Inclusion Health Action in General Practice (IHAGP): evaluation

Overall Reflections

The Inclusion Health Action in General Practice (IHAGP) programme was introduced to tackle persistent health inequalities by enabling practices in deprived areas to adopt inclusive, proactive, and patient-centred approaches.

This chapter synthesises findings across the three programme themes, patient engagement, workforce development, and proactive outreach with extended consultations, and reflects on what has changed, what has worked well, and what challenges remain. It draws on quantitative survey data, qualitative interviews, and patient feedback to provide a holistic assessment of IHAGP’s impact and its implications for sustainability and policy.

Evidence of impact across themes

IHAGP has delivered measurable improvements in patient experience, staff capability, and practice culture. Staff survey data highlight the breadth of perceived benefits: 43% identified improved patient outcomes as one of the most important impacts, while 41% cited enhanced staff knowledge and confidence. Other significant impacts include better access to care (30%), increased patient trust or satisfaction (29%), and more inclusive practice approaches (27%). These figures suggest that IHAGP has not only introduced new practices but also influenced the ethos of care delivery.

When looking at the patient experience from the patient survey, 88% agreed that they were listened to at their last appointment, 88% that they were treated with dignity and respect and 80% that they were given enough time. These figures suggest that patients in IHAGP practices are able to identify with some of the benefits that IHAGP sets out to achieve.

Qualitative accounts reinforce this picture. Staff repeatedly described how IHAGP created space to “pause and think” about what good care looks like for their communities. One practitioner reflected:

“Everyone feels they’re doing a better job… you’ve naturally improved staff well-being.”

Patients echoed these sentiments. In the patient survey, 54% strongly agreed they were given enough time during their last appointment, and 56% strongly agreed they were treated with dignity and respect. Extended consultations were particularly valued:

“The extended appointment times have been great for staff and also for the patients… we proactively created smear clinics to try get our defaulters in with great success.”

These findings indicate that IHAGP has begun to shift the experience of care for those who often face the greatest barriers. However, the depth and durability of these changes require closer scrutiny.

Integration and Sustainability

Perhaps the most striking finding is the tension between reported integration and actual sustainability. On the surface, IHAGP appears embedded: 42% of staff respondents said activities are fully integrated into routine practice, and 47% said they are partially integrated. Yet when asked whether these changes could continue without funding, 63% said they would stop, and only 6% believed they were fully sustainable.

Some IHAGP‑supported changes are likely to endure without continued funding because they involve shifts in knowledge, culture, or relatively small operational adjustments. These include redesigned DNA (Did Not Attend) letters, strengthened staff understanding of health and healthcare inequalities, improved trauma‑informed approaches, and the development of new community links. Staff described these changes as part of how things are now done routinely, suggesting they are reasonably sustainable because they require minimal additional time or resource once established.

Other aspects of IHAGP, however, depend heavily on additional capacity and would not continue without funding. Respondents were clear that extended consultations, proactive outreach, targeted recalls, and the dedicated time required for staff to identify and engage harder‑to‑reach groups are reliant on IHAGP resources, primarily for locum or backfill cover.

This contradiction reveals an important truth: integration does not equal sustainability. Practices have adapted workflows and embraced new ways of working, but many of these changes are contingent on IHAGP resources, particularly for locum cover, dedicated time for staff learning, and outreach capacity. As one GP commented:

“Most of it would stop overnight… we can’t maintain the GP locum backfill. We certainly couldn’t maintain the practice nurse backfill.”

The dependency on funding is further underscored by staff priorities for sustaining work: 80% called for long-term funding, 41% for dedicated staff time or posts, and 39% for additional funding. Without these supports, the risk is clear: IHAGP’s gains could unravel, leaving practices unable to maintain the improvements achieved.

This tension also raises a fundamental policy question: is IHAGP intended as a short-term enhancement or as a structural correction? If the latter, then fixed-term funding is not enough. Some reflected that practices in deprived areas need predictable, long-term resources to provide equitable care, not as an add-on, but as a core component of the system.

What Has Enabled Change and What Holds It Back

IHAGP’s successes have been driven by a combination of practical enablers and cultural shifts. Dedicated time and resources were repeatedly cited as critical, allowing staff to attend training, run peer support groups, and conduct proactive outreach. Community link workers emerged as a linchpin, bridging clinical care and social support. Investments in interpreting devices and trauma-informed training improved communication and confidence, particularly for patients with language barriers or complex needs.

Yet these enablers sit alongside persistent barriers. Lack of time was the most frequently reported challenge, with 69% of respondents citing it as a major obstacle. Staff shortages compounded this pressure, being reported by over half of staff survey respondents. Language and cultural barriers remain significant despite translation tools, and IT system limitations, including difficulties in coding extended consultations, have reduced the ability to monitor and evaluate the programme. These constraints highlight the fragility of progress and the need for systemic solutions rather than short-term fixes.

Unintended Outcomes and Uneven Implementation

IHAGP has generated positive unintended outcomes, including new peer support networks that reduced isolation and stigma, and improved screening uptake among groups historically disengaged from preventive care. Staff also reported a cultural shift toward trauma-informed, patient-centred practice:

“Our general approach when dealing with patients has changed. We take more time to listen and try to explain things.”

However, the evaluation also uncovered risks. Some practices used IHAGP funding primarily to cover structural gaps rather than delivering the “additionality” envisaged by the programme. While this adaptation reflects real need, it raises questions about whether IHAGP is functioning as an innovation fund or as a stopgap for systemic under-resourcing.

IHAGP is a highly targeted, small‑scale programme, currently reaching only a limited number of practices, and provides modest annual payments relative to a practice’s core funding. It was never designed to replace the broader system of investment in general practice. IHAGP funding is therefore intended to provide additional, flexible capacity for innovation, not to close structural gaps in the system.

Seen through this lens, occasional use of the IHAGP resource to relieve operational pressure likely reflects the reality of delivering care in high‑deprivation settings rather than a programme drifting from its purpose. At the same time, these adaptations underline the importance of being clear about IHAGP’s scope and limitations: its reach is modest, its funding is annual, and it cannot be expected to address structural workforce or resourcing challenges at system level.

This distinction matters. IHAGP offers valuable learning about approaches that support inclusion, trust and engagement, but expectations of the programme must align with its scale and design. Recognising this helps avoid misinterpreting pragmatic use of IHAGP funding as mission drift and instead positions the programme as a focused test‑bed that sits alongside, not in place of, the wider funding framework for general practice.

Extent of Cultural Change

Despite these tensions, IHAGP has catalysed meaningful cultural shifts. 65% of staff reported a positive impact on wellbeing, and 59% said it increased their desire to stay in their role.

Staff described feeling more empowered, more collaborative, and more patient centred. These changes, though harder to quantify, may be among IHAGP’s most significant achievements. They suggest that when resources allow time for reflection and innovation, practices respond with creativity and commitment.

Yet cultural change alone cannot sustain practice. Without structural support, the risk is that enthusiasm will dissipate under the weight of operational pressures. As one staff member warned:

“We’re happy to do the work… but we need the time to do that.”

Conclusions

This evaluation of IHAGP demonstrates that targeted investment in general practice can deliver meaningful improvements in access, patient experience, and workforce capability.

Across all three themes, staff in IHAGP practices reported tangible benefits: patients felt listened to and valued, staff gained confidence and skills, and new approaches, such as extended consultations and proactive outreach, have begun to address long-standing gaps in care for vulnerable populations. These achievements matter because they demonstrate that when resources are provided, practices respond with creativity and commitment, even under intense operational pressure.

However, the evidence also reveals a structural fragility that cannot be ignored. While 42% of staff respondents report that IHAGP activities are fully integrated into routine care, 63% acknowledge that these changes would stop without funding.

This contradiction underscores a critical point: integration does not equal sustainability. Practices have embedded new ways of working, but these are contingent on IHAGP resources, particularly for locum cover, dedicated learning time, and outreach capacity. Without continued investment, the risk is that progress will unravel, leaving practices unable to maintain the improvements achieved.

This tension raises important questions about how IHAGP should be understood within the wider funding and delivery landscape. IHAGP is a highly targeted programme, currently reaching only a small subset of practices and providing modest, annually allocated funding. It was not designed to deliver system‑level redistribution of resources.

Given this context, IHAGP cannot be interpreted as a structural correction or a mechanism to address wider workforce or funding distribution issues across Scotland’s 800+ practices. Instead, its purpose is to provide additional, flexible capacity to test and strengthen inclusion‑focused approaches within a limited number of practices serving populations at heightened risk of healthcare inequalities.

If IHAGP is understood as a time‑limited enhancement designed to support innovation, its impact will naturally remain constrained unless learning is absorbed and supported through wider system processes. If it is expected to sustain resource‑intensive activities such as extended consultations and proactive outreach, then temporary funding will not be sufficient; practices would require predictable, longer‑term investment to maintain these elements. Clarifying IHAGP’s role in relation to core funding streams is therefore essential to ensure that expectations are realistic and that the programme continues to add value as a targeted, learning‑oriented initiative.

The evaluation also highlights the complexity of measuring success. IHAGP has delivered cultural change, staff report feeling more empowered, more collaborative, and more patient-centred, but cultural change alone cannot sustain activity. Without structural support, enthusiasm will dissipate under the weight of operational pressures.

Moreover, the flexibility of IHAGP, while enabling local innovation, has led to uneven implementation. Some practices have used funding to deliver transformative initiatives, while others have used it to cover basic service gaps. This variation reflects real need but raises questions about whether IHAGP is functioning as an innovation fund or as a stopgap for systemic under-resourcing.

Unintended consequences also warrant attention. While IHAGP has generated positive outcomes, such as perceived improved screening uptake and reduced social isolation, there is a risk that the visibility of IHAGP, and the narrative of success surrounding it, could obscure the scale of the challenge and lead to complacency. Health inequalities are deeply entrenched and cannot be solved by short-term, small-scale interventions alone. IHAGP has shown what is possible, but it has also highlighted the limits of what can be achieved without wider change.

In short, IHAGP has delivered proof of concept. It has shown that targeted investment can unlock innovation, improve patient experience, and enhance workforce capability. But it has also shown that progress is fragile, uneven, and dependent on continued funding.