institute of Population Health Science, Queen Mary University of London
58 Turner Street, London. E1 2AT