Inclusion health action in general practice: early evaluation report

Chapter Six: Conclusions and recommendations

This report has considered how different practices have used their IHAGP funding, the impacts of IHAGP, and lessons learned. Much of the delivery during the 14 months of IHAGP has centred on extended consultation and outreach, and training and development activity. While some patient engagement has been delivered, this has been limited and tended to build on existing activity. The different challenges for practices undertaking activity in this specific area have been identified.

The first 14 months of IHAGP have produced important learning on the value of the approaches across all three strands. Each practice has implemented its approach in different ways, depending on their individual contexts, systems, resources, staff and priorities. Early lessons include the need for practices to have protected time to plan, identify priorities and delivery mechanisms, to have capacity for delivery, and to have access to examples of approaches taken by other practices.

Clear successes have been captured. Patient support groups enable peer support, promote self-management, tackle isolation, and reduce the demand for appointments. Enhanced skills and knowledge have contributed to changes in culture and new approaches, processes and working practices. Extended consultation and proactive outreach have led to contact with ‘missing’ patients and improved health outcomes for many individuals, linked to a deeper understanding of patients’ needs and improved patient knowledge of the healthcare system and their own role in health improvement. Positive impacts on staff morale and satisfaction have been identified, including validation of their efforts to address health inequalities.

There is an appetite for the continuation of IHAGP. Consideration of how to build on what has worked well, and maximising the enabling factors while addressing barriers can inform future programme planning. Factors which have supported IHAGP include the resources, support and enabling role of the IHAGP programme, data collection and analysis, the use of digital tools, input by knowledgeable and passionate staff, and creation of additional resources, for example, by involving medical students. The main barriers were difficulties in finding staff cover, lack of access to training providers, limited funding amounts and short-term timescales, IHAGP communication in the early phases, and the time required for activities such as proactive and targeted outreach. There remains a gap in understanding the experiences of practices which did not take part in IHAGP. The evaluation therefore did not capture insights into how the barriers to adopting the programme could have been reduced or overcome.

Some practices were unable to create the additional capacity they needed to deliver their IHAGP-funded activity in full, and staff worked additional unpaid hours to help ensure the delivery of programme activity. A few found that committing resources and time to the delivery of IHAGP activity reduced their capacity to support other patients. There were also some observations that patients could be concerned or suspicious if they were contacted as part of proactive outreach, though these were overcome through subsequent conversations with patients. Through closer contact with patients, some practices identified barriers to accessing other medical services and found ways to navigate these. There was some negative feedback about IHAGP coordination, particularly in the early phases, and some reflected on IHAGP within the broader context and argued that it distracted from the wider issues that practices in deprived areas across the country face.

Activity delivered through IHAGP is unlikely to be sustained without continuation funding and the potential for the impact of work already delivered by IHAGP to endure is variable. While there were many references to the vast scale of work to address health inequalities, and discussion of the factors outwith practices’ control, there is no doubt that more could be achieved if the programme continues. With greater funding and longer timescale commitments, the learning and impacts generated by IHAGP could be significantly enhanced.

Participants indicated that the IHAGP themes are appropriate, although challenges in delivering patient engagement activities were noted. Additional themes for consideration include stronger links with partner agencies, patient health literacy, patient populations that require intensive support, specific missing groups, social prescribing, and the provision of specific training for all practices. Some practices have found ways to enhance capacity, which could be replicated in the future, enabling IHAGP to play a significant role in developing the future workforce. IHAGP networking webinars were valued and there is an appetite for continuation of these to build a community among Deep End practices, for ongoing development, and as a route to access examples of uses of IHAGP funding.

Recommendations for the Scottish Government:

1. As a minimum, for continuation funding to be sought for IHAGP.

2. For acknowledgement that the rapid evaluation findings make a case for greater investment in the programme over longer timescales.

3. To build on the findings about enablers and barriers and use these to shape future iterations of IHAGP.

4. To consider and respond to the suggestions on additional themes and strands of activity in any future iterations of IHAGP.

5. To involve other partners who can play a role in addressing the unmet needs identified through IHAGP; for example, gaps in patient health literacy.

6. For ongoing case study development to capture examples of approaches which can be shared more widely.

7. To disseminate the knowledge to practices working with similar patient populations across Scotland.

8. A focus on longer-term monitoring and evaluation is needed to evidence the impact on practices and patients, and the benefits for the wider healthcare system.