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

Methodology

Approach to recommendation

In May 2022 the Primary Care Health Inequalities Development Group was established to take forward the Short Life Working Group recommendations. Members of the group were consulted on the approach to the recommendation. A research advisory group (see Appendix I) was formed to comment on the proposed approach and the work as it progressed, and to advise on any academic work or data that had not been considered or was not yet published on this topic.

Following initial scoping research and stakeholder consultation, researchers adopted a phased approach to preparing the report. This consisted of gathering existing evidence related to the recommendation, mapping barriers against a patient ‘journey’ and identifying where there might be cluster points of barriers faced by multiple groups. A clear research question was developed to guide the literature search and presentation of evidence:

What are the barriers facing those most impacted by socioeconomic inequality to accessing primary care in Scotland at different points of the primary care journey?

In January 2023 the Scottish Government library team ran a literature search using their database, incorporating key words from the recommendation. The search strategy is presented in Appendix II. This search considered published articles on this topic from the last 5 years, with a focus on Scotland. After reviewing the literature and in consultation with the research advisory group, a 2013 framework developed by international public health researchers on access to healthcare was selected to inform the presentation of findings from the literature review^[32]. This framework considers healthcare in a broad sense, allowing for a focus beyond general practice, and incorporated the perspectives of both patients and healthcare services. It was also being used concurrently in Scottish Government work on access to general practice [33], facilitating the sharing of findings across these two workstreams.

The framework depicts ‘access’ to healthcare as entailing six elements, which are influenced by patients but also healthcare systems. The six elements are 1) Healthcare needs, 2) Identifying healthcare needs, 3) Seeking healthcare services, 4) Reaching healthcare resources, 5) Obtaining or using health care services, 6) Consequences of using services. This conceptualisation has inspired but been adapted for the presentation of literature in this report.

In line with the focus on the healthcare system, the literature reviewed for this report was analysed with reference to just four areas of the framework: ‘Perception of needs’, ‘Healthcare seeking’, ‘Healthcare reaching’ and ‘Healthcare utilisation’, with the latter re-titled ‘encounters’. Further, in the report these elements of the patient ‘journey’ through primary care are not represented as a linear framework, but as broad and overlapping ‘points of engagement’ with primary care. This moves away from a linear representation to acknowledge that individuals may enter primary care at different points, which may not begin with an awareness of health need. Further, individuals may move back and forth between points – for example in the case of patients who frequently do not attend booked GP appointments, who may become ‘stuck’ when trying to reach primary care. In the following chapter, the literature reviewed is presented according to these four broad categories of engagement with primary care.

In developing the report for publication, the Scottish Government library search was conducted again in August 2024 to ensure the inclusion of up-to-date literature. This search yielded 42 articles for inclusion in the evidence review (see Appendix II). Some articles outwith the database search have also been included, either identified from reference lists, highlighted by the research advisory group and colleagues from relevant policy teams, or where they supported claims made in the reviewed literature (for example, Scottish Government and Public Health Scotland statistical publications).

Involving voices of experience

Communities across the UK have sophisticated understandings of the causes of socioeconomic causes of health inequalities. Echoing academic research these recognise the complexities of health status beyond behavioural factors, highlighting the influence of material circumstances and lived experiences of deprivation on health^[34]. Social scientific work has demonstrated that emphasising the impact of disadvantage within research and the media can be stigmatising for the communities and individuals most affected by health inequalities[35]. It is therefore important that these voices or those of their representatives are heard during policy development to ensure sensitive and non-stigmatising language, and to ground efforts to reduce inequalities within lived experiences of disadvantage.

In acknowledgement of this, in September 2023 a draft version of this report was presented to members of Voluntary Health Scotland (VHS), a charitable organisation working with the voluntary sector. VHS held this meeting “to contribute a strong voluntary health perspective to the work of the Primary Care Health Inequalities Development Group”. The meeting was attended by a range of organisations representing those with disabilities, refugees and asylum seekers, ethnic minorities, and those with additional support needs. NHS staff were also present, along with a community link worker. The researchers sought feedback on primary care barriers grounded within participants’ experiences of working with those most in need. The discussion ranged from obstacles posed by transport and finances, the challenges for non-English language speakers and the importance of ‘joining up’ the range of initiatives to reduce inequalities at local and national level. Examples of the effects of barriers to accessing primary care on individual service users, for example around anxieties and fear of negative experiences, were also heard. The views of members at this meeting are presented throughout this report, ensuring voices of experience are heard alongside the review of academic and policy literature. This report has also been influenced by contributions from the Chance 2 Change peer support group, which are referred to throughout29.

A ‘plain English’ infographic demonstrating the findings of this report is provided in Appendix III.

Limitations

The Short Life Working Group recommendation is broad. Whilst scoping literature for this report it became clear that the focus had to be narrowed to produce a clear research question and manageable body of literature within the timeframe. The recommendation highlighted six key points for consideration: barriers to access, waiting times; delayed presentations with serious conditions; "missingness"; perverse incentives; and negative behaviours when unable to access care. These concepts were used to conduct the library search and feature in the literature review, however most are not considered substantively to maintain the broader focus on barriers to primary care at various points of engagement. Further, this evidence review was not able to consider the links between the barriers to access and excess deaths and premature disability, as very few of the sources reviewed explicitly considered the relationship between the two (work on ‘missingness’ being the exception). This, as well as the need for quantitative data on missed appointments, are areas that require further research. Some of this work is ongoing within Scotland^[36].

This report identifies key points of engagement with primary care at which barriers to access may be faced relating to socioeconomic inequality. Socioeconomic inequality is patterned differently across Scotland, and intersects with other inequalities including ethnicity, disability and age^[37]. It is a complex concept and can be measured in different ways, including by occupation or by the Scottish Index of Multiple Deprivation (SIMD)[38]. In this report, socioeconomic inequality is discussed in a broad sense, in terms of the impacts of material deprivation. Some of the literature reviewed did consider its intersections with other aspects of inequality. These other determinants of health are highlighted where appropriate. The literature search only identified research with adults. The review does not consider the experiences of young people or of individuals seeking health care on behalf of a dependent.

This report presents the results of a literature review but is not a systematic review, meaning relevant literature is likely to have been omitted from the literature search. Much of the literature identified by the search focuses on general practice, with only a small number of articles considering other primary care services. Further, due to the broad scope of the recommendation, the reviewed articles represent a wide range of communities and experiences, rather than considering any in-depth. Instead, this report provides a broad overview of barriers to primary care faced by those experiencing socioeconomic inequality in Scotland, based on a review of recent evidence from the Scottish context. The aim is that the report will heighten awareness of these barriers and encourage efforts to address these within ongoing programmes of primary care reform in Scotland, and at the level of professionals involved in service delivery.