Inclusion health action in general practice: early evaluation report

Chapter Four: Learning

This chapter sets out the findings on learning, identifying enablers and what worked well, challenges and barriers, and wider lessons about work to address health inequalities.

What worked well?

Monitoring returns showed that many practices were already working on health inequalities, but that the IHAGP resources and support helped them to have a greater focus on, or expand work, in this area. This has resulted in resources being better targeted towards those with higher or complex health and social care needs.

“This programme has allowed me from time to time just to see how we step back and do things, I know they have to be done. But there's a list, 100 miles long, that comes up before it. And it's just brought it up to the top of the list.”

Across conversations, funding for protected time to plan and deliver IHAGP activity was identified as crucial. Staff also noted that willingness among team members to work in new ways was an important enabler. The programme monitoring report notes that practices are putting additional funding into this work from their main budget allocation, to enhance this resource.

Some staff emphasised the enabling role of the IHAGP programme. Many stressed the programme's significance as a driver for action. Some specifically valued the focus on three themes that shaped their ideas and activities. In these discussions some staff stressed that they felt the IHAGP steering group contributed knowledge, networks and impetus which they felt had encouraged participation in the programme and driven it forward.

“What I think is quite good is that we are given boundaries as in, these are what you can look at. I even asked, can we get an idea of what we can and what we can't spend it on?”

Several highlighted the value of data and digital tools. One described using tools to reinforce activity and encourage shifts in culture, for example, by sending daily reminders to follow up with patients who had not attended (see Case Study 1: Fernbank). Another described the role of technology in improved contact; reaching patients by phone and email instead of letter. They described this as a faster and more effective form of communication, and better use of resources (see Case Study 2: Extending and strengthening activity to address health inequalities). In another example a practice updated its text messaging system to give non-English speaking patients time to translate the message, and this has led to decreased missed and repeat appointments and time spent on the phone.

“We've also introduced kind of digital ‘asynchronous consulting’, I think is the formal term. So basically things like e-consult or online consulting where patients can send in the details of what's wrong with them and then we can decide what the best way of dealing with it is.”

Others used patient data to inform targeted outreach, either by self-directed review or deploying resources such as the Scottish Therapeutics Utilities tool^[2], or the CarePlus model (described in the introduction section of the report) to try and identify specific patient groups or those with the greatest need. One described using data to inform a multi-disciplinary approach, making better use of resource by having the right professionals present at the right time.

“We've started the coding process of marking these patients so that the data could be extracted and have set up our multi-disciplinary team meeting in a smaller scale on a monthly basis with these targeted patients, having a practice discussion about what we can do to intervene. [Using] the categories that we had in SHIP [Social and Health Integration Partnership] for example vulnerable children and families, the frail elderly, palliative care, impending crisis - that helps when we're having a structured meeting, for example our health visitors will be there when we're discussing the vulnerable children but there's no need for them to be there when we're talking about frail elderly.”

On recording and monitoring, one noted that IHAGP provided an opportunity to capture aspects of work that they had not recorded before. For example, they had previously met patients with complex needs outwith surgery hours because they would not fit in the booking system. Now, they have introduced a code to capture these appointments and gather evidence of the extent and nature of this work. Another noted the value of this data for planning and managing capacity during clinics.

“We wouldn’t necessarily have coded our interpreter consultations before, and even though there are a lot of these patients who are in interpreter consultations, there are a lot of white British English-speaking patients who take a lot of time just because they have other deprivation needs. So that's been quite helpful to sort of to quantify that…it's good for say visiting doctors, or new trainees, or new doctors to come in and if they see that there's been a previous extended consultation they know then that they can book a double appointment so that it's not impacting on the rest of your surgery.”

Group development and facilitation by knowledgeable and passionate staff with excellent interpersonal skills was highlighted as an important enabler of patient engagement, and some practices brought in visiting staff for this expertise. One staff member suggested groups had the greatest chance of success if they built on existing networks.

Under the training theme, practices emphasised the importance of protected time for planning and review, identifying and prioritising training topics, identifying materials and trainers, booking the training and creating staff capacity to attend.

On extended consultation, staff in one practice described creating additional resource by involving medical students in data review, and working with partners in community and recovery services to identify missing patients. An interviewee from another practice described work to address language barriers that could restrict access to medication. They had started providing interpreters with information about pharmacy opening times and addresses, to inform patients where and when to go, and how to get there.

Challenges and barriers

Some practices were unable to create the additional capacity they needed to deliver their IHAGP-funded activity. In a few practices, reflecting their commitment to the programme, staff were working additional unpaid hours to deliver the IHAGP activity. The Scottish Government programme monitoring summary notes that two practices reported a reduction in capacity to support other patients in the practice, suggesting that resourcing is still not sufficient to meet need in some areas.

In some practices, staff highlighted difficulties in finding cover for training, noting a lack of available locums, and an inability to make a ‘buddy’ system for GPs work, due to overall lack of capacity in the wider primary care system. They reflected that this hampered their practice’s ability to engage in outreach or whole-staff training events. This reduced the volume of activity or impact of training, because delivery in smaller groups restricted opportunities to learn from peers and took longer, stalling momentum. In these cases, training and other activity was often done on personal time, despite additional funding to cover this.

“We can't get locums. So it's just basically extra hours for ourselves and most of us don't have the extra hours to give. But obviously we did short term because we all recognised that this project was important.”

Signposting to various training resources and organisations was provided to participating practices, however some staff still described difficulties in finding specific training on health inequalities. In these cases, staff had undertaken their own research and delivered the training themselves. However, they noted that the quality and impact may have been greater if they could have sourced something tailor-made, with specialist input.

“Being able to source good material for training has been quite difficult. I think actually having it delivered and having that opportunity for discussion would be great, absolutely great. I think people get so much more out of that. And then being challenged on how you put that into practice, how do you make this happen in your practice, how can you make a difference as a receptionist?”

Many highlighted challenges linked to IHAGP funding amounts and processes (see Case Study 6: Challenges and Barriers). 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 such as hiring new staff. One felt the programme was limited by restricting the number of practices invited to participate, noting that not all had taken up the funding. They felt that participation should not have been optional, and that other practices across Glasgow and further afield needed and could have taken up the opportunity.

“The way in which these things are funded, which is kind of short term with possibly longer is detrimental in its own right. We wouldn't run an accident emergency department like that or some of these big services with little bits here and there.”

Some felt that time-limited funding discouraged participation in the programme or prevented investment in development activity, due to the unsustainability of any changes introduced.

“I suppose it was just trying to be realistic, because, the amount of money wasn't enough to really you know, you couldn't employ somebody off that. You couldn't. It's non-recurring. So you can't change a system. It had to be something that was going to be a sort of short term intervention. And so a lot of that I could tell was going to be around cultural change really more than anything else.”

One described difficulties with the new NHS Greater Glasgow and Clyde interpreter service. While this is not attributable to IHAGP, it impacted on the activity they were delivering.

“This newer service (interpreter) is more problematic. Sometimes you can get an interpreter, sometimes you can't. I was in a meeting with other Glasgow practice managers yesterday, and we're all having the same issues, and in fact one had an interpreter hang up just a couple of minutes into a consultation saying they weren't going to do it. So it creates huge problems and huge barriers for the patient which obviously is not good and not what we're trying to do.”

There was some negative feedback about IHAGP coordination. A few participants reported that clearer communication from the Scottish Government about IHAGP from the outset, and more information and suggestions about how funding could be used would have improved their understanding and enabled them to make better use of the resource. However, many stressed that this has improved as the programme has been embedded.

Practices also experienced wider system challenges. These included staff recruitment and retention, limited practice space, IT difficulties, and sustainability concerns, including short timescales and uncertainty around funding, with many practices investing additional funding from their main budget. The programme monitoring report notes that some practices described limitations in IT systems' capacity and flexibility.

One staff member reflected that complex areas of work, such as the introduction of trauma-informed approaches, require additional changes and resources that practices do not have the funding to provide. For example, staff may require access to clinical supervision and reflection sessions or further training on boundaries, stress management and safeguarding.

Some reflected on the particular challenges associated with the patient engagement theme, which were linked to the limited IHAGP timeframes. Another noted that buy-in and understanding were required and that some staff needed help to appreciate the benefits of enabling patients to connect with peers. They feared that some viewed patient groups as a way to disseminate information or consult about operational issues, rather than offering patient benefit. While it was not possible to explore this with all practices, these specific challenges may have contributed to low uptake of theme one activities.

“I think some of the constraints of the short-term limited funding programme are particularly relevant to [the patient engagement theme] because you can't set up something with patients or peer support group for a very short period of time, and it does need proper resourcing and it needs a bit of knowledge and expertise to do some of that.”

Those involved in proactive, targeted outreach stressed that this could take a significant amount of time; an afternoon on the phone might only result in engagement with a small number of patients. While staff emphasised how resource-intensive this activity is, they noted the significant impacts on patients they successfully engage with (see Case Study 4: Outreach).

Some described frustrations and barriers linked to factors outwith practices’ control, such as waiting lists to access different health services.

Key learning on implementing activity to address health inequalities

Building on the enablers and addressing the barriers identified earlier in this chapter is key to implementing activities to address health inequalities. Practice staff reflected that the activities delivered through IHAGP effectively improved services, reached target populations, encouraged engagement with healthcare and prevented patient harm. 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, given more capacity to upskill their teams and deliver proactive preventative work.

“I think it needs to be addressed from the root. There's no point in putting more and more money into secondary care because if it's not being addressed, you know, dealt with at the root, then you're on a hiding to nothing.”

Many reflected that IHAGP has achieved a broad range of positive impacts, such as improved quality of life leading to an overall reduction in demand for services for patients with better health. However, some noted that a proactive approach might trigger an increase in service demand by identifying unmet needs and demand among missing patients.

“It's probably one of my learnings from Stewart Mercer’s work was when he did the CarePlus study. It wasn't that people that went through the CarePlus study got better, it just got worse more slowly than the people who didn't. And to a certain extent, it's I think it's something you have to kind of learn that there aren't any happy endings. You don't solve people's lives at all, but you can support people to keep well longer.”

Practice staff frequently described the health impacts of wider social stressors and systemic inequalities and injustice, such as poverty, job instability, poor nutrition, isolation and trauma. Insufficient funding and the need for preventative, community and population-level health interventions were emphasised. While positive about experiences with IHAGP, many viewed the funding and activity as inadequate in the face of the challenge. They felt these activities should already be resourced and embedded within primary care.

“A lot of what is recommended for doing in the programme is stuff that we know needs to be done and there's just not a moment in the day to do it. We spend our days firefighting and it would be so wonderful to actually really properly do absolutely everything. I mean, the whole approach to [identifying missing patients] you know, I would want to do that all, that's what we should be doing all the time. But we literally firefight the whole time.”

Some reflected that IHAGP activities will have an impact on some patients, but not all. They suggested that proactive and preventative approaches to address inequalities will reduce demand in the long-term, but recognised that a small group of patients absorb a significant amount of practice time due to mental health and trauma. These patients might not engage with mental health support, or cannot access it because they don’t meet the high thresholds for specialist services.

“We're all going to have people who, no matter how many times you see them, and however long you give them, these same people will come and see us twice a week, and we’ll run late and we’ll never make any progress, we’ll never get them to realise the root cause of their issues is their previous trauma and something needs done about it. We can keep trying and keep trying, but nothing really makes a significant difference. So what we're trying to do with [IHAGP] is identify those people at a younger age to try and make the difference to prevent them from becoming these people who have such high need that is essentially always going to be unmet.”