Inclusion health action in general practice: early evaluation report

Chapter Two: IHAGP engagement and activity

This chapter provides an overview of programme engagement and activity. It covers practices’ aspirations and motivations for engaging with the programme, the number of participating practices, types of activity, and rationale for delivery against specific themes.

Aspirations and motivations for practices

Reflecting on their motivations for involvement with the IHAGP programme, practice staff expressed a personal interest in addressing health inequalities. Many noted that they see daily manifestations of inequalities, which have widened since the pandemic.

At a broad level, many welcomed the opportunity to explore the impact of enhanced preventative and inclusive healthcare approaches, and how they might contribute to wider change. For example, some hoped to test new approaches and expected the learning within practices would inform others; one hoped that the programme would demonstrate the cost and resource implications of activities such as extended consultations and make the case for additional funding to be allocated to GPs in deprived areas to allow more time with patients who have complex unmet needs.

Some viewed the programme as an opportunity to validate, resource and build on work they had already begun, either through involvement in programmes such as the Deep End GP Pioneer Scheme, the Govan SHIP Project or work by the Scottish School of Primary Care. Others described it as a way to continue self-instigated approaches to shift from reactive to more preventative models of care.

“I suppose a lot of it is about capturing what we're doing, but also kind of validating what we're doing as well. So I suppose I always felt a little bit worried, you know, externally it would be seen as not a good use of time that I was spending all this time with just one person. But actually what this programme allowed me to say is, oh, actually what I'm doing is a thing that you're meant to do. It just kind of validated a little bit that it was OK to do that and it was the right thing to do that as well”

A few mentioned local leaders and inspirational colleagues who championed the opportunity and motivated others. While many reflected on the programme's potential as a catalyst for change within practices, linked to enhanced capacity, better understanding, improved approaches and upskilling through training, others focused on the direct impacts on patients. They viewed the resource as an opportunity to offer enhanced services, identify patients’ needs, and widen their reach within communities.

“We have such a big population of people where language [and] cultural differences are a real barrier. Our receptionists… don't necessarily understand some of the cultural barriers that, I'm going to say particularly women coming into general practice will face, so that was something that we had a bit of a focus on.”

While participants were highly motivated, many expressed caution about what could be achieved through IHAGP due to the limited funding and timescales; one interviewee described the need for realistic expectations. Another reflected that IHAGP might not make a significant difference for existing patients, but it could deliver and inform approaches that prevent worse outcomes for patients in the future.

“It's a small first start. I think our health service does not reflect needs. It's very demand-driven, very reactive and very failure-driven. We spend huge amounts of money downstream when we should be investing much further upstream… It doesn't fill the gaps at all, but at least it's the first step in recognising there is a gap and recognising the GP practices can help to bridge that.”

Number of participating practices and breakdown of delivery

The majority (66 of the 80) of practices invited to take part had opted in by December 2023. Most practices (46) were delivering activity under one theme, 16 were delivering against two, and three practices were delivering activity across all three themes.

Monitoring data as at December 2023 demonstrates that eight practices were working on theme one (patient engagement and community participation), 24 practices were delivering activities related to theme two (enhancing workforce knowledge and skills), a decrease from 35 in August 2023, and 52 practices were delivering against theme three, (proactive outreach and extended consultations), an increase from 32 in August 2023.

Some intersections between themes emerged; for example, one practice which had received funding for theme two delivered training for their admin staff around signposting for wider needs. This activity is expected to encourage patients to join some of their patient groups and therefore contribute under theme one. Similarly, another practice reported that staff attendance at a patient participation group enabled staff to identify and address unmet need in certain groups and arrange follow up appointments that otherwise might have been delayed or not happened. This activity also aligns with and contributes to theme three. Another practice combined themes one and three by engaging with their local women’s group to understand why people often do not attend smears and breast screening appointments, particularly for women who use drugs and/or alcohol, do not speak English as a first language or have trauma/mental health issues. The surgery and women’s group hope to work together to offer further information, engagement and open surgeries to encourage attendance.

Theme One: Building inclusive patient engagement and community participation.

Over 200 patients have been supported with engagement and participation. Funding has been used for room hire and refreshments, activities and resources, and practice staff time to support community groups. Examples span walking groups, groups for men and women, peer support and practice-led patient participation groups. The funding has largely been used to support existing groups to reinstate, maintain or increase their activities. This is the least commonly chosen theme; practices which selected this were typically building on existing work in this area.

Furthermore, approximately 800 patients have been given the opportunity to provide feedback to help inform service development and improvement. In one example, a practice has used the feedback they received from patients to make improvements to their appointment sytem.

Theme Two: Enhancing workforce knowledge and skills for health inequalities

Over 200 staff members, including a range of clinical and non-clinical roles, have been trained in health inequality and trauma-informed practice themes. Topics include suicide prevention; gender-based violence; drugs and alcohol; chronic pain; long-term disease monitoring and management; abusive behaviour; data management; conflict negotiation; and medical coding. This includes practice-wide sessions and protected individual learning time with funded backfill, with examples of training being developed and delivered internally, as well as the use of external organisations. This is the second most commonly chosen theme; motivations included recognition of the scope to improve the practice culture so that staff are more accommodating and understand patient needs and experiences, and for upskilling to encourage changes in practice, policy and processes, and to create efficiencies and capacity within practices.

Theme Three: Enabling proactive outreach and extended consultations

This was the most commonly chosen theme for IHAGP activity; practices described motivations such as awareness of missing patient groups and additional challenges and barriers for specific patient groups that cannot be addressed in standard consultation slots.

Approximately 7,000 extended consultations and outreach appointments have been conducted through IHAGP, with interventions involving staff across the practice. This is likely an underestimate of the number of extended consultations and outreach appointments as not all practices consistently record or report this data. Activity under this theme varies, spanning extended appointments, home visits, improved resources and navigation, and proactively contacting patients.

This activity has largely been targeted at specific patient groups including older people, those living in the most deprived areas, people with multiple or specific conditions, patients with multiple medications, those with a history of substance misuse, frequent attenders, and individuals who do not speak English as a first language.