Inclusion health action in general practice: early evaluation report

Chapter Five: The future

This chapter sets out the appetite among practices for programme continuation, sustainability considerations, and potential areas of development.

Continuation

There is a clear appetite for continuation of IHAGP across practices who participated in evaluation interviews. Many called for increased and recurring funding to sustain or further develop and enhance IHAGP activity.

Sustainability

A common theme across interviews was that the activity delivered through IHAGP could not be sustained without continuation funding. While a small number identified aspects of change that they hoped to be able to resource and continue, many said the activity would stop without funding.

“If the money was to stop next year, basically, everything will go back to business as usual. I don't think it would achieve very much. There might have been a change in attitudes towards people missing appointments and a greater willingness to contact people. But no, this can't be done without resources. A little bit of money [cannot] change the world. This is... To me, this has to be the start of the ship turning round.”

Others noted that continuation without resource would require additional out-of-hours work which they thought would negatively impact staff job satisfaction and morale as well as their wellbeing, and would affect recruitment and retention.

Overall though, the potential for the impact of work already delivered by IHAGP to be sustained is variable. For example:

• In terms of patient engagement, patients participating in IHAGP activities may have experienced some lasting impacts through increased knowledge and connections. However, the value of these groups as a means to address issues such as loneliness, for example, will end if the groups stop. It is unlikely that groups will continue at the same level or scale without ongoing funding; they require facilitation by skilled professionals and resources such as venues and information materials.
• The culture changes attributed to IHAGP may continue while staff are in post, but retention is an issue in the medium to longer term. Without funding, there may not be scope to offer training for new staff, nor access to the shared experience that underpinned much of the commitment that has stemmed from IHAGP activity.
• New systems have been established in some practices. However, without continuation funding, extended consultations and proactive outreach are likely to end, or at best substantially reduce, because they are resource-intensive. As some staff noted, practices often used IHAGP funding to resume an activity which had been proven through the Govan SHIP programme. When that funding ended, the activity stopped.

Areas for development

There were mixed views on the themes covered by the IHAGP programme. Some reflected that it broadly spans the areas they thought were most critical for their practices and offers sufficient flexibility to implement activities that work best in their context. A few suggested additional potential themes and strands of activity for consideration in any future rounds of the programme, namely:

• stronger links with partners and other professionals, such as pharmacists, social work, health improvement teams and community link workers, given the number of patients with complex conditions and lengthy medical histories.
• patient health literacy and education, noting the potential role of other services in helping people to understand their specific condition or how the health system works.
• patient populations which require intensive support, such as those with multiple comorbidities, chronic pain, refugees and people seeking asylum, or people with diabetes.
• specific missing groups; for example women who have never had a smear test, pre-teens, young people with adverse childhood experiences, or those over 85 with no recent history of contact with the surgery.
• social prescribing, boosting elements of patient engagement, which had the lowest uptake, and considering other ways to meet patients’ needs.
• specific training across the programme, such as health inequalities, dealing with aggressive patients, and trauma-informed approaches.

“There's so much more that we could do from a sort of social prescribing, you know, peer support, patient support that would make a huge difference to people.”

Some practice staff reflected on ways to enhance capacity or help to tackle recruitment and retention challenges for practices operating in areas of disadvantage, such as doing more to encourage trainee GPs to consider working in these areas after they qualify.

“In X area we produce every year something like 24 newly qualified young GPs. So if we had the ability to approach them early on in their training to say once you're finished training, here is something that you might want to consider, working in X, and we would then have, particularly the 'Deep End’ practices to say to start with, we would have a ready source of young GPs ready to basically give us the GP resource that you need for the protected time.”

A few highlighted that IHAGP could play a role in developing the future workforce, noting that student placements were a core feature of the Deep End Pioneer Scheme, which evaluated positively.

The IHAGP networking webinars were valued by those who attended them and have informed some practice interventions and approaches. However, not all practices engage with this network and there is scope to increase efficiencies and enhance the dissemination of knowledge developed through the IHAGP programme, including awareness of effective tools, services and resources.

“It's entirely transferable. I just pinched all the graphs off Public Health Scotland, it took quite a long time to put it all together. So [sharing this could] save somebody else doing the same thing.”

Practice staff are keen to learn, and would like greater access to examples of other approaches or uses of IHAGP funding.

“Have the practical examples or expectations all clear before sending out invites and cash. Since it started, there has been some stuff come round, trauma-informed care, [we also need] practical examples of how you can reach out to minority groups to improve their screening uptake… I think it would make a difference to engagement and people really say, right, that is something that resonates with me, we can try that. Rather than having broad themes where you're thinking, ‘I'm not really sure what that means, or how are we actually gonna do that?”

Some requested support for training, with the programme monitoring report highlighting feedback from practices for training to be organised and delivered centrally. However, while the monitoring report highlights the potential efficiency and capacity benefits, it also acknowledges the potential disadvantages of reduced flexibility and choice.

Given the reported impact of training on approaches, culture and patient experiences, there is value in considering wider changes to staff induction processes to ensure that all practice staff benefit from the learning.

While IHAGP is intended to act as a bridging mechanism between the current general practice funding formula and any future funding model which takes a fuller account of deprivation, there were several calls to expand the programme. Some practices also highlighted the potential of IHAGP to gather learning to inform other practices with similar patient profiles both within Glasgow and in other areas of Scotland.

“The government needs to sit down and say right we are going to do this as a national program specifically targeted at deep end practices in the country and it needs to be rolled out on a sustainable basis.”

However, one practice described it as a ‘drop in the ocean’, with limited reach in one area of Glasgow, and argued that it distracted from the wider issues that practices in deprived areas across the country face, including greater demand, widening health inequalities and ever-growing financial pressures.

“It lets people off the hook a bit with thinking this is all sorted, and I mean this at national level and the government level.”

The evaluation has gathered examples of practices capturing new data from activities delivered by IHAGP. There is scope to formalise and enhance this data capture, although this would require additional, dedicated resources. Further consideration is required of the potential for this programme to gather evidence of the value of preventative approaches in the long-term and the wider impact on health inequalities, patient outcomes, and demand for health services. Any further evaluation of the impact of IHAGP should also address the gap in direct patient feedback.

“I would be keen to understand more about how it could be embedded into mainstream practice, and what the learning from this programme is around how we support, and how we support practices generally with changes around multidisciplinary team working, and what effective practice in areas of high deprivation looks like.”

Several argued that if IHAGP continued, the funding timescales should be lengthened to allow practices to fully commit and invest in the approaches.

“The difficulty I feel with this is how much effort do you put into something when it might disappear? When we only have so much time and effort to put into things, when there's still a lot of competing interest.”

One reflected on the commitment across practices involved in IHAGP, noting that some delivered more activity than others for similar levels of funding. If the programme continues there may be scope to explore this or set clearer expectations for practices.

Finally, there were suggestions that while the IHAGP programme is “better than doing nothing”, there is a need for a more ambitious reconfiguration of primary care funding to deliver transformational change. One suggested that IHAGP could play a role in this. They argued that practices should already be delivering the types of activity encouraged by IHAGP, and felt that the programme had the potential to capture more insight into the challenges and enablers to working in that way.

“What does it take to enable GPs to spend more time with the people who really need it, and how much more time, and what does that look like, and how do we start to track and quantify that, and then what would that take to build this into the way in which practices work every day? Because that's meant to be part of what practices are doing, and so for me there's lessons in there around how you look at the outcomes, and the value for money, and the practice activity as part of the normal GP contract, because that's the billion pounds, that's the bulk of what practices are paid to do and that's where I think the bigger gain comes in. This is how we can use this as a kind of trigger for supporting that change in practice through the rest of the system.”