Inclusion health action in general practice: early evaluation report

Chapter One: Introduction

Background to the IHAGP programme

In March 2022, the Short Life Working Group on Health Inequalities in Primary Care published a report that recommended that the Scottish Government create a new ‘enhanced service’ to provide general practices with increased resources targeted at addressing health inequalities in disadvantaged areas. The intent of the recommendation was to:

1. Address a gap between existing demand-led funding allocation processes and patient needs associated with inequality.

2. Act as a bridging mechanism between the current general practice funding formula and any future funding model/approach which takes fuller account of deprivation.

In response to this recommendation, the Scottish Government worked with the Primary Care Health Inequalities Development Group and other stakeholders to develop the Inclusion Health Action in General Practice (IHAGP) programme. The development of IHAGP was informed by the existing evidence generated from previous local initiatives, which included the evaluation of Govan Social and Health Integration Project, the Deep End Pioneer Scheme, the Chance 2 Change project, the CarePlus study and research on “missingness”.

IHAGP provided funding for individual general practices during 2022/23 and 2023/24. This was targeted at general practices within NHS Greater Glasgow and Clyde, which operate in areas of blanket deprivation. 80 of the 100 “Deep End” practices^[1] are in Glasgow and were invited to take part in the IHAGP programme.

Funding allocations to each practice varied, and were formulated based on each practice’s patient list size and the proportion of their list living in an area of high disadvantage as classified by the Scottish Index of Multiple Deprivation (SIMD). A total of £1,300,000 was allocated to the programme, with £300,000 in the financial year 2022/23, and a further £1,000,000 in 2023/24.

In the financial year 2022/23, 66 practices participated in the programme, with initial funding allocated in March 2023 for activity until August 2023. In the financial year 2023/24, the same number of practices participated in the programme, with funding allocated in two tranches: the first in September 2023 and the second in March 2024. Over the duration of the programme the allocation of funding to participating practices ranged from £3,446 to £49,415.

The funding was intended to support work which helps to prevent health outcomes worsening for people with greatest need and/or proactively engage those who need support to manage their health and social circumstances. The funding provided through the programme could be used to support activity under one of the three IHAGP themes:

1. Developing connections with the local community - implementing inclusive patient engagement/community participation approaches to create or enhance existing patient/community participation capacity.

2. Enhancing workforce knowledge and skills - practice staff access education, knowledge resources or training on health inequality and health equity.

3. 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.

Purpose and approach of the evaluation

In November 2023, the Scottish Government commissioned social research agency The Lines Between (TLB) to carry out a rapid evaluation of IHAGP. This report sets out the evaluation findings on how different general practices used IHAGP funding; the impacts of IHAGP-funded activity; and lessons learned from the programme. The findings will be used to inform decisions about IHAGP’s future.

This report draws together a range of evidence. The main source of evidence is qualitative interviews with practice staff participating in the IHAGP programme between January and March 2024. A diverse sample of practices were initially invited to participate in interviews (See Appendix Three for further details of sampling approach and characteristics). However, due to low uptake, all 66 practices participating in the programme were later invited to take part in the research. The 9 practices who declined to participate in the programme also declined to participate in the research. A total of 23 staff members across 15 practices were interviewed for the research (16 GPs, 5 practice managers, 1 community link worker (CLW) and 1 pharmacist). In addition, 3 senior strategic stakeholders were interviewed to inform the background and recommendations of the report and to explore alignment with practice perceptions. Most of the interviews were individual and took place over video call, however there were also 2 paired interviews, 4 face to face and 2 over the phone. Overall, the heterogeneity of data collection approaches did not create any limitations or affect the analysis or reporting process. See Appendix Three for further details.

In addition to the interviews, the report is informed by a review of programme documentation and observation at IHAGP webinars, network and steering group meetings. All practices participating in the IHAGP programme were required to submit two monitoring forms to the Scottish Government (see Appendix Four) in September 2023 and January 2024, though many submissions were delayed. Where consent was given, these forms were shared directly with TLB and provided background to staff interviews. The Scottish Government also provided two anonymised summaries of the quantitative data and thematic analysis of free-text response from the monitoring returns which were drawn into the overall analysis.

Analysis and reporting took place during March and April 2024. The analytical team developed a collaborative and robust coding framework and the analysis was peer-reviewed. The report presents key themes reported commonly across practices, as well as views shared by individual or small numbers of general practice staff, to ensure all views are represented. When discussing findings specifically related to an individual IHAGP theme, the total number of participants varies across each theme. Therefore, phrases such as most and many do not relate to a specific number, but a proportion of participants that are delivering activity under that theme. Where findings are not related to a specific IHAGP delivery theme, such as wider learning, phrases such as most and many account for the proportion of views across the population of staff that participated in the evaluation. Quotes have been edited for readability; some content has been removed or changed to shorten quotes or protect anonymity but the meaning has been retained.

In addition to the main report, eight case studies have been produced to highlight key themes and lessons in more detail at the practice and activity level (Appendix One). Appendix Two provides a breakdown of the acronyms and abbreviations used in the report. Further details of the methodology are also included in Appendix Three and evaluation materials in Appendix Four.

Data limitations

Participation in the research among general practices was lower than hoped due to a lack of capacity within practices and the short timescale for the evaluation. Interviews were conducted with a self-selecting sample and likely reflect the views of practices with the highest capacity to engage with the programme and may not be representative of all practices’ experiences. The extent to which changes reported are attributable to IHAGP (especially as some practices have invested additional funding from other sources into their projects) is not always clear.

Additionally, non participating practices did not take part in the research. They had been invited to take part- to explore barriers to engagement, and whether any changes could be made to the programme that would enable or encourage participation. However, no practices took up the offer and the report therefore does not present any findings in relation to this.

Furthermore, the evaluation was not able to directly engage with patients or staff outside primary care, due to the time constraints for delivery of the evaluation, and the timeline involved in gaining the required ethical approval. Therefore, findings presented in this report relating to outcomes for patients and the healthcare system are based on perceptions of general practice staff.