Inclusion Health Action in General Practice (IHAGP): evaluation

Theme 1: Patient engagement

Theme 1 of the Inclusion Health Action in General Practice (IHAGP) programme focused on building inclusive patient engagement and community participation.

Considering the complex challenges faced by patients living in socioeconomically deprived areas – such as trauma, language barriers, isolation and stigma – this theme sought to address healthcare inequalities driven by barriers to accessing or engaging with services, ensuring that patients were met where they were and provided with holistic support tailored to their needs.

Objective of the theme

The objective of Theme 1 was to increase patient and community trust and engagement with general practice teams amongst those in socio-economicially deprived areas, to reduce healthcare and health inequalities. Activities under this theme were designed to:

• Improve trust and relationships between the practice, patients and the community.
• Provide patients with better access to appropriate health and service information.
• Improve patient knowledge and motivation to better self-manage their health conditions.
• Enable the practice to collect and act on patient feedback to make improvements.
• Improve staff knowledge of patient population, services available and the link worker role, linking to the benefits of workforce training and development in Theme 2.
• Equip and support staff to better meet patient needs.

By achieving these objectives, Theme 1 aimed to create a more inclusive practice environment whereby patients had the information and trust to engage with the appropriate health services.

Summary of activities

From the implementation data gathered through the monitoring form section of the staff survey, 43% of practices undertook activities in this theme. Practices engaged in a wide range of activities under Theme 1, reflecting the flexibility of IHAGP funding and the diverse needs of local populations. Activities included peer support groups, community outreach, clinical initiatives, proactive engagement and collaboration and training.

Types of Activities Delivered

Types of activities delivered under Theme 1 were varied across a wide range of initiatives. Common themes included:

• Establishment of support for peer support and groups: such as bereavement groups, mental health peer support, ADHD (Attention Deficit Hyperactivity Disorder) children’s group, diabetic patient groups and chronic pain classes.
• Community outreach: including walking groups, yoga referrals, sports centre partnerships and community health talks.
• Clinical initiatives: such as structured diabetes clinics, cardiovascular disease (CVD) focused action, extended consultations for complex patients, anticipatory care for housebound patients and frailty outreach development.
• Proactive engagement: new approaches to engage patients who miss appointments (often referred to as ‘DNA’ or ‘Did Not Attend’), especially where this is repeatedly, or are ‘missing’ ^[6] from care. This included, for example, increased recall efforts and invites, referrals to other community wellbeing services, and outreach to asylum seekers/refugees.
• Collaboration and training: providing linkage to other services and training opportunities, such as working with community projects or providing pharmacy hub training and student dietician involvement.

Staff survey data depict the range of engagement activities used under Theme 1:

• 71% of staff reported changing forms of communication to suit patients,
• 65% reported updating facilities and information,
• 59% reported providing translated materials,
• 35% reported changing how they work with community link workers,
• 33% reported supporting existing health or wellbeing groups,
• 27% reported seeking feedback from specific patient groups or undertaking patient engagement exercises,
• 22% reported creating new health or wellbeing groups,
• 20% reported changing how they work with voluntary/community partners,
• 14% reported creating new peer support groups or patient panels,
• 14% reported supporting existing peer support groups or patient panels.

Overlapping with Theme 3 (Enabling proactive outreach and extended consultations), most staff described proactive outreach and extended consultations in line with activities under Theme 1, including contacting participants through a variety of means to reach those who are “missing” or have been out of care for periods of time. For example, inviting patients to attend diabetic clinics or drop-in cervical smear sessions, or using translation services or software to contact those who do not speak English.

Others described efforts to provide better linkage to useful information and services, and a few mentioned facilitating new or existing groups under this theme. One patient reflected:

“I’ve been sent to [health and wellbeing sessions], just when I was struggling with my mental health after [major] surgery. So, I’ve been referred to mental health and wellbeing groups with nurses at different surgeries and things. They’ve been quite helpful – I went to a sleep support one, and I didn’t find it much help, but some of the other ones have been quite good, just to have a chat with people in similar situations. It makes you feel like you’re not alone with how you’re feeling.”

Approach and Target Groups

Some staff reflected on how patients were identified and invited to participate in these activities under Theme 1.

One described the approach as informal: “Opportunistic invites from wider team to engage with community link / money advice / whole family wellbeing.”

Others discussed intentionally identifying those that would most benefit from these groups and specifically inviting them to participate, often for clinical services: “We identify groups that would have the most benefit and call them in groups of 5-10 at a time.”

A variety of staff roles referred patients to activities under Theme 1, including community link workers, GPs and administrative staff. Some staff described discussion of these referrals at Multi-Disciplinary Team (MDT) meetings to discuss and agree on approaches.

Staff survey data explore the myriad of different ways patients were selected or encouraged to take part:

• 68% of staff reported that patients were invited based on clinical risk or needs,
• 55% reported that patients were invited based on societal vulnerabilities,
• 36% reported that these activities were open to all patients,
• 30% reported that these activities were advertised to a specific group with flyers or other materials,
• 16% reported that patients were referred to take part from a community or voluntary group.

In cases where patients were invited to participate based on clinical risk/need or societal vulnerabilities, staff explained that this process often involved substantial and repeated effort from staff to identify those to invite, and contacting them through multiple means (text, letter, call) where appropriate. Similar views were expressed by staff whose practices have worked on Theme 3 (Enabling proactive outreach and extended consultations).

In line with the aim to address health inequalities, practices used funding from the IHAGP programme to engage with specific vulnerable populations:

• The “most socio-economically deprived patients”.
• Patients with complex conditions or trauma, such as mental health issues, addictions, neurodevelopmental conditions and those who are housebound.
• Patients with additional language needs and those requiring interpreting services.
• New patients, especially those with alerts (where practices use electronic patient records to document and flag patient needs) or language barriers.
• Patients who were identified as having missing appointments (‘DNA’ or ‘Did Not Attend’).

Participation and Roles

For peer support groups, staff who completed the survey often mentioned small groups of 5-10 patients that participate in each group. However, this figure was described as varying widely week on week. Thinking about her experience running a mental health group, a staff member explained that this variation comes with the challenging subject matter of the groups:

“I mean it's the thing about mental health - people will come if they want to, but if they're not having a good day, they'll pull out. So, we've had people that have came once and not came back for two months.”

Some mentioned the active role of community link workers in leading groups, although one or two mentioned other staff, including clinical and administrative staff, that support these groups. One community link worker stated that she shared responsibility for leading a monthly group with community link workers at other practices in the area via a rotating lead, although she regularly updated clinical and administrative staff on these groups.

According to staff survey data:

• 58% reported that the practice led these groups,
• 8% said someone else, such as a charity, led these groups,
• 35% reported that both the practice and a charity lead these groups.

For community outreach, link workers were described as an invaluable resource, in terms of knowledge and linkage to community services and to address social determinants of health:

“What we've noticed is when we've been maybe registering patients as well, we're looking at them and thinking to ourselves ‘OK, then maybe you might not want to see a GP, but it might be handy if you see our link worker’ because yeah, again, it's another thing that we can maybe look at them and [say] ‘think you're going to need additional help.’ So, you contact them and say, ‘this is here and they might be able to help you.’”

For clinical services, staff often cited multiple methods of contact, including phone, text and mailed letters as avenues they used to expand patient engagement under Theme 1. However, for these activities, staff members discussed that, despite their efforts, some may not be in a place to take up such an offer at that time:

“We do have some families who are chaotic and their engagement is patchy, particularly with our family welfare workers… And there are times that we have to say, well, maybe just don't try for three to six months again like, you know, maybe now is not the best time to capture them.” This staff member continued that it takes “time and resources” to reach those that “for whatever reason, can’t or don’t want to engage”.

Reflections

Implementation

Thinking about factors that helped make engagement under Theme 1 successful, 66% of staff mentioned dedicated time or resources, often using locums to help identify and target patients, or free up time for other staff to do so, also translation software freeing up time that might have been previously spent in translation or misunderstanding. Without this funding and support, staff in interviews reflected that they would not be able to maintain outreach.

Other factors that staff respondents reported helped make the engagement successful included:

• 52% of staff respondents said support from link workers/community partners,
• 50% of staff respondents said strong connection with the community,
• 48% of staff respondents said strong team buy-in,
• 39% of staff respondents said staff training.

18% of staff cited that learning or sharing from other IHAGP practices helped make patient engagement successful. Reflecting on her experience attending an introductory workshop on the IHAGP programme, a staff member referenced patient engagement activities such as “booklets for people that English isn’t their first language, in different languages, so like induction booklets for the practice” which she replicated and brought to her practice.

It is notable, however, that structured mechanisms intended to support shared learning, such as IHAGP webinars, a Microsoft Teams channel and cluster ^[7] sessions, did not feature strongly in staff accounts. This may reflect variation in engagement or limited coverage of these activities in the interviews and surveys, rather than an absence of benefit. A more explicit focus on capturing how practices engage with these shared learning platforms in future evaluations may help to better understand their contribution.

Benefits

Overall, many staff members reported perceived benefits for patients because of activities under Theme 1:

• 50% of staff perceived that patients who participated had increased attendance at appointments/meetings,
• 50% perceived improved mental health and wellbeing,
• 48% perceived increased proactivity in looking after their health,
• 45% perceived increased confidence in looking after their health,
• 43% perceived improved physical health and wellbeing.

One staff member shared feedback collected recently from a patient group:

“We asked what things people liked most about [the group], and they said how easy it is to speak to people. They get a lot from being with other people and knowing you're not alone. Sharing of experiences is helpful and weirdly enjoyable… And then the last one is ‘I've never been to anything like this group before. I never knew anything like this existed. And I wonder, had I did it earlier in my life, I may have had better coping skills.’”

Along these lines, another staff member reflected that, with efforts to improve patient engagement:

“You can see that patients then feel valued, you know, and they've probably had very low self-worth for a long time. That's a lot of the reasons why they don't come like well, I'm not worth it.” She also stated that, combined with proactive outreach, some patients are diagnosed with other conditions or illnesses that have previously gone untreated, allowing them to receive needed care that improves their physical health.

About three in ten staff cited that they noticed increased trust in clinicians from engaging in these activities and reduced need for appointments. A staff member reflected that the patients in her group had a greater understanding of the strains on staff, increased patience, and greater awareness of where to go to get support.

Other benefits referenced by staff for patients included friendships, which combat social isolation, and a greater understanding of people from different backgrounds for staff, which breaks down stereotypes.

Benefits extended to other groups, such as those in their household:

“Because they're in a better space, [patients are] not arguing as much with their partner; they're not expecting too much from other people because they're now going out themselves, like a couple ladies that were so isolated, they're now doing their own shopping, which sounds like nothing. It's massive because for the last like four months before that, they were getting their family members to bring their shopping because they didn't want to go. So, it's just giving them a bit of confidence to do these things that they'd lost.”

Staff also mentioned changes they noticed in other staff who participated. 61% of staff noticed that colleagues who participated appeared to have increased understanding of the challenges patients face, with one staff member reflecting on how these activities had made her more knowledgeable about supports available for specific groups in her area, like hoarders.

Other perceived benefits noticed in staff who participated include:

• 50% noticed increased collaborative working,
• 50% noticed increased satisfaction in their work,
• 41% noticed improved morale.

Reflecting on these benefits, one staff member said: “I actually think it's been a really good team building exercise for us to, to feel like you're working towards something worthwhile.” Another stated that: “I think it's given us a focus in a job that's easy to get burnt out.”

Challenges

Although staff mentioned the use of translation software and services to better engage patients, 59% of staff cited language or cultural barriers in implementing activities under Theme 1. Even with translation software, one staff member explained that these measures may not be effective as one would hope, requiring the use of Google Translate or an internet connection for patients, and expressed interest in hearing more about best practice for engaging those with additional language needs.

Staff were also cognisant of the perceived challenges patients face that may make it less possible for them to take up offers of healthcare, despite repeated attempts using varied formats:

• 43% cited practical barriers (e.g. time, travel, caring responsibilities) for patients,
• 32% cited competing priorities for patients,
• 27% cited low patient interest,
• 27% cited limited patient understanding of health inequalities.

These challenges exacerbated the staff time needed to make contact with patients. Similar to the views expressed by staff in practices working on Theme 3, one staff member explained the process she followed when trying to engage patients:

“[The practice nurse] would initially text them to invite them again. They didn't respond to that at all. I would then send them an individual personalised written letter, which took time; I had to go through their notes and try and understand, maybe from previous notes why they wouldn't have come. That worked for a few people. For a few people, that didn't work. Then the practice nurse phoned them to try and opportunistically [reach them]. That was difficult because we usually had to phone five or six times before we manage to get anyone. If she got them and they still didn't come in, then I would phone them. I would have blocked time to phone them and that has worked. Actually, it's very time consuming because it means me constantly trying to phone people, which takes me out of surgery to other things.”

Iterating this, another staff member summarised:

“You can send a letter with an appointment [to engage patients]. Sometimes that didn't work, sometimes you had to phone them. You need to repeatedly try and engage patients. It's not as if you would offer one appointment and that person or family would come. It didn't work that way. Again, you have to be really proactive to get patients in.”

Furthermore, 32% of staff cited difficulty identifying or reaching patients that would benefit the most, with this also requiring substantial time to review records.

Perhaps as a result of these challenges, 45% of staff cited limited internal time or staff capacity in delivering this Theme and 9% of staff noticed increased stress and workload pressure in those delivering this Theme.

Other challenges mentioned in delivering this work include:

• 23% cited lack of suitable venues or resources,
• 7% cited limited capacity in community/partner organisations.

Referring to a previous group that provided diabetes education prior to IHAGP, a staff member reflected that, despite this group’s success in getting patients to engage, they lost the room and were unable to continue the initiative, with implications for similar groups under IHAGP.

Summary

Under Theme 1, practices have undertaken a range of patient and community engagement activities, including peer support groups, community outreach, clinical initiatives, proactive engagement and collaboration and training. Supported by actions under Theme 2 and Theme 3, activities under Theme 1 have begun to provide better linkage between practices and community services, facilitating holistic support.

Staff at a variety of levels and roles in the practice were described as influential in delivering activities under Theme 1. Administrative, clinical and multi-disciplinary staff were often mentioned in relation to identifying and contacting those that would most benefit from Theme 1 activities, while community link workers were thought to be vital in signposting to community services or facilitating groups.

While some of the groups delivered under this theme were led collaboratively between practices and third sector partners, many were practice-run. And despite concern about additional strain on third sector delivery groups, reports of barriers due to third sector capacity were low overall.

Participating in Theme 1 activities was associated with a range of perceived benefits for the physical and mental health of patients. Staff described instances in which patients reported increasing confidence taking care of their health and were more knowledgeable about where to go for support outside the practice.

In addition, staff reflected on the cumulative benefits arising from Theme 1 activities, including increased understanding of patients, increased morale and meaning and team building. They repeated many of these benefits when discussing the impacts of Themes 2 and 3.

Indeed, reported activities under Theme 1 highly overlap with reported activities under Themes 2 and 3, suggesting that practices are not working within the constraints of, and their work is much more fluid between, the themes.

Furthermore, staff discussed that the process of identifying and inviting patients to participate was time-consuming and resource intensive, made possible by dedicated time and additional locums/part-time staff, necessitating continued funding to ensure this level of proactive outreach continue.

Overall, Theme 1 activities strongly align not only with programme objectives, but with activities under Theme 2 and 3, providing a solid foundation for actions to help to address healthcare inequalities. Further efforts to increase understanding of this theme and gather comprehensive feedback on patient experience would support further activity under this theme.