Inclusion Health Action in General Practice (IHAGP): evaluation

Theme 3: Outreach and extended consultation

Theme 3 of the Inclusion Health Action in General Practice (IHAGP) programme focused on enabling proactive outreach and extended consultations with patients who are at high risk of physical or mental ill health due to poverty and inequality and yet are not engaging with healthcare or find it difficult to engage effectively in healthcare systems.

It was felt that longer appointments and outreach would allow clinicians to address complex needs holistically, reducing missed opportunities and improving continuity of care.

The ‘Extended consultations and Outreach’ theme was a specific focus of the IHAGP programme over 2025, as it has had the greatest uptake by practices and the clearest potential to have a direct impact on patients at high-risk of health inequalities.

Theme 3 recognises, and seeks to understand and address, potential reasons for ‘missingness’ in healthcare. This includes patients who may have had previous negative experiences of healthcare services, such as those whose past care was not trauma-informed, and those who have felt rushed, unheard or discouraged by service providers or the healthcare system more generally. Some patients are ‘missing’ from healthcare due to a history of adversity or psychological trauma, or they may struggle to make use of healthcare due to logistical barriers such as transport poverty, digital exclusion, additional language needs, insecure employment or carer responsibilities. Some patients may not consider themselves worthy candidates of care, particularly if they are concerned about burdening the healthcare system, do not want to ‘make a fuss’ or do not feel that their issue/s require GP care. ^[8]

Objective of the theme

The objective of Theme 3 was to promote improved patient experience and engagement with health services and ensure that practices experience fewer missed and repeat appointments among some patient cohorts. Activities under this theme were designed to:

• Identify people for targeted outreach.
• Proactively contact/engage identified patients through appropriate mode (e.g. telephone, email, text).
• Involve Multi-Disciplinary Team (MDT) meetings to discuss targeting and coordinating care.
• Identify people for extended consultation activity.
• Provide extended consultations to identified people.

By achieving these objectives, Theme 3 aimed to encourage those who may not reach out for, or attend, appointments – i.e. those who may be categorised as the ‘unworried unwell’ or ‘unseen unwell’ – to do so as needed.

Summary of activities

From the implementation data gathered through the monitoring form section of the staff survey, 91% of practices undertook activities in this theme. Practices sought to undertake proactive outreach or offer extended consultations to a range of target groups. Though the aim remained the same, practices reported various activities under Theme 3.

Approach and Target Groups

Practices utilised IHAGP funding to target different ‘high-risk’ population groups. These included:

• High-risk and vulnerable patients identified via MDT reviews.
• Housebound patients with chronic diseases, frailty, and polypharmacy needs.
• Patients with complex conditions, mental health issues, addictions, and multimorbidity.
• 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 with additional language needs.
• Patients who have missed appointments (referred to as ‘Did Not Attend’ or ‘DNA’), especially repeatedly, and those missing from care ^[9].

Staff survey data demonstrates the extent to which specific population groups were targeted, in that practices identified patients with the following characteristics:

• Complex long-term conditions: 69%.
• Additional language needs: 63%.
• Multiple conditions: 59%.
• History of repeated non-attendance: 52%.
• Clinical risk (e.g. long-term conditions): 50%.
• Asylum seeker: 50%.
• Experiencing poverty/economic deprivation: 49%.
• History of mental health issues: 47%.
• History of drug and/or alcohol use: 33%.
• Other: 11%.

Types of Activities Delivered

Core activities delivered under Theme 3 included extended consultations and proactive outreach with patients, as well as operational changes and monitoring and coding efforts. Examples of these are provided below:

Extended Consultations:

• Double appointments for complex cases, interpreters, mental health, and trauma.
• Structured multi-step diabetic clinics (e.g. patients attend with a nurse, then GP, then pharmacist to meet their needs).
• Named GP for palliative patients and to provide continuity of care to patients who would benefit from it.

Proactive Outreach:

• Phone calls, texts, letters, opportunistic invites, and MJOG (NHS messaging tool) reminders.
• Outreach clinics for DNA (Did Not Attend) patients and ‘screening defaulters’ (bowel, cervical).
• Community engagement and collaboration with Community Link Workers (CLW) and Money Advice services.

Operational Changes:

• Early morning extended hours and pre-bookable slots for flexibility.
• Locum cover to increase capacity for urgent and extended appointments.
• Use of translation devices and Language Line ^[10] for accessibility.

Monitoring and Coding:

• Alerts and Read codes (a standardised medical coding system) for patients needing extended consultations.
• EMIS (electronic patient record system) searches for housebound, care home residents, and those not seen in >12 months.

Staff survey data highlights the most commonly undertaken activities:

• Extended consultations for complex patients: 93%.
• Targeted reviews for patients with high clinical and/or social needs: 59%.
• Proactive patient contact: 56%.
• Delivery of home visits: 38%.
• Community-based clinics: 9%.
• Other: 9%.

In the patient survey, 22% identified proactive outreach as having taken place in the last twelve months and 30% that they had experienced an extended consultation.

Further details on the methods used to undertake the two most common activities –targeted outreach and extended consultations for complex patients – are set out below.

Targeted outreach: Methods used

Some staff responding to the survey outlined their methods of targeted outreach, with many taking a similar approach to the following:

“We have undertaken targeted outreach to priority patient groups through phone calls, letters, and community events, and offered extended consultations to address complex health needs. Activities have been both planned and responsive to emerging needs”.

A few described having “protected time set aside for GPs” to carry out tasks, including polypharmacy reviews and contacting patients who have not been seen by the practice for a number of years or have frequently missed appointments (DNAs).

Others said they do an audit of ‘defaulters’ or non-attendees of specific health screening programmes, particularly cervical and bowel screening. One survey respondent shared the following:

“Bowel screening non-responders are sent a text after not returning their kit. The text is sent in their own language. They are asked to respond with a keyword to signal they would like a replacement kit. We then organise the bowel screening service to send new kits out”.

Similarly, a staff interviewee shared their approach to proactively reaching out to those who have not attended their cervical screening appointments:

“I'm the only person in the practice that does smears. So, I was just looking through our defaulters list initially, just calling anybody who was on the defaulters list just to check, did they know they were due [their smear test] and offering appointments. And if we couldn't get them on the phone, we would text them. If there were language barriers, I would do a translation and put it in a text for them. I added the links on what smears are, trying to kind of give a bit of information at the same time.”

Extended Consultation: Methods used

Several staff survey respondents also offered details on their extended consultations. A few mentioned the process of identifying and adding codes for patients suitable for these extended appointments.

A large proportion of practices reported offering extended consultations – also referred to by many as ‘double appointments’ – for patients with complex health needs or alerts on record. These extended appointments ranged from 20 to 60 minutes in length.

Extended consultations have also been used for with additional language needs, largely to provide adequate time for interpretation and translation services:

“EMIS [GP IT system] searches for difficult to reach patients, targeting non English speaking patients who find it difficult to engage, offering 30 min appointments and engaging with interpreter services”.

One practice said they offer newly registered patients extended consultations with the practice nurse. Although uncommon, a couple of practices discussed extending the timeframe of all routine appointments and then increasing this allotment depending on patient need:

‘All of our routine appointments are now 15 minutes, and if patients need interpreters, a 30-minute appointment is allocated”.

One interviewee commented on the potential pitfalls of extending appointments for patients outwith the target groups:

“If some are offering 15 minute appointments, when actually most practices do 15 minute appointments anyway, it's just brought them up to the par. It's not taking them over [into having extended consultations]”.

One patient reflected on how the extended consultation works for them and noted how useful they found them:

“My GP books me in at the end of the day when surgeries are done. So, if she wants to spend an hour, she does that. So, she books me in when she’s not got appointments scheduled. I find that useful.”

Reflections

Implementation

Aside from the methods outlined in the section above, some staff survey respondents noted the value of utilising community link workers to identify and target patients, including those in ‘harder to reach’ groups:

“We targeted patients in our shared care methadone programme. We asked our drug councillor to help us identify those who may be avoiding or DNA appointments. Our CLW was also instrumental in identifying patients and linking them with the IHAGP programme in our practice”.

Indeed, almost half (48%) of staff said that support from non-clinical staff or link workers had helped the delivery of their Theme 3 related activities.

Clear patient lists and targeting were seen as very helpful in enabling proactive outreach and extended consultations – selected by 46% of staff survey respondents. Adding codes and alerts to patient files was considered a valuable ‘extra step’, in keeping a record of important characteristics, potential vulnerabilities and needs and thus making it easier to find a list of ‘target’ patients.

Over a quarter of staff survey respondents (28%) felt that IHAGP resources to support their approach and the wording of patient outreach communications had supported the delivery of their work, while 16% noted the usefulness of shared learning within and between practices.

As could be expected, ‘protected staff time’ (46%) was seen as crucial in facilitating proactive outreach and extended consultations with patients. This is particularly important where patients may not respond to certain forms of communication and staff need time to ‘trial’ different methods of contact:

“Initially, [we contacted patients we were reaching out to] through phone calls and then texts and then we lettered some… Phone calls are probably more effective than letters because you get to hear from the person”.

Benefits

Staff survey data sets out the views of some practice staff on the benefits of proactive outreach and extended consultations. A majority of respondents (67%) saw the work under this theme as leading to improved outcomes for specific patients, while 65% felt it led to better continuity of care. There was also a sense that proactive outreach and extended consultations enabled the development of trust between patients and providers (35%), provided key opportunities to address – and indeed identify – unmet clinical needs (45%), and thus helped to improve clinical outcomes (37%).

In the patient survey, all of those who identified having experienced proactive outreach or an extended consultation rated these to be helpful.

In addition, 76% of patients who experienced proactive outreach reported an increase in their confidence in asking for support and 69% an increase in trust in their General Practice Team.

Similarly, when it came to longer appointments, 69% of patients in the survey who had experienced these reported an increase in their understanding of their health condition and the same proportion an increase in their trust in their General Practice team.

Relatedly, several staff respondents noted the value of extended consultations in allowing a ‘deep dive understanding’ of complex issues. They saw this as giving patients more time to explain their symptoms, experiences and specific circumstances, in turn, offering healthcare professionals more time to listen to, and work with, patients to best meet their needs.

Challenges

In reflecting on the changes that work under Theme 3 led to, some responding to the staff survey flagged an increased workload for staff (33%). Some staff interviewees also acknowledged how integrating IHAGP activities into their regular workload was initially daunting:

“I suppose initially, yeah, I found it a little bit harder to sort of put [time for] it in because you think ‘Well, how am I going to do that on top of everything else that I'm doing?’.”

Staff survey respondents were also asked about the challenges they faced in implementing Theme 3 related activities, with lack of time presenting a barrier in over two-thirds of responses (69%). Staff shortages have also threatened the ability to undertake proactive outreach and extended consultations to patients – cited by over half (52%) of survey respondents.

Outreach was, in itself, a challenge for some, with 40% of staff surveyed reporting difficulties in reaching patients. Indeed, the same number (40%) experienced repeated non-attendance at appointments despite the additional efforts. Reflecting on instances of non-attendance for cervical screening, one interviewee shared how, although their efforts have led to patients coming forward, some may remain unwilling or unable to engage with particular health activities, and practices have to respect this:

“There'll be some that just don't want to discuss it and don't want a smear... and there's some that will take an appointment but don't turn up for it. And you'll see a pattern where that's happened, that they'll take the appointment, but they'll either cancel it or not turn up because actually they didn't want to come in the first place. So, I've tried to have conversations, tried to explore why they don't want the appointment or what's put them off”.

A few staff respondents (10%) cited IT limitations as a challenge, perhaps indicating a lack of up-to-date technologies, an inability to undertake efficient coding or less advanced information filing/sharing systems.

Summary

Under Theme 3, practices have taken steps to promote improved patient experience and engagement with health services and reduce the number of missed and repeat appointments among various patient cohorts.

Practices have been particularly focused on identifying patients to reach out to, proactively contacting them through various modes of communication, while at the same time, identifying which forms of contact work best for different patients.

Practices have also provided extended consultations to patients across a wide range of groups, most often those with complex long-term conditions and with additional language needs. However, a few respondents discussed extending the timeframe of all routine appointments. While these timeslots are often increased depending on patient need, there is the risk that lengthening appointments for the general population of a practice reduces the benefits of extended consultations to those in specific target groups, i.e. ‘those who need them most’.

Proactive outreach and extended consultations encourage the development of trust between patients and providers, offering key opportunities to address unmet clinical needs and improve clinical outcomes. It also enables staff to gain a better understanding of patients’ holistic needs.

It is critical that staff have dedicated, ring-fenced time to facilitate IHAGP activities, including those under Theme 3. This is particularly important where patients may not immediately respond to outreach, and gives staff more scope to identify, code and monitor target patients – including the ‘unseen unwell’.

Overall, Theme 3 activities strongly align with programme objectives, with particular efforts to reduce missingness and directly target those at high-risk of health inequalities. It is important to acknowledge and look into solutions around the challenges raised by participants, including the impact of staff shortages or IT limitations on efficiency and their ability to carry out the relevant activities. Such improvements will leverage the extent to which practices can continue to strengthen patients’ experiences and engagement.