Inclusion health action in general practice: early evaluation report

Chapter Three: Achievements and Outcomes

This chapter presents IHAGP’s achievements and impacts on staff, patients and practices, based on the perceptions of practice staff interviewed for the evaluation.

Achievements

A huge range of activity has been delivered through the IHAGP programme, as described in Chapter 2. When asked about achievements, practice staff focused on the changes they attributed to this activity; many described positive feedback from their colleagues about the practice’s participation in IHAGP and felt it had contributed to a boost in morale and increased job satisfaction for some staff.

“Making it a whole practice project is really useful. Getting everybody involved, and letting them know what it is and enjoying it as well. Getting a bit of satisfaction out of it. For the doctors to be able to start enjoying their jobs, you know, enjoying what they like to do. Spending time with their patients, making their patients better, has been really good for them. So being able to enjoy it as well has been quite good for us. Otherwise, I don't think we would have kept going with it as long as we have.”

Staff delivering patient engagement activities reflected that these groups create a forum for peer support, promote self-management, tackle isolation, and can reduce the demand for appointments which stem from loneliness and factors other than clinical need (see Case Study 2: Extending and strengthening activity to address health inequalities). Staff valued the time they were able to spend with community groups, finding it provided an informal environment to gather feedback and interact with patients.

Some of those working on skills and knowledge described changes in culture; for example, noting that staff were more tolerant and compassionate after training, or that practitioners had developed greater skills, leading to more efficient and effective patient care (see Case Study 3: Training). Examples of changes to policies and new approaches to patient contact and engagement were shared. Across several practices, a whole-team shift was attributed to shared training and a practice-wide commitment to new approaches.

“Health inequality is just not something [we talked] about with reception staff before. They would come and say, ‘[patient] just gave me an absolute mouthful; they've been rude and they told me to f*** off’. And I would always say, ‘Right, OK, that person's got really significant mental health problems, I don't think that they meant that at you personally’. And [before] they would have probably said, ‘you're not supporting us, you should have put that person off the list’. And now this is giving them a bit of insight as to why we respond the way we do.”

Under the outreach and extended consultation theme, achievements included breakthroughs with patients linked to greater time, rapport, trust, and improved understanding by patients of the healthcare system and their own healthcare needs. Staff described contact with people with a history of non-engagement with the practice, or progress for those with complex health conditions or those new to the NHS, leading to changed behaviour or better treatment and care.

“They're just maybe not used to the NHS because they've never had an NHS. So they sometimes don't know what some of your role is actually. Or they're used to a system that's more privatized. You need more than a double appointment because it's actually explaining, ‘no, that's not how it works. This is my role and here's what happens next. You see the specialist after me if I think it's appropriate’. I mean, there's a cultural difference but there's a sort of health literacy difference of how the systems work. Like I saw someone who's not a perfect English speaker, and they had no idea that out of hours services existed. So those sort of things can lead to poorer health outcomes because they might have waited until Monday, you know? There's a cultural difference. And a slightly subgroup of that is the asylum group, they definitely have complex health needs. More than just their language, they are a complex group that require more time.”

One explained that through closer contact with patients they had become aware of, and helped patients overcome, barriers to accessing other medical services with opt-in models. Opt-in models could act as a particular barrier for their practice population.

“We've referred patients onto mental health services or other things where they've got an opt-in. We phone the patients to say, ‘listen, you still want to be seen; you need to opt in to the service. I would do it now’. We give them a phone number because we've also found that sometimes the patients haven't received the letter and then they're discharged from the service. Or they're told to respond in seven days [on a letter] dated the 6th. They received the letter say on the 8th. That's not giving a lot of time for somebody to respond back. So it's good that we get an electronic copy sent to us for us to be able to help improve patients’ engagement.”

Several staff noted changes to systems and processes that the practice introduced, enabling them to better understand and accommodate those with access barriers, and identifying who to offer extended consultation to. A number of practices reported changes to their ‘did not attend’ policies, shifting from a punitive approach to one which was more considerate of their patients' circumstances.

“It's definitely impacted on how we send letters. Instead of saying ‘this is your second DNA [Did Not Attend] - the next one you’ll have to find another practice’, we're adding a comment around, ‘if you're having issues in coming in at certain times of the day please call us and let us know’. It's not as harsh as it was before… we're trying to get a better understanding. Because there are patients that regularly DNA we want to try and find out what's going on with them, is there support that can be put in in another area, does the link worker need to get involved, you know this sort of thing.”

Examples of wider achievements include greater use of outside resources, such as specialists, other health partners, and universities, to access additional capacity, resource and expertise. One staff member noted that IHAGP activity had provided further justification for continuing funding for community link workers, stressing the integral role that this resource played in supporting proactive outreach and community engagement activity. Another highlighted the contribution of IHAGP in supporting students’ learning about working with patients in areas with high levels of health inequalities and social challenges such as poverty.

“Our pharmacist has started getting dietetic students to talk about diabetes [at patient groups]. And it's been really eye-opening for the students. I'm not sure the kind of dietary stuff they talk about with our patients is quite what they get taught at Glasgow University. So I think it's been more an education for them than it has for the patients”

Several mentioned the value of IHAGP seminars in developing knowledge, sharing resources, and building relationships with other practices working to support similar patient populations. One believed their work might influence activity at a senior level in the Health and Social Care Partnership (HSCP).

“A lot of what we see comes down to how poorly nourished our patient groups are. And GPs have probably got a big role to play in shouting about that. I've been banging my drum about that for a long time. Finally, there's going to be an HSCP meeting in a couple of weeks' time about changing things. Now, I don't know if it's going to make any difference. But I suppose [there is] that bit about GPs having leadership roles within communities and being listened to at leadership level.”

Outcomes for staff, patients and practices

Practice staff noted that participation in the IHAGP programme had contributed to a boost in morale for some staff and had increased GPs’ time with patients targeted through their activity. Some staff reflected that additional staff capacity had reduced the guilt and anxiety they experienced, as they could now provide patients with the time they needed. Before the IHAGP funding, unsustainable workloads and the need to work additional hours to catch up were described. Some practices also reported greater satisfaction for administrative staff as they felt they were making a more direct contribution to improving health outcomes. Some described observing a shift in patient behaviour when they were able to feel heard and had their needs met.

“We have more GPs on over the week and it's better. The workload is better. I don't feel guilty about offering [extended appointments] - this person does need doubles because they're really complicated and it takes time. I don't feel guilty about that because I'm doing a better job, but I don't now feel like I'm depriving other people of appointments too. You know, it's, it's that balance.”

Some noted that training other staff to carry out a wider range of tasks reduced stress and created greater job satisfaction because they could focus on activities that delivered the most value to patients. Some practices also reported more efficient multi-disciplinary team (MDT) working, and increased team-working and collaboration through discussing and implementing the work together.

A small number of practices described changes to roles and responsibilities following training and development of new skills. One example of this is where healthcare assistants (HCA) in one practice have taken on clinical responsibilities that would normally be provided by the practice nurse. This involved the practice nurse writing new protocols, which were approved by the GPs in the practice. Training was provided for the HCAs, which has enabled them to assist the practice nurse with aspects of chronic disease management reviews and to undertake new patient medicals, for those first registering.

A few staff reflected that their colleagues had developed greater insight and understanding of patient experiences, which motivated them and helped them to feel supported in their role. For example, trauma-informed training supported a shift in thinking about patients’ needs and helped staff to understand why an aggressive patient might not be struck off. Suicide prevention training reduced stress and anxiety when dealing with patients in crisis. Without training, these factors contribute to dissatisfaction and high turnover among those in patient-facing roles.

“Some of the trauma-informed stuff that we've done with the administrative staff is starting to filter through. You know like women coming into practice, being aligned with a female GP so that they can talk openly and there's not the same issues around chaperones and things. So, it is starting to filter through slowly.”

Several highlighted the impact of training on health inequalities, such as improving understanding and motivating staff.

“That statistic that people who miss appointments are eight times more likely to die is really powerful. And it's really changing how people see missed appointments. So people are now really much more proactive at coding them and are following people up and phoning them. And often they're not waiting for a protected clinic time - we each have a little bit protected admin time every week. So I regularly see people coding it as an outreach clinic, but they're doing it in their admin time to follow people up who haven't been to see them or what have you.”

Most practice staff were able to share examples of improved patient experiences and outcomes based on changes they observed and direct feedback they received from patients (see Case Study 5: Extended Consultation).

Views among those delivering patient engagement activities included feedback that patients are enthusiastic about the approach, more informed and empowered to make decisions about their healthcare, and feel valued and listened to. Staff also described improved uptake of a greater range of support, such as physiotherapy, other clinics, attendance for various tests, and information and resources. Engagement with the groups by practice staff provided opportunities for practices to identify and address unmet needs in certain groups and arrange follow-up appointments that otherwise might have been delayed or not happened.

Under the skills and knowledge theme, practice staff highlighted that some patients demonstrate a higher level of trust with staff who have participated in training; for example, more engagement with staff and fewer patient confrontations and complaints after staff completed trauma-informed training.

Among practices engaged in outreach and extended consultation activities, staff highlighted that patients generally found the proactive contact from practice staff important, and that successful engagement with a patient considered ‘missing’ or unlikely to attend often resulted in an appointment. However, some staff reflected that when they called patients as part of proactive outreach activity, they could initially be concerned or suspicious. Staff explained that patients were not used to being contacted in this way by their GP and described their efforts to put patients at ease, by explaining that the contact was nothing to worry about and it was a call to check in and discuss their needs, (as illustrated in Case Study 8: Staff Reflections on Patient Care).

Staff in two practices noted that the extended consultation had allowed them to build relationships with patients with complex needs, resulting in improved engagement, better care continuity, reduced presentation at accident and emergency (A&E) and lack of escalation in health issues (see Case Study 1: Fernbank).

In monitoring reports, some staff noted impacts including increased patient understanding of their condition, positive lifestyle changes, better engagement with services, improved trust between practices and patients, increased uptake of screening services, and reduced hostility and aggression. Such shifts resulted in a “noticeable difference in many patients’ health and wellbeing”.

“Particularly things like chronic disease management, you know, they're much more likely to engage in it if they do feel that it's not just, you know, just us ticking boxes or whatever. When they feel that it's individualised and that we're looking on them as individuals and reaching out to them and wanting to help them, wanting to know what they feel, you know, wanting to hear their views, you know, I think that makes a big difference to them too.”

With better information, communication and planning, patients have more time to prepare for and engage with appointments. Stress and anxiety about interactions with the practice are less fraught because patients are able to access the care they need, and have faster access to test results, prescriptions and other information in accessible formats. Health professionals are less rushed, which can also contribute to better patient experiences.

“I would hope the patient will have a better relationship because they don't feel rushed either. You know, when I feel rushed, they'll feel rushed, we're both stressed, it's a bad combination. You're only human, your temper will probably get a bit shorter with them or, you know, not as compassionate as you'd like to be.”

Some practices reported fewer missed and repeat appointments, reduced waiting times, and a decrease in A&E and out-of-hours attendance among some patients. Increased efficiency, capacity and continuity of care were also described as positive outcomes of the programme by some staff. The programme monitoring report noted that one practice has reduced its wait time for a routine appointment from two to three weeks to two to three days (though this may not be entirely due to IHAGP).

Overall, practice staff perceived the activity they have delivered to be contributing to increased accessibility to care and support, and to instances of improved health and wellbeing among those patient populations targeted by work supported by IHAGP.