Research published today in Lancet Public Health provides five key principles to help GPs offer equitable care
GPs and primary care services are at the forefront of work to tackle health inequalities in the UK but, despite thousands of studies of different interventions, the evidence about what works remains inconclusive. In part, this is because the studies tend to disregard the many overlapping drivers of health, such as gender, ethnicity and policy on housing and education, which together explain the sharp differences in health and wellbeing between different groups in society.
In a new approach to the problem, rather than seeking a one-size-fits-all formula, researchers have used the existing evidence to generate five principles for equitable primary care. The research was funded by the National Institute for Health and Care Research (NIHR).
The goal is to support GPs to offer equitable care, by helping them address the complex social determinants of health. The five principles are part of an action framework for healthcare professionals and decision makers showing how general practice can contribute to reducing health inequalities.
The research team was led by Dr John Ford, now at Queen Mary University of London, and Dr Anna Gkiouleka, researcher at the Primary Care Unit at the University of Cambridge. The team studied research on interventions that increase or decrease health or care inequalities in general practice, looking for the qualities that inform successful interventions
They found 325 studies addressing these questions, covering a wide range of interventions, settings, and populations. Even when interventions seemed to focus on single aspects of care, for example, invitations to screening programs, the team found that their effectiveness was subject to other aspects, like the availability of patient contact details. So, instead of producing a long list of interventions that would likely only work in the context in which they were developed, they focused on extracting transferrable evidence about the common qualities that inform successful interventions.
Dr Anna Gkiouleka said: “Healthcare services, and especially general practice, can help to address the health inequalities that arise from the complex web of factors that influence our health over our lifetimes: the social determinants of health. We found that there are common qualities that characterise successful interventions, which we have distilled into these five key principles”.
She explained the implications for GPs, health services and policymakers that flow from the five principles: “We want to highlight the value of accurate data collection and maintenance of patient records, appropriate communication material, service convenience, work to address patient living conditions and actions to engage disadvantaged patients in primary prevention”.
We need to continuously assess how well quality improvement strategies are working for disadvantaged groups and whether interventions are delivering for people experiencing social and economic disadvantage.”
– Dr Anna Gkiouleka, researcher, Primary Care Unit, University of Cambridge
The five key principles to help GPs offer equitable care
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Involve coordinated services across the system (connected)
The evidence describes how care decisions and interventions interact to shape a ‘landscape of inequalities’, where disadvantaged groups are affected by multiple forces. General practice services and interventions should be understood, designed, and delivered as connected components of coordinated action towards equitable general practice.
For example, ineffective collection and use of patient information can lead to ineffective patient risk assessment and screening uptake, which in turn means that disadvantaged patients with increased risk of cardiovascular disease or cancer may not receive the care they need.
Some patients may additionally be disadvantaged by the impact of GP practices’ financial incentives schemes and by some physicians’ biased perceptions.
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Account for differences within patient groups (intersectional)
The evidence shows that care and interventions do not reduce inequalities when they do not account for differences among patients. General practice needs an intersectional perspective to account for the different impact of services and interventions among patients according to their circumstances and experience of (multiple) disadvantage.
For example, educating patients about their condition and its management can improve self-management behaviour and related health outcomes. But there are practical barriers for patients with complex social circumstances, low income, or limited transport options.
Translating written communication to engage with patients who have limited English language skills without accounting for differences in literacy or dialects used within groups excludes certain patients from engaging with information material.
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Make allowances for different patient needs and preferences (flexible)
General practice should make allowances for different patient needs and preferences in terms of time, communication, and provided support.
Socially disadvantaged individuals might need:
- encouragement to get involved in decision making;
- practical assistance with visiting their practice.
When telehealth programmes are implemented, some patients might need training or translation services.
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Integrate patient worldviews and cultural references (inclusive)
Inclusive care is designed and delivered in a way that does not exclude people based on assumptions about who they are, what they need, and how they ‘should’ behave.
Cultural understanding between practitioners and their patients supports work to address health disadvantages. Culture influences how we understand disease, health, healthy behaviour, the role of family, and gender roles.
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Engage communities with service design and delivery (community-centred)
Everybody involved in general practice should have a say in how care is conceived, (re)designed, and delivered, to support long-lasting relationships of trust.
Tailoring services to local need improves care for disadvantaged patients and involves a series of elements including:
- familiar premises for the delivery of interventions;
- uninterrupted communication;
- the integration of patient worldviews in the design and delivery of services;
- integrating community members in care delivery in supportive roles.
Increasing ethnic and language concordance between patients and practice staff and enabling practice nurses to operate as communication bridges between patients, clinical, and non-clinical staff helps address inequalities.
Reference
A Gkiouleka, G Wong, S Sowden, C Bambra, R Siersbaek, S Manji, A Moseley, R Harmston, I Kuhn, J Ford: Reducing health inequalities through general practice. Lancet Public Health, June 2023
Contact
Lucy Lloyd, Communications, Primary Care Unit, University of Cambridge
Image
Dr Jon Ferdinand for the Primary Care Unit