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

Introduction

This report responds to a recommendation from the Scottish Government’s Primary Care Health Inequalities Short Life Working Group ^[1]. Among its recommendations, the group called for further research into barriers to accessing healthcare associated with socioeconomic inequality. This chapter outlines the wider policy context within Scotland, describes the Short Life Working Group and introduces their recommendation.

Policy Context

Health inequalities

Health inequalities are “systematic differences in the health of people occupying unequal positions in society”^[2] and can be observed in life expectancy, access to care, experiences of care and health risks. Some differences in health status are attributable to factors that mean they are avoidable and unfair, and thus require political attention[3]. Examples of these factors include socioeconomic status relating to employment and income, protected characteristics (ethnicity, disability or sexual orientation), geography, and social exclusion such as homelessness[4]. These often interrelate in different ways and shift across the life course, therefore individual experiences within these particular groups are varied.

Scotland faces persistent health inequalities^[5], the root causes of which largely lie outside of healthcare services[6]. For example education has significant implications for health[7], and experiences of discrimination including racism have health impacts for individuals and communities[8]. In Scotland, the prevalence of health inequality is closely tied to socioeconomic inequalities, which relate to income and associated factors including housing and living standards. Scotland continues to see high inequality of wealth, earnings and educational attainment, alongside a stagnation of earnings in the decade following 2010[9]. Income is a key determinant of health, with financial security supporting people to feel in control of their lives and maintain healthy behaviours. Income levels also have material impacts, influencing exposure to stress, the housing in which people live and their neighbourhoods, and their access to and quality of healthcare.

According to the most recent Scottish Government Long Term Monitoring of Health Inequalities report published in 2023, in 2019-2021 healthy life expectancy was 25.8 years lower for men in the most deprived areas compared with the most affluent, and 25.7 years lower for women^[10]. Socioeconomic inequalities for other measures of health and wellbeing are also stark. Populations in the most deprived areas of Scotland are also more likely to experience conditions such as chronic pain [11], coronary heart disease and diabetes[12], poorer oral health[13], have lower rates of cancer screening[14] and are more likely to require emergency admission[15].

Income inequality is a particular concern in light of recovery from the COVID-19 pandemic and the rising cost of living. These factors have had greater negative impact on those groups most adversely impacted by health inequalities, though health inequalities were already on a rising trajectory ^[16]. In 2022, the Scottish Parliament’s Health, Social Care and Sport Committee called for urgent action across all levels of Government, to ensure that tackling health inequalities continues to be a focus for preventative action across all relevant policy areas [17]. Several health policy plans and strategies in Scotland have already focused on tackling health inequalities, including Equally Well (2008), Public Health Priorities for Scotland (2018) and Everyone Matters: 2020 health workforce vision (2020). However, despite sustained policy attention, inequalities in health and access to healthcare remain wide[18].

A complex range of factors contribute to the persistence of health inequalities in Scotland. Long-term and cross-sector approaches to tackling health inequalities and coherence across policy areas are required to ensure that existing inequalities do not widen further16. Though social and economic factors are the primary drivers of health and wellbeing, healthcare is nevertheless recognised as an important determinant of health ^[19], and plays a role in mitigating the effects of wider inequalities[20]. It is within this context that changes to the delivery of primary care services are being implemented across Scotland. Tackling health inequalities has been emphasised as a key aspect of this reform1.

Primary care transformation in Scotland

Primary care is the first point of contact with the NHS and encompasses services such as general practice (GP), dentistry, eye care and community pharmacy. Primary care professionals offer accessible health care and support to individuals and families within the community when it is needed^[21].

In Scotland, the delivery of primary care has seen incremental change since devolution^[22]. A new GP contract in 2018 led to revised models of service provision and workforce changes, including the establishment of primary care multidisciplinary teams (MDTs) to ensure GPs retain the role of expert medical generalists. This led to an expansion of roles such as allied health professionals, pharmacists and pharmacy technicians, and community link workers (CLWs). It also entailed the creation of community treatment and care services (CTACs), and the vaccination transformation programme [23]. The contract and associated changes to services were underpinned by a Memorandum of Understanding (MOU)[24]. The MOU committed to a vision of general practice as informing, empowering and serving local communities through this multidisciplinary approach, and was updated for 2021-2023[25]. Since the implementation of the contract, Scottish Government data shows that in 2024 there are now 4,925 whole time equivalent (WTE) staff working in MDT services[26].

Reducing inequality was included as an aim of the 2018 contract. As a first (or only) point of contact for many, and due to its embeddedness within the community, primary care has a key role in addressing health inequalities1. This includes through early intervention and secondary prevention, but also through patient advocacy and community engagement. With levels of ill health expected to increase as the population ages, and much of the projected growth in illness relating to conditions managed by primary care, these services will have an even bigger part to play^[27].

Some patient groups face barriers to accessing primary care, which may be economic, health-related or structural. These are both a consequence of and contributor to wider health inequality, as the inability to engage with primary care services can further entrench disadvantage. This report considers barriers to accessing primary care that can be associated with socioeconomic factors, in response to a recommendation from the Scottish Government Primary Care Health Inequalities Short Life Working Group. Though including a small number of examples from other primary care services, the report largely draws on research from general practice.

Primary Care Health Inequalities Short Life Working Group

The Primary Care Health Inequalities Short Life Working Group was established by the Scottish Government in October 2020 in recognition of the role primary care can play in responding to health inequality in Scotland. Its formation took place against the backdrop of the Fairer Scotland Duty, which from April 2018 placed a legal responsibility on public bodies in Scotland to consider inequalities of outcome caused by socioeconomic disadvantage^[28].

The group drew on the expertise of a range of stakeholders across policy, clinical practice and the voluntary sector to work towards lasting change. It worked collaboratively with an expert reference group, the Chance 2 Change community peer support group, to represent the views of people with lived experience of disadvantage ^[29]. The Short Life Working Group drew on this diverse expertise alongside existing evidence to identify and recommend actions that it expected to have meaningful and sustainable impact on health inequalities in Scotland. In March 2022 their 23 recommendations were published under four broad themes; Empower and Develop the Primary Care Workforce; Leadership, Structures and Systems; Empower and Enable People and Communities; Data, Evidence and Knowledge[30]. Five of these 23 recommendations were ‘foundational’. A 2023 update demonstrated that progress had been made on all five foundational recommendations, with this work taking place against a background of refreshed Scottish Government commitments relevant to health inequalities, and wider societal change including the cost-of-living crisis[31].

The current report was commissioned in response to one of five foundational recommendations under the Data, Evidence and Knowledge theme:

Commission an investigation into how barriers to healthcare themselves contribute to excess deaths and premature disability related to socio-economic inequalities. This foundational recommendation is for work to examine: barriers to access for different groups; waiting times; delayed presentations with serious conditions; "missingness" from health care; perverse incentives and behaviours created by targets; and negative behaviours/coping strategies people may resort to self-manage or self-medicate when unable to access care and support.

Data on missed appointments and 'missingness' should be recorded and reported: safe, effective and equitable health care depends on understanding of who misses appointments or does not engage with services. Work should be undertaken to build on previous data linkage analysis.

This report responds to several but not all aspects of this broad recommendation, by identifying and describing evidence relating to the barriers to primary care faced by those most impacted by socioeconomic inequality. The report presents a review of literature focused on Scotland and published within the last 5 years. Evidence on barriers is presented according to where these may be experienced at different points of engagement with primary care. The approach taken to the recommendation is outlined in the following chapter.

The literature demonstrates that challenges to accessing primary care in Scotland are multifaceted. Multiple factors tied to socioeconomic deprivation impact one’s ability to seek and reach healthcare including social and physical environments, societal attitudes, and access to knowledge, social connections and resources. When placed in the context of complex mental and physical health needs, disadvantage with respect to these factors can compound to create insurmountable barriers when faced with the spaces, systems and procedures entailed in contemporary primary care provision. The implications of these issues for policy are discussed in the concluding chapter.