Socioeconomic inequality and barriers to primary care in Scotland: A literature review

Executive Summary

Introduction

Health inequalities are systematic differences in health between different groups within a population, and in a policy context the term generally refers to those differences which are avoidable and unfair. Some of these inequalities relate to broader socioeconomic factors including income, housing and living standards, termed socioeconomic inequalities. Though the root causes of health inequality largely lie outside of health systems, healthcare services offer opportunities to address some of the impacts of health inequality on individual patients.

Primary care encompasses general practice, optometry, pharmacy and dentistry, and is the first point of contact with healthcare for many individuals. Some patients face barriers to accessing primary care, which can be economic, health-related or structural. This is a consequence of, but also contributes to, wider health inequality.

Primary care is undergoing transformation in Scotland, and tackling health inequality is emphasised within programmes of primary care reform. In October 2020 the Scottish Government established the Primary Care Health Inequalities Short Life Working Group in recognition of the role that primary care can play in responding to health inequality in Scotland. Informed by an expert reference group composed of people with lived experience of disadvantage, the Short Life Working Group developed 23 recommendations. One of these recommendations called for the Scottish Government to:

Commission an investigation into how barriers to healthcare themselves contribute to excess deaths and premature disability related to socio-economic inequalities.

This report responds to this recommendation by presenting a literature review on the barriers to primary care faced by those most affected by socioeconomic inequality in Scotland.

Barriers to accessing primary care in Scotland

In the report, literature is presented according to four ‘points of engagement’ with primary care: ‘awareness of health needs’; ‘seeking support from services’; ‘reaching services’ and ‘encounters with primary care services’. The literature reviewed for this report identifies several factors that intersect with socioeconomic inequality, including ethnicity, disability and geography. There is therefore great diversity of experiences within the populations defined by the literature as socioeconomically deprived. The literature reviewed largely focuses on general practice, though many of the findings have relevance for primary care more widely.

Awareness of health needs

Identifying a health need requires literacy and numeracy skills to make decisions and take actions on health. Those with lower health literacy generally have poorer health outcomes. In seeking care, individuals must position themselves as a ‘candidate’ for healthcare. Isolation and low self-efficacy can influence individuals’ perceptions of themselves as eligible for care. Messaging from within primary care can also discourage engagement, for example where services are perceived as being for ‘emergencies’ only.

Barriers to recognising a health need and positioning oneself as a candidate for care can be addressed through active outreach. Those affected must be heard and represented in efforts to improve health literacy, and empowered to view themselves as eligible for and deserving of healthcare.

Seeking support from services

Though they may recognise a health concern, individuals might not seek support from healthcare services due to low awareness of who or where to turn to, low expectations for care, or fears concerning their health. Some individuals are less likely to know where to turn when their GP surgery is closed, which can lead to delays in seeking care or having to self-manage symptoms. Navigation of the healthcare system requires work from all patients, but can be particularly difficult for those unfamiliar with the system, such as refugees and asylum seekers, or those whose first language is not English.

Previous experiences of primary care can impact efforts to seek support. Some communities have reported negative experiences with healthcare professionals and a lack of trust. Avoidance may also be related to wider fears of institutions and professionals, or past experiences of racism and discrimination. Anxiety about the possibility of receiving bad news is also raised in the literature.

Enabling those experiencing disadvantage to seek care requires sensitive healthcare interactions that eliminate discrimination. It also requires tailored outreach to those communities less likely to engage with preventative care such as screening, to minimise fears and build trust.

Reaching services

Reaching a primary care service requires resources including transport, finance and time, but also motivation and self-efficacy. Those with fewer resources can have less flexible employment conditions, posing barriers to accessing care during daytime hours. Technological exclusion can also make engagement difficult for those with limited access to resources. The common practice of receiving a callback from a GP later in the day can be a barrier to accessing care for those with caring and employment responsibilities, those requiring an interpreter, and those with complex support needs.

Some individuals may not attend GP appointments on multiple occasions, due to a complex combination of barriers preventing engagement with healthcare. These patients are described within ongoing academic research as ‘missing’. ‘Missingness’ is more prevalent within areas of socioeconomic deprivation, and these patients are more likely to be admitted to hospital and at greater risk of premature death.

Universal procedures to encourage attendance such as text message reminders may not be appropriate for ‘missing’ patients, and thus contribute to widening inequality. To facilitate access to primary care, the literature recommends tailored support, digital hubs providing access to the technologies required to engage with healthcare, and the simplification of systems to schedule a GP appointment.

Primary care encounters

Experiences of interacting with primary care services are shaped by structures of healthcare, but also interpersonal relationships between professionals and patients. Those experiencing socioeconomic disadvantage can have more complex health concerns that require more time, but have poorer experiences of general practice consultations.

Patient experiences of healthcare interactions are also impacted by health professional understanding and empathy. Negative experiences of healthcare interactions can make individuals feel humiliated or powerless. Increased practitioner understanding of the challenges faced by those experiencing socioeconomic deprivation, such as food insecurity, may facilitate empathetic interactions.

The literature suggests that for groups with complex health and social needs, patient care requires an individualised approach. It also encourages increased knowledge and training for practitioners relating to the issues facing those from deprived areas and marginalised groups. Addressing imbalances in service provision and patient need within deprived areas should be a key consideration within primary care reform.

Discussion and conclusion

Multiple factors tied to socioeconomic deprivation impact one’s ability to seek and reach healthcare. These include social and physical environments, societal attitudes, and access to knowledge, social connections and resources. In the context of complex mental and physical health needs, disadvantage with respect to these factors can compound to create barriers to access when faced with the spaces, systems and procedures entailed in contemporary primary care provision. This occurs in different ways for different communities.

The literature review has highlighted four areas of relevance for policy. Firstly, primary care must be experienced and perceived as approachable by all. The literature suggests that this message could be strengthened. It must be more easily accessible, ensuring that access is not prevented by employment and caring responsibilities. The systems in place to access care can pose a barrier to those with complex mental health needs, and the settings in which primary care is accessed outside general practice, such as community pharmacy, can present privacy concerns. These are tangible barriers to points of entry to primary care, which are amenable to change.

Seeking healthcare can be highly sensitive, with health concerns intimately tied to wider life circumstances. Previous negative experiences with healthcare professionals can pose a barrier to future healthcare access. Racism and discrimination is one example, with racism directly impacting health as well as posing a barrier to accessing care. Improved understanding of the challenges related to socioeconomic deprivation may facilitate empathetic interactions with patients. Efforts to support the workforce in this regard should adopt an anti-racism lens.

Enabling patients to feel eligible for and deserving of care is key to overcoming some barriers to access. This goes beyond primary care to wider policy areas and institutions, but its location at the heart of communities presents valuable opportunities for intervention. Establishing links between healthcare services, especially general practice, and the wider communities they serve, can facilitate patient empowerment and has the potential to enhance continuity of care.

Those living in deprived areas often have greater need and more complex health issues, but the delivery of care in these areas is more heavily impacted by workload pressures, recruitment, staff retention and quality of care. Inequalities in the accessibility of care and patient experience should be considered within programmes of primary care reform, informed by input from those most affected and their representatives.