Inclusion health action in general practice: early evaluation report

Appendix One: Case studies

Introduction

In March 2022, the Short Life Working Group on Health Inequalities in Primary Care published a report that recommended that the Scottish Government create a new ‘enhanced service’ to provide general practices with increased resources targeted at deprivation. In response to this recommendation, the Scottish Government worked with stakeholders to develop the Inclusion Health Action in General Practice (IHAGP) programme.

IHAGP provides individual practices in the most deprived areas of Greater Glasgow and Clyde with funding to undertake specific areas of work to help to prevent health outcomes worsening for people with the greatest need and/or proactively engage those who need support to manage their health and social circumstances. The funding provided through the programme can be used to support activity under one of the three IHAGP themes:

• Developing connections with the local community –to create or enhance existing patient/community participation capacity.
• Enhancing workforce knowledge and skills – whole practice team access to education, knowledge resources or training on health inequality and health equity.
• Proactive outreach and extended consultations – enabling proactive outreach and extended consultations with patients who are at high risk of physical and/or mental ill health due to poverty and inequality, and who are frequently ‘missing’ from services.

The eight case studies in this Appendix illustrate the work carried out as a result of IHAGP funding. Each case study has a different focus:

• Case Study 1 explores a whole team approach to service development.
• Case Study 2 shows IHAGP funding used by a general practice to extend and strengthen activity that aligns with each of the three IHAGP delivery themes.
• Case Study 3 summarises findings from interviews in seven practices that have invested in training and development to enhance workforce knowledge and skills.
• Case Study 4 is based on interviews with staff in three practices that have used funding to encourage proactive engagement with patients.
• Case Study 5 outlines approaches to providing extended consultations for patients with the greatest need, based on interviews with staff in ten practices.
• Case Study 6 presents the challenges and barriers faced by eleven practices.
• Case Study 7 is based on interviews with staff in three practices that have used funding to deliver patient engagement work.
• Case Study 8 presents examples of staff experiences of engaging with patients through IHAGP.

Please note that this work is based on interviews with staff and does not necessarily represent patient experience. Some quotes have been edited to protect anonymity.

Case Study 1: A whole team approach to equity-informed service development

Introduction and context

This case study is based on an interview with the Practice Manager at Fernbank Medical Centre. The practice is delivering IHAGP activity under the theme of extended consultation and outreach, taking a whole team approach to make this effective.

Fernbank Medical Centre is based in Springburn, Glasgow and has a patient list of just over 5000. The practice has a young patient population notably young males and young families – from its work with asylum seekers and refugees.

“We do have children and older people, but a big chunk of our practice is aged between 20-40. We have two doctors, one advanced nurse practitioner, two practice nurses, a health care assistant and three receptionists.”

It was explained that the practice tends to have less frequent contact with a younger patient population, compared to an older demographic. Furthermore, asylum seekers and refugees who are not in stable accommodation often live transient lives, moving to different areas, and having to register with a different practice.

“Having the younger patient population, you don't have as much contact with them as you would the elderly population….. So say the average patient contacts a doctor maybe about four times a year, we can have patients that we just never see from one year to the next. Quite a high number of those in that age range, and we had a lot of movement with asylum seekers as well, so they were constantly moving.”

Motivation to join the programme

Staff at the practice recognised that while they were already working to allocate the right time to the right patients, the programme offered an opportunity to focus on this approach. They sought to formalise this culture within the practice and encourage the whole team to adopt it.

“We felt that we probably already did a little bit of this work without thinking. So we thought it would be good to have the time to build on it and take it a bit further.”

“[Doctors] just want to see their patients. They don't want the admin side of things - they just want to see people and to have the time to spend with them because sometimes they're under enormous pressure. If they've got a queue of people waiting, I think they feel a lot of the time they're basically just fire-fighting.”

A whole team approach

The IHAGP funding has paid for extra staff hours and allowed the practice to introduce extended consultations for some targeted patients with higher level of unmet needs. While extended consultations are normally provided by a GP in the practice, depending on patient need, sometimes this can be carried out by an Advanced Nurse Practitioner (ANP).

“So we have given [the ANP] an extra session per week….and [the ANP will] either do a normal clinic, and [GP in the practice] will see some for long consultations, or sometimes [the ANP] will, depending on the patient.”

Identifying patients who would benefit most from extended consultations was the responsibility of different roles, with the practice taking a whole team approach to this. One component of this was working alongside medical students who were keen to undertake project work to help in the process of identifying patients who had barriers to health care.

“They identified a lot of patient groups that were DNA’ing [patients who ‘did not attend’ appointments] quite often, and people that we hadn't thought of that weren't accessing health care.”

Across the team, the administrative tasks of trying different ways to engage with patients to maximise take-up have been an important enabler in the project’s success. There are clear examples of adopting new approaches to more effectively establish contact with patients.

“Admin, researching what patients have to be called in, taking time to work out things like that, lettering them, contacting them. Sometimes you can spend time having a conversation with one of them first of all, encouraging them to come in, and reassuring them. So all these things will take time... we’ve got that time to spend on these things now. That's where the bulk of our funding has gone.”

“We've been finding different ways of contacting the patients...phone calls, texts, emails...we had a patient who just would not communicate with us at all but we managed to get them by email - somebody we had not had contact with for a long time and were quite worried about - they had a lot of health issues and had suddenly started to depend on A&E. Now we've got that managed, and they’ve got a way to contact us that makes them feel comfortable. To have the time to do things like that, it's been really enjoyable and it's really benefited the patients.”

The whole staff approach required new ways of working; providing timely electronic reminders was one helpful method of creating and embedding a whole team approach for an evolving culture.

“When we first started, we were just a bit unsure about how to get going with it... I sent wee reminders to our electronic system especially at the start of the clinic: ‘remember anyone that you feel is suitable’ or, ‘refer their name on to me and I can get in contact with them’…. Now I think we're more into the swing of it and we can remember, so even the admin staff are saying, ‘Mr so and so, he was on the phone, we've not seen him for a while - do you think he would be suitable?’”

Work like this has helped to raise awareness of those who are ‘missing’ and embed the new approach across the wider primary care team. For example, community link workers and addiction support workers have also been involved in identifying patients who would benefit from extended consultations.

“It’s also helping us identify more patients for our community link worker. So [the community link worker is] quite heavily involved and [has] been identifying patients that are suitable for it. Our drug worker as well has identified quite a few patients who we weren't aware of struggling with their health, but were almost afraid to come to the doctors in case their medication changed or stopped.”

Communicating the benefits experienced by patients has also been an important component of the whole practice approach. When staff hear encouraging stories resulting from the new way of working there is more of a team approach to enabling better patient care.

“If a receptionist refers somebody and it turns out it works quite well and it's a good referral, then speak to the rest of your staff about that - it makes them feel more confident about mentioning it as well. Definitely, making it a whole practice project is really useful.”

Deeper insights into patient healthcare needs

The additional time created through IHAGP enables a fuller, more open conversation about a patient’s life. With more time there is an increased likelihood of the patient raising the issues that really matter to them, and of the doctor gaining a greater understanding of the patients’ wider circumstances to enable the most effective treatments to be identified and agreed.

This new approach has resulted in improved care for many patients, including those referred by reception staff, and positive patient feedback:

“A lot of doctors will tell you that patients don't tell you the most important thing that's going on. You know, they'll start with their sore toe and the mark on their arm and an average consult is about 10 minutes. So you could be in for 15 minutes and then they turn around and tell you this massive thing that's going on with them. When it's an extended consultation, they can relax, [doctors] can talk to them and ask them about other things that are going on in their life, not just medical issues - they can find really out important things that are affecting their health. And they can take time to consider all different options and the best treatment for that patient. It makes the patient feel that they've been listened to and taken seriously.”

“A lot of their health is improving, and it might be that they get a referral to elsewhere, but at least if we're listening to what's going on, we get the time to listen and we can send them to somewhere that can help them.”

“A lot of the patients are giving good feedback and quite a lot of it verbally, you know, coming over and saying, ‘It's been so good’, ‘I've been so well looked after’, ‘I felt I was listened to’, ‘I felt the doctor wasn't rushing me out the door’, and so that's been good.”

“One patient identified by one of our receptionists, hadn't been in for a long time, and was complaining about the practice, but we looked at it. They’re not very good on the phone, you know, and we're doing a lot of telephone calls and not a lot of face to face appointments. They weren’t sure how the system worked - we've managed to get them in… and they’ve left very, very happy and praising us.”

Benefits for staff

Staff members described feeling encouraged and motivated by the results of the new approach.

“The doctors have been expressing that they're enjoying it as well. They're getting a lot of job satisfaction out of it, and I think with the patients feeding back to them as well, you know, ‘thank you doctor’, ‘thank you for listening to me’, they get a lot of pleasure out of that as well.”

Challenges and next steps

There are some challenges in measuring success in this area of work, but the practice is considering ways of doing this as well as targeting other groups using the methods already successfully employed across the team.

“Staff record all A&E attendances, so I'm going to look at a select number of patients who were frequently in A&E, and look and see, has there been a reduction?” I get the feeling that it's made a difference.”

“We have come up with more and more groups as we're going on and all the staff are involved in that. They're all in charge with identifying these patients. At the moment we're starting to look at over 45 males who never contact us…working men that just did not want to pursue a doctor...So we're constantly updating, constantly changing, constantly looking at different groups, so our numbers are quite high at the moment for our health inclusion.”

Case Study 2: Extending and strengthening activity to address health inequalities

This case study outlines the way a general practice in Drumchapel has used funding from the IHAGP programme. The practice has approximately 5,300 patients, of whom about 65% live in an area of high disadvantage, as classified by the Scottish Index of Multiple Deprivation (SIMD).

The practice was one of the few that utilised funding across all three priority areas: patient engagement, enhancing knowledge and skills, and outreach. This breadth allowed some flexibility; while work to address health inequalities predated the practice’s involvement in the IHAGP programme, the funding was used to extend and strengthen this activity.

Funding enabled the practice to pay for:

• Staff time to attend patient support groups and room hire costs.
• Staff training on preventing suicide, attendance at a ‘Refresh and Reboot’ conference for the Practice Manager.
• Protected time for GPs, allowing appointments to be extended and for proactive outreach calls to targeted patients.
• More time with patients and less reliance on locums

IHAGP funding enabled the practice to spend more time meeting patients’ needs. Staff said this meant they could widen their focus and work holistically; moving beyond the immediate health care issue to underlying issues. One GP highlighted:

"I think there's a lot more to helping people with physical and mental problems than just a prescription. Ideally, to do it properly and to be able to really make a difference to them, you need to have the time and be able to look at the psychological, the social, the support. If you've got the time to be able to spend with them and deal with the whole person, not just the one issue, that makes a huge difference.”

Another GP noted that the smaller practice size compared to other practices had enabled them to deliver the programme effectively.

“I think it's enabled us not to be so reliant on locums. We have used it to pay for locum sessions, but they are quite hard to get. So, we've been able to provide internal locum sessions or use flexibilities in the system. So, it's definitely been an enabler in that it's removed that bottleneck, which is probably quite a barrier for quite a number of practices that are already feeling that they've got larger list sizes and work in a different way.”

Enhancing early intervention

Practice staff reflected the IHAGP programme enabled them to be creative, and consider the best way to improve patient outcomes and adopt preventative practices:

“There are patients who may have gone too far, and we can keep trying and keep trying, but nothing really makes a significant difference. So, what we're trying to do is identify those people at a younger age to prevent them from becoming these people who have such high needs that are essentially always going to be unmet.”

The funding also facilitated more cost-effective ways to deliver preventative support, which included re-starting a patient support group that had been running prior to the COVID-19 pandemic but had stopped.

“The patients who went to [a community] group at the start were very much the people who we would see week in and week out with chronic problems we didn't have an answer to. When they were coming in to see us, it was more just for someone to talk to and a bit of support. And it's incredible how that group has now given them the support that they need. And that's meant that they need fewer appointments with healthcare professionals.”

Impact of the IHAGP programme on staff and patients

Protected time to address health inequalities has had a positive impact on staff morale and legitimised their focus on health inequalities.

“It can be the most satisfying job in the world when you've got the time to spend with people, and you feel that you can do it properly and go the extra mile with them. And it gets so frustrating when you've got the pressure of time and people are coming in with four different problems in one consultation and you can't do it properly. Absolutely, it's made such a huge difference.”

“It's good to feel validated, it's something that we've been doing for a while, and it adds to that validation, so that's been a wider positive impact for us.”

While the GPs cautioned the direct impact of IHAGP on patients was limited and perhaps intangible, some benefits were identified, for instance, potential avoidance of health decline, or improved patient engagement with treatment.

“Sometimes you feel you spend a lot of time and don't get anything back in terms of outcomes. And I think to a certain extent, it's an act of faith that there's evidence behind it to say that this type of working has better outcomes.…I think it's something you have to 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… It's what hasn't happened. That's the improvement rather than what has happened.”

“We can help, to a certain extent, with chronic disease management or mental health issues. But having the time to be able to spend with patients to explain to them and educate them so that they see where we're coming from, they're much more likely to engage with treatment and self-help if they understand the logic behind it. So, it's a case of trying to work with them, but that takes time.”

No negative or unintended consequences for the staff, patients, or practice were identified by those interviewed, and they expressed a desire for continuation funding to sustain the additional activity delivered through the IHAGP programme.

“I think it's been hugely beneficial. And I think it feels as though it's the tip of the iceberg that we've started, and it would be great if we could carry on. But as I say, I think the only way we would be able to do that would be with funding because there’s not the time and the resources to do it without, with the demand that we're under on a day-to-day basis.”

Changes within the practice

Funding provided by the IHAGP programme enabled the practice to dedicate time to enhance data recording protocols and establish codes to identify patients who did not attend appointments. This data was used to proactively contact specific groups, such as those considered to be at high risk:

“We could have patients that book for an appointment at 14:30 that don't turn up to their appointment til 16:30 because of something happening in their chaotic lives. So, we've never really recorded those DNAs…whereas now we're going to try and be a bit more proactive with them.”

The practice was also able to make better use of existing information; drawing on welfare benefit reports to identify patients who had not recently seen a GP, for example due to barriers linked to poor mental health.This allowed GPs to contact those patients and link them to other, more relevant, services (including the practice CLW).

“The next step is for me to say, ‘Look, I think you would benefit from this service. I’ll put you in touch with them’. It’s not a mental health problem in terms of what a doctor or a psychiatrist can fix. It’s you know, it’s years of social deprivation and entrenched health beliefs. And the link workers, from a social prescribing perspective, allowing them to maximise their potential, are going to have a much more effective role than I can really.”

An enhanced interface between staff and patients was also highlighted; for example one GP reflected on the value of the training for receptionists on suicide prevention:

“To give them the knowledge and the understanding that they can help the patients and react to them in a way that’s, you know, going to be okay from the patient’s point of view.”

Case Study 3: Equipping staff to tackle health inequalities

This case study presents findings from interviews with staff in seven practices who have used the funding to enhance workforce knowledge and skills, by investing in training and development.

Rationale for training and development activity

Practice staff said that health inequalities are evident every day in their work with patients, but understanding of causes and manifestations varies. They viewed the IHAGP programme as an opportunity to develop a consistent foundation of knowledge and understanding about health inequalities, understand the impacts of health inequalities, and identify the range of contributory factors.

"I felt that the education, the training was the most crucial part if we were going to move forward as a practice. There's no point in putting initiatives in without staff having that level of understanding. So the first base had to be education.”

A need for development opportunities to underpin improvements to patient experiences and support patients’ wider holistic needs, was highlighted by practice staff.

“A lot of our admin staff for example deal with patients who have communication needs or financial needs as part of their day-to-day, but haven't really had any formalised training. So we're looking at improving people's knowledge and comfort in dealing with people with financial or deprivation issues.”

Upskilling to transfer responsibilities between clinical roles

Staff upskilling has been prioritised by some practices to enable teams to transfer responsibilities between clinical roles and support service development. They noted this enhances skills and knowledge, creates capacity in other clinical roles, and contributes to a seamless and responsive patient service.

“We just wanted to make people more skilled in certain areas that would free up time higher up the hierarchy. It makes you more efficient if the right people are seeing the right people at the right time.”

Approaches to staff development

Practices have focused on providing development opportunities for clinical and non-clinical staff. In some instances, staff have all undertaken the same training; in others, practices targeted specific areas of development at particular staff, depending on aims and priorities.

“Every so often people present agitated or distressed at the reception desk. So, they've had suicide awareness training and communication skills training, just to try and make it a better interface between the public and the practice, both from the patient's point of view and the receptionist's point of view.”

In some cases, a blend of bespoke training has been developed by practice staff in addition to drawing on existing materials and opportunities. There has also been variety in training delivery, including sessions led by practice staff, self-led learning through online modules, and bringing in other individuals and organisations.

“I looked at organisations that delivered health inequalities training across Glasgow, contacted two or three, had no response whatsoever. So I'm no expert in health inequalities but I had to go away and do a lot of training, a lot of reading, a lot of looking at things so I could then deliver with confidence to the team so that's what I had to do.”

“We also got our link worker to do a session with us about what it's like to live on benefits. We had [external organisation] to deliver two workshops on stigmatisation.”

Staff explained that health inequalities are broad, which gives them scope for development activity across a range of areas that align with and contribute to the programme aims. This has been reflected in the wide variety of training and development activities undertaken, which include:

• Suicide awareness
• Conflict de-escalation
• Trauma-informed practice
• Understanding health inequalities
• Chronic pain and pain management
• Active listening
• Mental Health First Aid
• Active signposting and care navigation

The enabling influence of the programme

The main barriers to undertaking training and development activity were reported to be time, capacity and cost. Combined, these prevented practices from:

1. Considering, identifying and prioritising areas of training

2. Identifying and sourcing training materials and/or providers of training

3. Planning, scheduling, booking and coordination activities required to put on development activities

4. Freeing staff to attend training or being able to pay staff to attend on non-working days

“I think the main thing is that it’s stuff that we would love to be doing all the time, but just don't have time.”

One practice explained that before the COVID-19 pandemic, practices had two to three afternoons of protected learning time each year where they would effectively close and focus on staff training and development. These stopped during the pandemic and have not been re-introduced which has also reduced the ability and opportunity for staff development.

The IHAGP programme has enabled practices to overcome these barriers in two main ways. Firstly, participation in the programme has acted as a catalyst for focussing and prioritising training and development activity related to health inequalities.

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

Funding is the second core enabling aspect of the IHAGP programme. Practice staff explained this was critical in freeing staff time and creating the capacity for the development of training resources, enabling staff to attend training, and/or planning and organising training and development activities.

“I think the biggest thing is that it enables us to have a different avenue for training the staff and getting the GPs available.”

“We held it last November, the second one through this IHAGP money, and again it was really successful. It's very difficult to get the staff away from work together, and we found that this was really successful. We utilised it to bond, and get the team working together, but also cover lots of different subjects that would enhance the team's skills.”

Achievements and the impact of enhanced workforce knowledge and skills

Overall, practices have been encouraged by the response and level of engagement in the training opportunities provided through the IHAGP programme. Staff described positive feedback from colleagues who have taken part in training, and perceive that it has helped to maintain morale, foster autonomy and demonstrate that staff are valued.

“I remember them asking a lot of questions, which is slightly unusual as sometimes these kind of teaching sessions they will all just sit there and go hmmmmm. You know, there was a lot of questions and they were quite surprised at things.”

In evaluation interviews, staff suggested that the development opportunities have helped to better equip practices with the skills, knowledge and confidence to meet their patients’ needs. Some reported having observed changes in colleagues' approaches and practice when interacting with patients, demonstrating greater compassion, understanding and empathy.

“I think when people are coming in and they're feeling unwell or they're stressed or they've got social worries or concerns, understandably they're anxious. And if they don't get the answer that they want or can't get seen immediately or whatever, the receptionists bear the brunt of it. So it has been hugely beneficial to them to have that extra training so that they can see it from the patient's point of view, and they've got a better idea how to manage it. I think that's made a difference.”

A small number of practices shared examples of changes to roles and responsibilities and/or processes because of the training and the implementation of new learning. This included equipping healthcare assistants to take on new clinical duties, and in one practice, the implementation of a new approach to responding to patients who do not attend appointments, those who were ‘missing’.

“This allowed us to give them extra hours to take on this extra workload and extra training, so that they could support the practice nurse a bit better.”

“We're now trying to find out, you know, why can't you make it? Is there anything that we can do? So we're questioning things a little bit more. I think sometimes there was not an understanding of what the patients were going through that had health inequalities issues.”

Case Study 4: Proactive healthcare in General Practice

This case study presents findings from interviews with staff in three practices who have used the programme funding to support outreach activity which is focussed on proactive engagement of patients.

Outreach and the opportunity to be proactive

Practice staff reflected that due to capacity, their work is largely demand-driven and reactive; they respond to patients' needs as they present. The IHAGP programme provides an opportunity to be more proactive in identifying and contacting patients with a history of non-attendance who are often ‘missing’ from services or those who could benefit from a a longer consultation or review.

“We spend our days firefighting and it would be so wonderful to actually do absolutely everything. I mean, the whole approach to missingness, I would want to do that, that's what we should be doing all the time.”

Targeting activity

Practices have taken different approaches in identifying patient groups to target through outreach, including patients who:

• Have missed a scheduled smear test
• Receive, or have applied for, Personal Independence Payments or Scottish Disability Payments and have not seen a GP for a period of time
• Are at an increased risk of falls
• Have missed medication reviews

For example, one staff member said:

"Obviously I look in these patients' notes and see when they last saw a doctor and we've got people claiming Universal Credit or Personal Independence Payment who haven't actually spoken to a doctor in a year……. so I've been keeping a record and actively seeking these people out in my outreach clinics because I think that they are really good candidates for this.”

Through the development of planned, targeted outreach activity, the IHAGP programme has been a catalyst for more opportunistic outreach work. Practice staff explained they were now more proactive in following up with patients that have not attended appointments on the day, rather than waiting until they are identified through targeted work.

"And it feels like good use of time that I've added to outreach clinic numbers by proactively reaching out to the patient and finding out why they didn't come there and then.”

Enabling quality improvement and process development

One practice reported that the use of the Scottish Therapeutics Utility tool (which searches GP IT systems for patients on multiple, higher-risk medicines) was an example of quality improvement activity in their outreach work and it had enabled them to clearly identify patients that could benefit from targeted engagement because of the medications they are prescribed.

"So that was a good quality improvement activity that I was able to use my outreach time for using this new tool…. that is able to extract data from our prescribing interface to pick people out who are at an increased risk of falls or, anybody who's at potential harm for the combination of their medications, if you're on three or four different things that can thin your blood, that sort of thing.”

Another benefit of carrying out the outreach activity, reported by two practices, is the development and introduction of a more consistent approach to recording and coding patients who fail to attend appointments and noting any follow-up undertaken. This was expected to better support future outreach activity and encourage ongoing proactive outreach across staff.

"We already had a system in place, but it's really beefed that system up and what has become systematic is recording. And when people don't come to see us, I think before, on the whole, we would just go ‘thank goodness’ and go on to the next patient. You can now really clearly see people are recording it and you can also see people are looking and you see little entries saying didn't attend, phoned the patient to find out what was wrong. Just there and then just using that appointment slot to phone them rather than just to say didn't attend. So that's been a change in practice. It's been quite interesting to see. I'm not saying we always do that, but we are systematically recording it anyway.”

"The other thing that we started doing was actually being better at coding people when they don't come for appointments, because the evidence is showing that people who don't come for their appointments have higher mortality than other people. So we thought it was really important to start coding these.”

Overcoming barriers linked to time and capacity

The IHAGP funding has been critical for practices in overcoming the time and capacity issues that prevent outreach activity from taking place. It has enabled practice staff to secure protected time to run outreach clinics or other outreach activities.

"I think time. Time, absolutely. That's the fundamental thing because it's very much been things that we've been keen to do as a practice over the years, but time is of the essence and just with the demand that we have, even without doing extra stuff. So just having that protected time is hugely beneficial.”

Two practices reported challenges with carrying out extended outreach activity. For one, the time to achieve even a small number of successes was seen as a challenge. However, practice staff still viewed it as a worthwhile investment of time, and making a positive difference.

"But it's a big time commitment for only a few. I mean, you might in the space of phoning people over two hours, you might only get to speak to maybe six or seven people. And out of those six or seven, you might succeed in getting three in. So it's a lot of time, but for those three people, it's really, really important.”

Another challenge stems from the time often required after the contact to address patients’ unmet needs and concerns. Aligned to this, GPs may find that aspects of meeting patients’ needs is out of their control, for example, if they require access to a different service or form of support, and there is a waiting list for access.

"So it does take on a barrel of work afterwards. It's not just a nice simple have the phone call and things will be rosy.”

"I have tried emailing the service to explain the severity of the person's situation. And they simply emailed back and said they're on a waiting list. There's nothing we can do, even though I'd ask them to upgrade it to urgent.”

What difference does outreach make?

Practice staff said that proactive contact with patients has been well received. Those involved in outreach work note that patients respond to the contact, are happy to engage in conversation, and consequently become more likely to engage with healthcare services.

"And it's just nice to hear, people in those situations, for the GP just to randomly cold call them. People seem to be very receptive of it, just saying to them, ‘We've just done a little review of people who might benefit from a phone call and your name's popped up, do you mind if we have a wee chat about certain things’, and they seem to be really keen on it.”

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

Practice staff described gaining further insight and understanding into the factors that influence non-attendance, as well as opportunities to address or minimise those barriers where they can. For patients, one of the main perceived benefits is gaining a sense that someone in the healthcare system is interested in them, their health and their wider needs.

Beyond this, staff provided a range of examples where successful outreach had led to patients attending the practice for tests, medicine reviews or general consultation to explore their health and wider needs.

“What was really important was that so many of them had said, but ‘now that you're on the phone to me, I'll come’. So our phone call is really, really important.”

"And I haven't been able to fix that other than to say somebody cares in the system and is willing to give you time and try and at least be with you in that way, even if I can't solve it.”

"I think we've done a lot more in the way of polypharmacy, reviews of elderly people at greater risk and done much more in the way of stopping medications that they've been on for a long time that maybe they don't need now.”

Case Study 5: The role of time in addressing health inequalities

This case study presents findings from interviews with staff in ten practices. Each practice has used programme funding to support approaches to providing access to extended consultations for their patients with the greatest needs.

Rationale for extended consultation

Staff across the practices described the range of health and wider issues and challenges faced by many of those in their patient populations. They also commented on how this can contribute to higher levels of demand and unmet need, and the importance of those in General Practice being supported and enabled to work in a way that can better meet those needs.

“I suppose it's really just need, there's an unending need for better care for patients and really this funding that we've been provided has been used to provide what we would see as better care, and for some of our more vulnerable patients.”

“I think there's a vast amount of unmet need and I think we're scratching on the surface at the moment, but I think it's definitely helpful because we have such high demand and such pressure on appointments. And realistically, if you're going to deal with the problem properly, you can only deal with a certain amount in one appointment. So to be able to have the time and the capacity to be able to spend a bit longer or, get patients back and focus on specific aspects has been very helpful.”

Staff in General Practice spoke passionately about wanting to do the things, and work in the ways that could have the greatest positive impact on their patients and provide them with the care and support that can help them overcome the various challenges they face.

“It’s trying to be proactive in terms of doing things to try and help those whose health is adversely affected by their social demographic.”

“Govan is one of the biggest areas for deprivation in Glasgow. I think trying to enhance the experience for the patients is a key thing.”

Making it happen

Practices described having extra protected time to plan and deliver extended consultation as being crucial and that partners in a practice were open to change and willing to adopt new models of working. Allocating more time was achieved through funding being used for additional hours for different roles, for example, a practice nurse to do some initial assessment work and medical tests before the doctor saw them, or locum time, which meant that there was an additional complement of GP hours.

“Time, absolutely. That's the fundamental thing - it's very much been things that we've been keen to do as a practice over the years, but time is of the essence and with the demand that we have, even without doing extra stuff, more often than not, we're doing reports and paperwork at home because we don't have time to do it during the day when we're here. So just having that protected time is hugely beneficial.”

Laying the groundwork for this work by identifying people who would benefit from appointments was an important early step. Involving clinical students on placement in the practice, as well as administrative staff in this process, eased the burden and created a collaborative approach across different team members, in addition to being a valuable learning experience for the students involved.

“We've identified a lot of people that we thought would benefit from it. I would say we were quite lucky but we were actually quite clever. A few medical students are in working for us, well training. And they were looking for a project to hand back in to their tutors, and they asked if there was anything that they could focus on. And we suggested, ‘we’ve got this new project identifying patients who we find have barriers to health care’. So we tasked them with that, identifying these patients. And the results were quite surprising. I'm glad they did it because they were looking at it from a different view than I would.”

The catalytic influence of the programme, beyond that of additional funding, was also recognised, with it bringing about conversations and creating the space to think about how things can be done differently.

“It was not only funding which was great, but it gave us a reason to have these discussions and a bit of brain space that was almost like it was required of us because there was money given to us but it meant that we were having these conversations.”

Focussing activity where it can be of most benefit

Extended consultation activity has been focused on patients who are most vulnerable, at the highest risk, or would benefit most from having additional time with a healthcare practitioner. This has included:

• Patients living with mental illness
• Patients living with chronic diseases or conditions (e.g. diabetes)
• Patients with multiple co-morbidities
• Patients with drug and/or alcohol-related support needs

For example, staff explained:

“We have a number of patients who would have what we call a ‘personality disorder’. And so with personality disorders, one type is an antisocial personality disorder which basically means that they find it difficult to engage well with other humans just in general… So what we managed to do with the help of this funding is that we understand our patients who are like that. So what we can do is offer extended contact time with them and an increased ease of access for them to our service so that they can effectively be listened to or be heard or feel that they're being heard.”

“I had [someone] who doesn't often come… one of our methadone patients, and just to know that there's a little bit of extra time, when they came I could also do their bloods, for example, because they’re just not going to come back…and it just allows you to offer a fuller piece of care.”

Several practices have also utilised extended consultations to support patients, who due to English not being their first language, face barriers to accessing healthcare and require additional support to understand and navigate the health system. This has included refugees and asylum seekers who have arrived in Scotland and been housed in the catchment area of these practices.

“A couple of years ago we tried to figure out how many people spoke different languages and there were 13 different languages spoken. Here is probably the most deprived area in Scotland.”

“So it helps with the translations, it helps to go over and reiterate that and agree that that's what somebody means. And usually you've got another member of the family when they're here as well.”

“We very frequently, several times a day, have to use the phone interpreting service and obviously everything takes double the amount of time for the same quality of consultation instead of it taking 15 minutes it then takes 30 minutes.”

Benefits and Impacts of Extended Consultations

A number of different benefits and impacts were reported as a result of extended consultation activity for patients and practice staff. Firstly, staff reported an improvement in patient experience, which was reflected in the positive feedback they received from patients.

“So having this additional time which we can afford to give now has been really beneficial… a lot of the patients are giving good feedback and quite a lot of it verbally, coming over and saying, ‘it's been so good’, ‘I've been so well looked after’, ‘I felt I was listened to’, ‘I felt the doctor wasn't rushing me out the door’, so that's been good.”

Staff also explained that extended consultations provided the additional time needed to have more person-centred conversations and explore in greater depth the health needs and wider issues and challenges that their patients face. This included identifying other services or support that patients could be referred to in order to meet their wider needs.

“[Patient] had [multiple] different quite complicated issues to bring up...and I've not seen them for a while, and it just allowed me to have half an hour with them, which I think was quite valuable to be able to go into detail.”

“And it might be that they get a referral to elsewhere, but at least if we're listening to what's going on, we get the time to listen and we can send them to somewhere that can help them. We've been doing a lot of work like that.”

Some staff described positive impacts for staff, which mainly related to reducing pressure and increased satisfaction in the care they are able to provide. It was also reported to have provided valuable learning and experience for training practices that have trainee clinical staff.

“The doctors have been expressing that they're enjoying it as well. They're getting a lot of job satisfaction out of it, and I think with the patients feeding back to them as well, you know, ‘thank you doctor’, ‘thank you for listening to me’, you know, they get a lot of pleasure out of that as well.”

“We have very capable [trainees] in practice just now, so it's meant that their appointments have filled up more readily and so we've been able to backfill some of that and give them experience and supervision.”

Overall, staff perceive that extended consultations are helping to ensure that they can provide the level of care that can have a positive impact on the health and wellbeing of their patients.

“It's been really, really enjoyable and it's really benefited the patients. A lot of their healths are improving.”

Case Study 6: Challenges and barriers to implementing IHAGP activities

This case study presents some of the challenges and barriers faced by 11 participating practices when implementing IHAGP activities.

Funding

Most practice staff highlighted challenges linked to IHAGP funding amounts and processes. The low-value, short-term nature of funding was described as limiting what practices were able to achieve or a barrier to introducing longer-term interventions, such as hiring new staff. Some also felt that the non-recurring nature of the funding prevented staff from investing in development activity or taking up funding opportunities in the first place, due to the unsustainability of any changes introduced.

"The amount of money…you couldn't employ somebody, It's non-recurring. … It had to be something that was going to be short-term… We did a project on looking for our missing smears….but long-term, it's impossible because we can't get locums to work out of the cities. So, it's just basically extra hours for ourselves and most of us don't have the extra hours to give.”

“Sometimes GPs don't engage with opportunities… because historically we've had our fingers burnt with investing time and emotion in projects. Only to find that after a year or two, it gets snatched away.”

Limitations with primary care funding generally were also raised. In this context, IHAGP funding was described as having minimal impact, used to deliver activity that should be happening anyway, or put towards pre-existing activity that was not adequately funded.

"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… (IHAGP) 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. It's very early days and it's still very insecure and fragile."

“The sort of stuff that IHAGP is doing…we should be doing it all the time, but there's just not enough resource for it at the moment.”

Some explained that the changes they had introduced could not be sustained without further funding or highlighted their continuation at a cost to staff wellbeing, and in turn, recruitment and retention. There were calls for increased and recurring funding to allow practices to sustain or further develop IHAGP activity. Others suggested that although 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.

“The GP is squeezed. It's a very perverse business model… It's then expected of us that we will do these things for reasons of compassion. And we do them for reasons of compassion. And then we reach burnout. And that's where you've got GPs hanging up their hats...and you've got a problem with recruitment.”

"It feels as though it's the tip of the iceberg that we've started, and it would be great if we could carry on… But the only way we would be able to do that would be with funding - there’s not the time and the resources to do it without, with the demand that we're under on a day-to-day basis.”

"If we had the time and the resources to be able to deal properly with things in the community… [that would] have a knock-on effect on the number of people needing to attend secondary care… There's no point in putting more and more money into secondary care because if it's not being dealt with at the root, then you're on a hiding to nothing.”

Systemic barriers

Wider social stressors and systemic inequalities and injustice, such as poverty, job instability, poor nutrition, isolation and trauma, were raised as barriers to tackling health inequalities by some practice staff. The need for preventative, community, and population-level health interventions, with GP input, was highlighted.

“The retail sector are making an absolute fortune out of making the population ill… S1s were taught in the school down the road how to add boiling water to dried noodles, that was their cookery. The council are quite happy to let Fish and Chip shops get licenses directly across from school gates. So it's so multifactorial…If you go into supermarkets in the well-to-do areas…you'll have a lovely fruit and veg aisle. And in [our area], the first thing that hits you is chocolate and crisps and full-fat Coke. And they know what they're doing.”

"A lot of what we see comes down to how poorly nourished our patient groups are. GPs have probably got a big role to play in shouting about that….I suppose that bit about GPs having leadership roles within communities and being listened to at leadership level… people just leave GPs to see the patients, but don't ever say ‘what do you think needs done?’”

A few reflected, however, on the difficulties GPs face focusing on preventative activity in the current climate of high demand and funding and time constraints.

“General Practice has lost that… proactive stuff… maybe never really had it. It doesn't feel like there's a time to do a lot of that stuff. … [For IHAGP activity, we have noticed the things] that aren’t working… Community Treatment and Care’s [CTACs] not working…. the struggle for appointments, and that's the things we've tried to fix…. But that's problem-solving, that's not being aspirational to try and improve health generally…. that front end stuff is harder to think about when you think ‘that may be a lot of time I put into that’.”

Communication, support, and administration

Challenges linked to IHAGP programme communication, support, and administration were raised. Most commonly, participants felt they would have benefitted from better communication about expectations for participation in the programme and support with idea generation for IHAGP activities. Some shared that while the freedom to decide how to spend funding was appreciated, the parameters were so broad, it was difficult to know what constituted acceptable IHAGP activity or where best to focus their efforts. Others described initially being unaware that the funding could be spent under more than one theme or on an activity that the practice was already delivering.

“Quite a degree of confusion as to what was expected reigned for quite a long time. Maybe still does.”

Suggestions to better support practices with idea generation and the practicalities of implementation going forward included:

• Publicising examples in newsletters to spread awareness of different practices’ approaches to utilising IHAGP funding.
• Holding more meetings (in person or Teams) to discuss what others are working on.
• Linking practices with existing services that can support them with implementation, such as health improvement teams and community link workers.
• Having GPs in advisory roles able to offer guidance.

Further administrative and communication challenges included some practices not being notified when they had received funding. Communication was, however, described by the participant below as improving with time:

“Communication is improving. In the first half of the year communication was very, very poor. People didn't even know they'd received the money in some cases or didn't even know they were part of the programme. So that's definitely improved.”

Finally, a couple of participants also raised difficulties with forms. One found feedback sheets hard to fill in. Another suggested personalising monitoring forms to avoid repetition for those filling them in and that reviewers offer more feedback from these.

“I don't know if [monitoring forms] can be personalised a little bit for each practice to say, right you've given us this and we now need it for this.. because every email I've had recently…has had a blank monitoring form…and I'm thinking do I need to do that?…. [And] I would like a little bit of feedback on what they thought and what I could be doing better.”

Case Study 7: Patient engagement for peer support and service development

This case study presents findings from interviews with staff in three practices who used IHAGP funding to enhance existing community engagement work or support new activities to connect with their local community.

Drivers of patient engagement activity

Those with experience in community engagement and facilitating peer support identified benefits for their patient population. IHAGP funding was viewed as a resource to expand or enhance this activity.

"That's something that we very much want to be able to expand because that can do far more than anything that we can give them medication-wise.”

"Particularly [a community group] loneliness group, the patients who went to that at the start were very much the people who we would see week in and week out and really with chronic problems that we didn't have an answer to. And when they were coming in to see us, it was more just for someone to talk to and a bit of support.”

Practices without direct experience also recognised the potential benefits of this type of activity. One staff member described a long-held desire in their practice to create patient groups, noting that IHAGP funding was the catalyst for them to take it forward.

"That's what I want out of this - just trying to make it, as a whole, a better practice so that we're more part of the community.”

"For many years we've been working with social prescribing and trying to be proactive in engaging with patients. So it's very much something that we as a practice have been trying to do for a long time.”

Harnessing what exists or creating something new

Starting community engagement activity can be resource-intensive and daunting; however, one practice manager explained that working with and supporting existing groups made it more feasible and achievable. Another described a need to create something new, due to a lack of suitability of existing groups for specific patient populations.

"We just fed into that, with new patients every week, and we would go with the patient the first time just so that they were feeling they knew somebody. It’s reassurance from myself, or from [colleague] or anybody, you're going to be fine when you go there, we'll go with you the first time and they've just all been going back.

"There is a lot of walking groups, some that can walk slow, some that can medium walk, some can fast walk, but the ones that were coming in with infirmities, with sticks and things, even felt when they were going with a slow walking group they were holding everybody back.”

One practice reflected that the experience of carrying out community engagement generated awareness of other opportunities and possibilities for patient support.

"The more you do of it, the more you start to see other areas that you could work in. Obviously, the patient groups that we've started recently has been specifically focused on diabetics, but I think patient groups for COPD [Chronic Obstructive Pulmonary Disease] or some mental health issues, there's so many groups…..and again, that's another area that you think people with chronic pain and arthritic conditions. So I think there's so many, the more you start looking, the more you're going to see”

Involving colleagues and partners

Patient engagement has incorporated input from different staff and partner organisations who bring capacity, experience and expertise, achieving mutual benefits for those involved.

"Get community pharmacies on board or, you know, the local church or something like that. I found that far easier to do with that little bit of support. I think it's made a massive impact.”

"We now employ some of our receptionists to go and help supervise at these meetings as well.”

“Yeah, I think having [community link worker] is invaluable, because without them we wouldn't have that initial person going, ‘do you know what, you would really benefit from this’, and that trust is there already.”

"I hooked up with one of the dietitians who's very enthusiastic and was great and she said if I was really interested in running a group, they would be interested from their side for their students. I could see a lot of benefits from that because they basically ran the group and I just got the patients and went along and it was students, it was a student-led thing. So the way we did it was we got, so I had two groups of patients and each group of patients was invited to two sessions, an initial session where it was a bit more about diabetes, and then the second session was more of a follow up and more about the practicalities and more free flowing…… So I just invited your normal Jo who has diabetes who tends to be, I was just thinking younger people are probably going to gain more from it in the longer term.”

Involving or demonstrating the impact to others in the practice was also described as a route to change perceptions and gain wider support for patient engagement activity.

"Yeah, because if you can say to someone, you know, we've seen this person on the walking group, right? And before we've seen them on the walking group and they had that social aspect in their life, they used to come in practice once a month and they used an appointment, right? And I can then say, well, that person hasn't been in here in six months What do you think that says?.”

Barriers to starting patient engagement activity

Practice staff shared their thoughts and experiences on the barriers to starting patient engagement activity, and two core themes emerged. The first related to knowledge and confidence in delivering this work. The second was uncertainty about the ability to sustain the activity due to a lack of clarity about continued funding.

"But things like more community connections, and going into the communities, bringing the services which are available in the communities to the health centre, and making patient groups and getting them involved, sending staff to them, that would require ongoing funding.”

“I would say there's a lot of uncertainty, like what's coming through, whether it's an ongoing thing, I think it is easier to plan if we know. It's really kind of tricky to plan things, and we are not sure whether it's an ongoing thing or not.”

"I was maybe a bit overwhelmed at setting it up myself, you know, in terms of like resources, time, confidence, and you look at all this stuff online, there's lots of stuff online about groups and they talk about having a, let's call it a facilitator and the structuring, like there's stuff in England about all these groups. Well, they're very structured and it's all intimidating. If you're looking at that, you're thinking ‘how am I going to do all of this?’.”

The importance of resources to start and sustain activity

Having the capacity and staff resources to connect with existing groups or establish new activity is critical to enabling this area of work, however, funding is also a key factor in enabling and sustaining patient participation. This could involve providing funding for arts and crafts materials, or for example, paying for refreshments at the end of a walk for patients on low incomes who were taking part in a walking group.

"It really helped because we've got a lot of people who don't work, very low incomes….so we came back to the cafe which was costing them maybe two or three pounds for their tea, so [colleague] said, ‘we've got the funds why don't we use it for that?’, and then that kind of started…they came back more because, they weren’t thinking, well it’s my turn to buy a cup of tea for everybody this week.”

"So yeah, I mean it's really been a pleasure to watch that actually, and that wee bit of funding, it's not mega money it's just a wee bit of funding that backs these wee groups up, that's what helps the best.

What difference does this activity make?

Practice staff identified the benefits generated by patient engagement activity for:

• Staff members
• The Practice
• Patients

Benefits for staff include enjoying involvement in this type of activity, and observing the positive impacts for patients, which enhanced experiences of their role.

“The people that have all been coming, can now go in different places and the confidence you can see in them. That's where I get the joy of my job when you actually see your job's working, and that's where you see that the results are.”

Patient involvement has also contributed to service improvement, with groups providing valuable feedback on how things can be improved and enhancing patients’ views on the practice and staff. Another benefit for the wider practice was shifting internal perceptions of how to support patients.

"And actually, you know, [groups] work as a good sounding board to get a realistic idea of how the patients view the practice and what they think we can improve on.”

“The patients do feel that the surgery’s doing something else for them, apart from just giving medication. And this is all about their mental health as well, do you know what I mean? So all these things, you know, it makes a big difference to some of them coming into the surgeries.”

“And I think building up the trust that we're here for something other than prescriptions helps us as well.”

One practice highlighted that working alongside a university to deliver patient engagement activity provided valuable benefits for students by giving them additional real-life experience with patients that they would not have gained otherwise.

“The university, they're delighted because for their students, it's a real-life experience and the [sessions] went well and our patients who turned up were really engaged and there was a lot of chats and I think on all fronts, it was a very positive experience.

Practice staff described physical and emotional benefits for patients stemming from the activities undertaken in these groups and the crucial peer support that patients can provide one another. This was seen to contribute to a reduction in healthcare service use.

"A lot of them are saying it benefited their physical health but it also benefited their mental health just because they had someone to talk to.”

"And, you know, the support that they've given one another and the self-esteem has been hugely beneficial to the people that attend these groups.”

"And it's incredible how that group has now given them support that they need. And that's meant that they need fewer appointments for the healthcare professionals.”

Case Study 8: Staff Reflections on Patient Care

This case study presents stories drawn from interviews with staff across five practices. These are examples of the experiences staff have had when engaging with patients through IHAGP activity and do not necessarily reflect patient experience.

Investing time to understand patient history

A key feature of IHAGP activity is identifying patients who could benefit most from proactive outreach and extended consultation. One GP identified patients with a typical long history of repeat presentations at A&E and out-of-hours services due to a combination of physical and psychological symptoms.

“[A patient] has a number of kind of fairly deep-seated post-physical and psychological problems. If you look back at previous notes, hugely present to accident and emergency and out-of-hours services. It was kind of hyper-investigated, you know, for basically lots of what we call somatic symptoms or psychosomatic as in these are real symptoms, but they are augmented or amplified by [the patient’s] psychological state.”

Before the appointment, the GP spent considerable time reviewing the patient’s medical history to fully understand their experiences and potential underlying causes for their frequent use of healthcare services. This allowed the GP to discuss this with the patient and describe what they had observed over the years. This supported the patient's understanding and provided reassurance that nothing was being missed.

"This [patient] has the classic long long history of multiple investigations and health inputs. What I was able to do with them is go through myself [many] years of medical notes which took me probably a day….and try and get to the bottom of why [the patient] is having these types of unmanaged chronic [problems] that's causing them so much anxiety and depression and low mood and dysfunction. So I was able to take a day to go through all that, and go back to [hundreds of] letters, and really gather a good picture in my own brain and then able to reflect that back to them. And I think that was helpful to bring them on the journey, that you are being listened to, you're not being ignored, but we're also not missing like a cancer diagnosis or that there's something sinister going on, but there's something very real to cause your pain so let's try and work at this together."

This approach positively impacted the patient and the broader health system.

"[The patient] almost has no presentation to accident and emergency now, [and] almost has no presentation to out-of-hours services. Now, that's not of particular benefit to us as a practice because it doesn't affect us, but it is of benefit to the wider health service. I think the patient also benefits because they feel listened to and validated and valued rather than ‘nobody's interested in me, I feel ignored, I feel like something's been missed’."

Prevention and early intervention

Helping patients better understand their health issues and the range of controllable factors that contribute to them can empower them to make choices and changes that positively impact their health.

Identifying these issues at the right time and taking the necessary steps can mean reduce or prevent more severe and complicated health issues in the future.

"So all of these things, it was just one extended consultation….. it's about prevention and having an early intervention…actually taking the time with them and having the processes in place within the practice, we were able to make a really big difference"

Advocating for patients

Proactively contacting patients to check in with them can reveal issues that require an intervention that would not have been known about otherwise.

"In other examples from the outreach, someone who thought [they were] on a waiting list for surgery. But they'd written to say [the patient] hadn't attended an appointment, and [the patient] didn't even know they had an appointment. They hadn't received the letter. They hadn't had any phone calls or what have you. So this is an appointment that they should have had months before…. It could be potentially life-changing if they didn't get treatment.

The GP liaised with other healthcare professionals to advocate on the patient's behalf and request a new appointment for their surgery. The GP also demonstrated their concern for the patient and reassured them that they were there to support them.

"So I was able to contact the service and say that [the patient] was unaware that they had an appointment and asked them to reappoint [the patient] and asked [the patient] to get back in touch if they hadn't heard from them [the service]. And really explained to [the patient]…it was important and I would follow it up on their behalf."

Understanding patient fears that act as barriers to engagement

Awareness of why different patient groups might not engage with healthcare services is critical to addressing those barriers. The knowledge and expertise of different professionals can provide those needed insights.

"Our drug worker as well, who runs a drug clinic once a week, [has] identified quite a few patients who we weren't aware of struggling with their health, but were almost afraid to come to the doctors in case their medication changed, or stopped. So that was a group that we never thought of. We just thought, drug users just don't bother coming to the doctors, or don't bother coming to their appointments and DNA."

Addressing patients' concerns and misconceptions can result in improved engagement and ensure they receive the required care, treatment, and medication.

"But it turned out [the patient] was actually quite afraid. [They were] afraid that one of their medications was going to get changed, and we really assured them about that. We got them in, got them their medication, what they needed, and they’re doing fantastic now."

One GP described their approach to initiating contact with patients to reduce fear:

“One example was before Christmas. The first time I'd done it, I'd just done the search and I was phoning down my list of people. I wasn't quite sure how to express it because if I was to phone up someone and say I'm phoning you because you missed an appointment, they'd instantly think I was phoning to tell them off. So I decided to say ‘I'm just phoning because Christmas is coming and I'm wondering how you're doing. It can be a tough time of year for people’.”

Proactive outreach patient to connect with vulnerable patients

One GP described offering proactive outreach to vulnerable patients, and the difficulty of getting access to the right support and the need for ongoing engagement.

“I mean, it hasn't solved their problems. Mental health team, unfortunately, haven't felt they can support them after assessment... So I'm still trying to offer them support. And in fact, they came to see me a couple of times and they stopped coming to see me. So they're still missing.”

Managing aggressive behaviour to provide continuity of care

Problematic patient behaviour is a challenge in general practice. This is often borne by receptionists, the first point of contact.

"I think administrative staff carry a huge burden in GP practices because they're usually the front line of everything, so when people at their most anxious or the most upset or the most frustrated or the most aggressive, it's actually the admin guys who get it first."

Rather than remove a patient from the practice list, one practice worked with them to communicate expected standards of behaviour, while acknowledging the individual's health problems as a contributing factor.

"It means that I see [a patient] for double amount of time if they call and I try and call them back the same day and we were able to sit down when [the patient] was being particularly abusive I was able to sit down and work out a plan with them, and the practice manager, so that they understand that there is a minimum standard of behaviour, but we do understand that [they have] personal challenges that our other patients don't.”

Finding an effective way to navigate these issues with patients has meant that they have been able to remain with the practice and receive safe and effective care and treatment.

"It provides continuity of care for them, and we've managed to get them off of all these toxic doses and we're managing them on medium strength [medications] that are much safer"

This case study demonstrates how activity delivered under the three IHAGP themes can contribute to meeting the needs of patients. While it is not representative of the experiences and benefits of all patients that have engaged with and been supported through IHAGP activity, it does provide insight into the significant benefits to health and wellbeing that can be generated at an individual level.

Final thoughts

These eight case studies have provided valuable insight into ways in which practices have used IHAGP funding, the impact of the funding and the challenges and barriers that practices have experienced.

We would like to thank all the practices and staff who took part in interviews to inform the case studies. Without their participation, these case studies would not have been possible.