Inclusion Health Action in General Practice: Early Evaluation Report

Executive Summary

In March 2023, the Scottish Government developed the Inclusion Health Action in General Practice (IHAGP) programme in response to a recommendation from the Short Life Working Group on Health Inequalities in Primary Care to create a new ‘enhanced service’ to provide increased resources for general practices in disadvantaged areas specfically targeted at activities to address health inequalities.

IHAGP provided funding to 66 individual general practices within NHS Greater Glasgow and Clyde. The funding was intended to support work to prevent health outcomes worsening for people with greatest need, and proactively engage those who are ‘lost’ to the system but need support to manage their health and social circumstances. Three themes for IHAGP activity were established:

• Developing connections with the local community - implementing inclusive patient engagement/community participation approaches to create or enhance existing patient/community participation capacity.
• Enhancing workforce knowledge and skills - practice staff to access education, knowledge resources or training on health inequality and health equity.
• Proactive outreach and extended consultations - enabling proactive outreach and extended consultations with patients who are at high risk of physical or mental ill health due to poverty and inequality.

The Scottish Government commissioned a social research agency, The Lines Between (TLB), to carry out a rapid evaluation to explore how general practices used the funding, the impacts of IHAGP-funded activity and lessons learned. The findings drew on monitoring data from participating practices submitted in September 2023 and January 2024. Interviews with a self-selecting sample of 23 staff from 15 practices were conducted between January and March 2024. Interviews with patients were outside of the scope of the study, so findings reflect the views of primary care staff only.

IHAGP activity

Eighty practices were invited to participate in IHAGP, and 66 had opted in by December 2023. The majority (47) were delivering activity under one theme, 16 were delivering against two, and three practices were delivering activity across all three themes.

Activity delivered in theme one (patient engagement and community participation), has largely centred on the creation of new, or enhancement of existing, patient participation groups, resulting in direct support for 200 patients. Furthermore, 800 patients have been given the opportunity to provide feedback to inform service development and improvement activity.

The use of IHAGP funding by practices under theme two (enhancing workforce knowledge and skills) enabled over 200 staff to undertake training related to health inequalities including trauma-informed practice; suicide prevention; gender-based violence; abusive behaviour; conflict negotiation; signposting; and medical coding.

Activity relating to theme three (proactive outreach and extended consultations) has resulted in the delivery of approximately 7,000 extended consultations and outreach appointments. This activity has focussed on patients identified as vulnerable, high risk or having the greatest needs due to medical conditions or social issues.

Achievements

Practice staff described improved morale, less stress and pressure, and increased job satisfaction. Some observed increased collaborative working through whole practice approaches, with staff feeling better supported in their role. Improved understanding of health inequalities, patient populations and needs was also reported.

Several examples were provided by staff of patients experiencing improved health and wellbeing as a result of IHAGP activity. Staff also reported that some patients had developed a greater understanding of their health condition and the various lifestyle factors and changes they were in control of. IHAGP activity was perceived by practice staff to improve access to healthcare and provide patients with greater care continuity, with this delivered in a more welcoming, accommodating and tolerant environment.

At a practice and system level, IHAGP activity has resulted in operational efficiencies for some practices, as well as improved systems and record keeping. There has been reduced demand and need from some patients, alongside fewer missed and repeat appointments. More widely, targeted work with some patients has resulted in reduced attendance at out-of-hours and accident and emergency services.

Enablers

The programme was viewed as a driver for action; with the three IHAGP themes helping to focus activity while providing flexibility in what could be delivered. Funding through IHAGP was highlighted as critical to secure the protected time required to plan and deliver IHAGP activity.

Willingness among general practice staff to work in new ways, take on new responsibilities, and work collaboratively were also critical enablers. The use of data and digital tools enabled new ways of communicating with patients, improved record keeping, and informed the identification of patients to target. Some practices had a foundation and momentum to build on, due to engagement in previous programmes to address health inequalities, or activity that was already underway.

Challenges

A range of wider system challenges were experienced by practices, including capacity in the system, limited availability of temporary staff, issues with staff recruitment and retention, a shortage of practice space, and limitations in IT systems. These affected the pace of progress, the interventions that could be delivered, and the impact on their patient populations.

Practice staff also acknowledged the wider social factors and systemic inequalities and injustice that influenced population health such as poverty, job instability, poor nutrition, isolation and trauma.

The relatively small sums and short-term nature of funding was described as limiting the scale of activity, and a barrier to introducing longer-term interventions, particularly those that required ongoing funding and resource. Staff were wary of introducing unsustainable changes. Practices also experienced a variety of specific challenges related to different themes and activities and noted that communcation from the Scottish Government could be improved.

Learning

Practice staff expressed that IHAGP-funded activities have improved services, reached target populations, and improved access to healthcare. Almost all described their usual day-to-day work as reactive and demand-driven, and many believed IHAGP demonstrated the potential for practices to have a greater impact on health inequalities and on improving patients’ quality of life, given more capacity to upskill their teams and deliver proactive preventative work.

However, some noted that a proactive approach might trigger an increase in workload by identifying unmet needs and demand among missing patients. Gaps in support for staff implementing trauma-informed practice into their day-to-day work were also identified.

While positive about experiences with IHAGP, many staff reflected on the scale of the challenge around health inequalities, feeling that activity delivered through IHAGP should already be resourced and embedded within primary care.

Conclusions and Recommendations

There is a clear appetite for continuation of IHAGP with calls for increased, recurring and longer term funding. Without this, the sustainability of some activity and development is at risk. The IHAGP programme themes are generally seen as spanning the areas thought most critical by practices, while offering sufficient flexibility to adapt to local contexts. Several expressed a desire to learn from what other practices have delivered, and would like greater access to examples of other approaches or uses of IHAGP funding.

Early lessons include the need for practices to have protected time to plan and identify priorities and delivery mechanisms, increased capacity for delivery, and access to examples of approaches and good practice.

Clear successes have been captured relating to patient care and support, changes in working culture and improved connection with, and health outcomes for, patients. Positive impacts on staff morale and satisfaction have been identified, including validation of their efforts to address health inequalities.

There is an appetite for the continuation of IHAGP among participating practices, particularly as some developments are unlikely to be sustained without it. Constraints within the primary healthcare system remain a challenge, as does the nature of the issues facing communities and individuals which were identified as needing more targeted, focussed and sustained support.

The overarching recommendation is for continuation funding to be sought for IHAGP as an enabler of person-centred and equitable care.