Inclusion Health Action in General Practice (IHAGP): evaluation

Implications for Theory of Change

The evaluation findings, tested through the Theory of Change (ToC) workshop, confirm that IHAGP’s underlying logic is sound: targeted funding creates capacity for practices to deliver more inclusive and proactive care. However, the evidence shows that the current models, both the overarching ToC and the three theme-level ToCs, need refinement to reflect how the programme works in practice, what assumptions hold true, and what conditions are essential for success.

What the evaluation revealed

IHAGP has enabled practices to implement activities that improve access, trust, and workforce capability. Proactive outreach and extended consultations have uncovered unmet needs, while training and practical tools have strengthened staff confidence and cultural competence. These findings validate the central causal link in the overarching ToC: additional resources unlock time and flexibility for equity-focused care.

Yet several assumptions contained within the theories of change were challenged. Integration of activities into routine practice does not guarantee sustainability, 63% of practices said work would stop without funding, despite reporting that changes were embedded. The collection of patient feedback as an activity, assumed to inform targeting and improvement, were reported to be weak.

Collaborative working, particularly across practices and with community partners, was less developed than expected in some cases. In addition, some activities, such as “extended consultations”, were diluted into standard 15-minute appointments, weakening the intended pathway to holistic care.

The workshop also highlighted that some outcomes are over-aspirational and difficult to evidence. Long-term impacts like reduced hospital admissions are unlikely to be attributable to IHAGP alone. Stakeholders called for shorter, more plausible causal chains and clearer definitions of success.

Implications for the Theory of Change

The overarching ToC should be reframed to emphasise IHAGP’s role as a mechanism to build knowledge and capability. Dedicated time, locum backfill, and flexibility are the enabling conditions created by IHAGP that allow practices to deliver proactive outreach, targeted extended consultations, and trauma-informed care.

Outcomes should focus on near-term, measurable changes, such as improved appointment completion for priority groups, patient-reported experience (“felt listened to”), and staff confidence, while treating long-term health impacts as longer-term outcomes IHAGP can support rather than direct results.

Funding and dedicated time are preconditions for lasting impact. Without these, the causal chain breaks.

For Theme 1: Community Connection, activity has grown, with peer support groups, outreach events, and partnerships becoming more common. However, the implementation of the activity for collecting patient feedback set out in the original model is weak. Practices rarely collect structured patient input, and collaborative working across practices or with third-sector partners is inconsistent. Link workers remain central, but their high caseloads limit impact. The revised model should make patient feedback an explicit output and link it to service adaptation. Collaborative working should be recognised as an outcome in its own right, and assumptions about link worker capacity should be realistic.

For Theme 2: Workforce Development, training has been a success, improving staff confidence and cultural competence. Satisfaction and retention are already included in the model, but the evaluation shows these outcomes are important and should remain prominent. Dedicated learning time, assumed to be available, was not universal. The revised model should separate outputs, such as training sessions and tools, from outcomes like application in practice and morale. Time for staff to learn and develop skills needs to be built in. Alternatives like short training sessions or brief team catch‑ups could be considered when it is not possible to set aside dedicated learning time.

For Theme 3: Outreach and Extended Consultations, the core logic remains strong: longer appointments and proactive outreach can help uncover unmet needs and support continuity of care. However, fidelity varied across practices. In a small number of cases, what was described as an “extended consultation” simply reflected routine appointment lengths in that practice, or additional time required for interpretation rather than targeted extra time for clinical complexity. Coding and IT limitations also made it difficult for some practices to record and monitor outreach consistently.

The revised Theory of Change should therefore clarify what constitutes an extended consultation, namely, purposeful, targeted additional time for patients with complex needs, and ensure this is supported by clear documentation. Standardised coding for outreach and extended consultations would also strengthen monitoring without adding unnecessary burden.

Workshop participants suggested moving away from rigid theme silos towards cross-cutting pillars that better reflect delivery, for example:

1. Meaningful Access & Continuity

2. Trust & Engagement

3. Workforce Capability

4. Data & Learning

This structure would simplify causal chains, highlight shared enablers and barriers, and make monitoring more practical.

IHAGP’s Theory of Change remains a strong foundation, but it needs to be sharper, simpler, and more realistic. It should recognise IHAGP as a capacity-building intervention, focus on measurable near-term outcomes, make sustainability assumptions explicit, clarify fidelity for key activities, embed patient feedback and collaborative working, and streamline nested models into cross-cutting pillars. These refinements will make IHAGP’s contribution clearer to policymakers and support decisions about scaling and funding.