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

Barriers to accessing primary care in Scotland: literature review

Health disparities relating to wider socioeconomic inequality have multiple causes. One element is the barriers faced in accessing healthcare, an important determinant of health. This chapter presents literature identified by the Scottish Government library database search according to barriers faced at four points of engagement with primary care: ‘Awareness of health needs’, ‘Seeking support’, Reaching services’ and ‘Encounters with primary care’.

The literature reviewed largely focuses on general practice, though many of the findings have relevance for primary care more widely.

Awareness of Health Needs

Engaging with primary care services relies on the ability to ascertain one’s own health needs, and a determination that it is appropriate to seek healthcare. These actions depend on knowledge and awareness of symptoms, health risks and of healthcare services on offer. As will be shown below, these factors must not be seen solely as a matter of individual knowledge and education, but as influenced by service provision and healthcare systems, alongside community and individual beliefs and expectations related to health.

Health Literacy

Though various definitions exist, health literacy can be understood as the “literacy and numeracy skills that enable individuals to obtain, understand, appraise, and use information to make decisions and take actions that will have an impact on health status” ^[39]. This could refer to their own needs or the needs of a person in their care such as a child or dependent adult. Health literacy has been described as a key determinant of health because it influences access and utilisation of care, interactions with providers, self-care and participation in medical decision-making [40]. Low health literacy is associated with poor health outcomes and widens health inequalities[41].

Health literacy can determine an individual’s identification of symptoms and health risks. A study with people who inject drugs (PWID) experiencing deprivation in Glasgow found that though possessing knowledge of basic health promotion messages, some were unaware of HIV risks and treatments, impeding engagement with pre-exposure prophylaxis (PrEP)^[42]. This population face barriers to mainstream services, but tailored delivery was shown to be effective[43]. The need for targeted interventions that are accessible and relevant to those most at risk has also been advocated in the context of early cancer diagnosis. A 2022 report from Cancer Research UK describes that Scottish people in routine and manual occupations (a proxy measure for more deprived groups), were less than half as likely to recall some signs and symptoms of cancer than those in managerial and professional occupations [44]. Research has also associated lower health literacy with confusion about and avoidance of cancer screening[45]. During the period 2021-2023, Public Health Scotland statistics show a 21 percentage point gap in bowel screening uptake in Scotland between the most (54%) and least (75%) deprived population quintiles[46], with a similar trend seen in breast and cervical screening44. Invitations to screening in Scotland are generally sent by letter[47], which may exclude those with literacy needs, as well as those without a permanent address. Some articles identified by the search highlighted other characteristics intersecting with socioeconomic deprivation which contribute to cancer-related health inequalities, including ethnicity[48] and disability[49].

Health literacy is closely related to access to digital information and digital literacy. A 2022 survey of 1,136 people commissioned by the Scottish Government on Public Understanding of Primary Care in Scotland found that those with a household income of £2,500 or more per month were more likely to report finding it easy to find information online about a health problem (74%) than those on a household income of £1,000 or less (51%) ^[50]. A study of general practice websites across Scotland found that 77% of the 3,823 webpages reviewed included content that exceeded the recommended reading age of 9-14 years old[51]. A Scottish study with young mothers experiencing disadvantage were less likely to use online information even if it was tailored to them due to complex behavioural and access issues, including financial. Instead, they relied on support workers to provide and link them to relevant information around topics such as pregnancy, housing, or postnatal care [52].

Low health and digital literacy impact on awareness of health needs and risks, and timely presentation of serious conditions. Health literacy can therefore be considered a determinant of health. It is important that health literacy is not just understood as a set of individual skills, but seen as situated within wider social and healthcare contexts. This places responsibility for change with healthcare systems rather than individuals, focusing policy attention on simplifying communication and reducing the complexities of the health systems that people must navigate39. Reflecting this, empowering communities and embedding health literacy within policy and practice is at the heart of the Scottish Government’s Health Literacy Action Plan for Scotland40.

Candidacy

Awareness of health needs may also be impacted by individuals’ perceptions of themselves as a ‘candidate’ for care. In academic literature, candidacy has been described as “the ways in which people's eligibility for medical attention and intervention is jointly negotiated between individuals and health services” ^[53]. As well as an awareness of health risks or symptoms, the identification of oneself as eligible for care can also be shaped by healthcare systems, communities and life experience. Studies have shown that individuals within socioeconomically disadvantaged settings may not identify themselves as a candidate for care because of an expectation of poor health within communities which, as described above, face a higher disease burden. Related to this, illness symptoms and experiences of discomfort may become normalised53. In the case of smoking and lung cancer, individuals experiencing economic hardship have voiced a lack of control and an expectation of poor outcomes regardless of access to healthcare, having witnessed the impacts of the disease within their communities[54]. Similar feelings of ambivalence were voiced by participants in a study on self-care and homelessness in Scotland. In this study, barriers to healthcare seeking were exacerbated by the need to prioritise the challenges of day-to-day living over long-term health. For these participants, outreach and rapport with health and care professionals was found to be key to productive engagement with services [55].

For individuals most affected by socioeconomic inequality, engagement with primary care may therefore only take place in the case of unmanageable symptoms or pain rather than for preventative care. This is reflected in statistics from the latest quarter (December 2024) that children and adults from the most deprived areas (SIMD 1) were less likely to have had contact with NHS primary dental care than those in the least deprived areas (43,550 compared to 50,072 children and 125,152 compared to 141,461 adults). A similar pattern was seen in participation rates across the previous two years^[56]. Infrequent contact with dental care contributes to a widening of oral health inequalities, with deprived communities generally experiencing poorer oral health, along with the implications of this for physical health, mental wellbeing and social life[57]. Targeted support has been shown to link families from more disadvantaged backgrounds to primary care dental services, positively impacting attendance [58].

The issue of perceived eligibility for care was brought into focus during the COVID-19 pandemic, where the mortality rate for COVID-19 in the most deprived areas of Scotland was higher than the least deprived areas^[59]. This has been linked to the higher burden of pre-existing conditions such as diabetes, obesity, and lung disease, but also inequalities in access to healthcare including vaccination[60]. Some reasons for impaired access included lower health literacy, the inability to take time off work and lack of affordable transport to vaccination centres[61]. However, a report from the ‘Deep End’ project, who work with deprived practices in Glasgow, also cites lower levels of patient knowledge, confidence and agency as preventing patients from engaging with healthcare [62]. This is reflected in one study from a deprived area of Scotland, where during the pandemic participants found it difficult to navigate changed systems for accessing GP services. Some avoided using services because they felt like a burden on the NHS, at a time when public health messaging was seen to discourage engagement with general practice[63]. In response to such messaging, more vulnerable individuals may lack the confidence, support and self-efficacy to position themselves as a candidate for care (see Box 1).

Box 1

Voices of experience: reflections from Voluntary Health Scotland member organisations

An organisation offering support to black, minority ethnic and refugee women and girls raised the issue of GP surgeries only offering emergency appointments, which individuals can assume means for something life threatening. The women they support may not have the confidence or language to explain and seek help for their health condition, or may not see themselves as deserving of care.

A myalgic encephalomyelitis (ME) charity described that some service users have not been understood or not believed by their clinician. This has made them hesitant to access primary care, until their health need then becomes an emergency.

The literature indicates that individuals affected by socioeconomic challenges may face barriers to ascertaining their healthcare needs. For some, overcoming these requires additional support from healthcare services and the provision of accessible health information, with recognition that digital services are not always preferable52. The barriers to establishing oneself as a candidate to receive care have also been highlighted. In some cases, these may be best addressed through active outreach, as exemplified in work with homelessness and in dentistry. Working with communities and the voluntary sector is also key, to ensure that those affected are heard and represented in efforts to improve health literacy, and to empower patients to view themselves as eligible for and deserving of care.

Seeking Support from Services

Though they may recognise a health concern, individuals may 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.

Knowledge about services

The Public Understanding and Expectations of Primary Care in Scotland survey analysis shows that 90% of those from the most deprived SIMD decile reported feeling confident that they knew about the range of services available (90%). However, this does not mean that individuals are aware of which service is best placed to meet their needs. For example, respondents with a household income of £1,500 per month or less were more likely to be unsure (26%) in knowing where to turn to if their general practice was closed, compared to those with a household income of £2,500 or more (14%)^[64].

The ability to seek an alternative to general practice is entwined with patients’ knowledge of wider service provision. A study with thirty community pharmacists across Scotland identified that as well as knowledge of their health and medication, understandings of the services offered by pharmacy personnel influenced the consultations they were able to hold with patients ^[65] (see also Box 2).

Box 2

Voices of experience: reflections from Voluntary Health Scotland member organisations

One member highlighted that in their experience patients often use hospital care if they cannot contact their GP. They highlighted that other health support initiatives, such as Pharmacy First, could have a positive impact if known about more widely.

A member with prior experience of working in Accident and Emergency explained that not knowing what was available meant she often saw patients whose health concern was not urgent and could have been dealt with in the community.

Unfamiliarity with NHS systems and difficulty accessing information in languages other than English can mean that migrants experiencing socioeconomic deprivation encounter additional hurdles to engaging with primary care^[66] (See Box 3). Gypsy/Traveller communities can face similar challenges, with the inaccessibility of medical ‘jargon’ and a mistrust of institutions also raised[67]. As a result, the most vulnerable, such as those experiencing homelessness, may have little choice in which service they are able to access, contributing to a lack of autonomy and sense of powerlessness [68].

Box 3

Voices of experience: reflections from Voluntary Health Scotland member organisations

An addictions and mental health charity raised that those seeking asylum may not understand the Scottish healthcare system, and may appear in the ‘wrong’ part of the system at the ‘wrong’ time. This can prompt a negative reaction from healthcare professionals and create barriers to future contact. The charity offers sessions with a support worker to explain NHS systems, which helps these individuals to engage.

The navigation of healthcare systems and services requires a great deal of work from all patients, but is a particular challenge for those with lower health and digital literacy. Understanding and navigating various primary care services is thus another area where inequalities can be exacerbated.

Poor experiences of care

Some of the literature describes that individuals can be reluctant to approach healthcare services due to previous experience of healthcare encounters. Two articles highlighted this in relation to pharmacy settings, where past engagements with pharmacy staff had been experienced as stigmatising⁶⁸, and in one qualitative study were cited as a barrier to collecting prescriptions[69]. Though taken from small studies, these experiences demonstrate that negative interactions with healthcare staff can have longstanding implications for patient trust (discussed further below in ‘Patient trust and practitioner-patient relationships’). Discomfort with pharmacy settings was also highlighted, with the public nature of this space experienced in one study as ‘intimidating’ or ‘embarrassing’[70]. Privacy has also been reported by pharmacists themselves as hindering them from taking medical histories in community settings⁶⁵. These studies suggest that concerns about privacy persist for some individuals, despite the widespread availability of consultation rooms.

Related to the issue of privacy, discomfort with discussing health concerns has been highlighted within the literature. For example, owing to the close link between health and difficult life circumstances, consultations can prompt stress or anxiety for those experiencing homelessness⁵⁵. The Public Understanding and Expectations of Primary Care in Scotland⁵⁰ report found that survey respondents from the most deprived areas were more likely to find it difficult to express health issues to a GP and more likely to go to A&E or call 111 in response to a new non-life-threatening health concern. Reluctance to discuss health was also raised in relation to stigmatised conditions such as lung cancer, whereby smokers from lower socioeconomic grades (a measure of deprivation associated with occupation) reported feeling judged for smoking and consequently expressed a sense of discomfort about engaging with screening services [71].

An expectation of negative encounters with healthcare professionals and lack of trust is linked to other barriers such as low health literacy and power dynamics within practitioner-patient relationships, but also shared experience within these communities of healthcare systems not working for them. Recent research has argued that the effects of these may be mitigated by person-centred care and outreach, for example from voluntary organisations^[72].

Avoidance and fear

As described in the above section on health literacy, in Scotland cancer screening uptake is lower in the most deprived populations compared to the least deprived. Whilst some of this variation will be attributable to material barriers such as financial constraints (see section below on ‘Reaching services’), literature on lung cancer has also shown that fear of diagnosis and of invasive procedures can influence screening uptake⁷¹. Hesitancy around seeking out or confirming risk has also been raised in relation to bowel screening[73]. For those living in socioeconomically challenging situations, fear of diagnosis can be compounded by some of the factors described above in relation to candidacy such as fatalism, low health literacy, mistrust of healthcare services and social isolation. Fears and anxieties about engaging with care are complex and embedded within individuals’ community contexts and encounters with illness throughout the lifecourse.

Racism and discrimination

For minority ethnic groups experiencing socioeconomic disadvantage, past experiences of racism, whether their own or within their families, could lead to anticipated discrimination within healthcare settings^[74]. As well as racism contributing to health inequalities through disadvantage related to the socioeconomic determinants of health, such accounts therefore also highlight racism as a driver of health inequality, influencing patient trust and preventing access to care.

This goes beyond individual experiences of healthcare to the wider healthcare system, which requires better representation of minority ethnic people, and improved data and reporting on racialised health inequalities in Scotland^[75]. System-level barriers to care are also highlighted in a Glasgow study with refugees and asylum seekers. The uncertainties and fears associated with the asylum process placed these individuals in a position of vulnerability and constrained their access to resources, impacting their physical and mental health[76].

The research above suggests that those who face multiple disadvantage are less likely to seek healthcare, even where they are eligible for care. These reasons are complex, and closely tied to health literacy, community experiences of health and care, and previous encounters with health practitioners and systems. To encourage those experiencing disadvantage to seek care requires sensitive interactions that eliminate discrimination within healthcare. It also requires tailored outreach to those communities less likely to engage with services such as screening, to minimise fears and build trust and understanding around the benefits of this care. Recent examples of such initiatives include Gypsy/Travellers Community Health Workers (CHW) ^[77] and Health Champions in Grampian[78], trained to promote and improve access to services for community members from ethnic minorities.

Reaching Services

Reaching a primary care service requires resources including finances and time, but also behavioural factors including motivation and self-efficacy. As seen above, barriers that limit awareness of healthcare needs and seeking support may exacerbate health conditions before an individual reaches primary care.

Resource constraints

Though an individual may act to seek healthcare, they may not be able to engage with services. A significant obstacle to accessing primary care is availability of resources, including financial^[79]. Transport is frequently cited by patient experience groups and charities as a barrier to reaching healthcare, both in terms of local provision and ability to afford a bus or taxi (see Box 4).

Box 4

Voices of experience: reflections from Voluntary Health Scotland member organisations

A charitable organisation providing transport for those with mobility issues and other vulnerable groups has seen an increase in requests for support to access primary care and other NHS services. They have witnessed some individuals cancelling transport to primary care because of costs. They also highlighted that some local councils in Scotland are restricting funded transport to health appointments only, posing further challenges for the most vulnerable.

Transport issues can be more keenly felt by those in rural areas who may need to travel considerable distances to healthcare, especially to specialist services such as sexual health testing^[80]. The centralisation of services in these areas can require longer journeys with associated financial and time costs. The availability and proximity of services is not just an issue for general practice and pharmacy, but also psychological and physical therapies that complement primary care, for example to manage chronic pain11. Rural and remote areas face distinct challenges to healthcare access and have unique patterns of health inequalities, however few articles on this topic were identified by the literature search.

More generally, employment conditions can also present a barrier to reaching services that operate during daytime hours, with some unable to afford time off work. Those who have less flexibility in their employment have reported being less able to get an appointment and see a particular GP, as well as lower satisfaction with opening hours^[81].

Technological exclusion

The increasing need for technological knowledge or equipment to interact with care services can pose a barrier to those with poor access to resources. Appointment systems can be difficult to navigate for those with complex needs without others to advocate for them, including homeless populations and those with substance issues^[82]. These individuals may need help to record or rearrange face-to-face appointments, for example if they have mental health or addiction issues. Active outreach has been beneficial for those who have limited access to WiFi and a computer, and to assist with health-related activities such as accessing prescription medication [83]. Even access to a smartphone does not ensure equality in digital access, with financial resources for top-ups and data not guaranteed[84]. Where individuals cannot afford to wait on hold to book an appointment with a GP practice, this can mean that appointments become unattainable. The common practice of receiving a callback from a GP later in the day can also be a barrier for those with caring and employment responsibilities, and those with complex support needs (See Box 5).

Box 5

Voices of experience: Chance 2 Change peer-support group

‘Waiting all day for the GP to phone you back’ was a key barrier to care identified by Chance 2 Change members. This could cause anxiety and exacerbate existing mental health conditions. Waiting for the phone call meant one member did not leave the house because they wanted privacy to discuss a sensitive issue. Some members reported waiting at home all day for a phone call, with one ‘too frightened to go to the toilet’.

VHS member organisations also highlighted the difficulty of navigating pre-recorded messages for those with support needs, as well as the requirement to wait on hold for up to an hour when calling the surgery early. Waiting is not possible for some patients due to being unwell, experiencing anxiety, or not being able to afford the phone charges.

The potential for digital tools to exacerbate inequalities was highlighted during the COVID-19 pandemic, when remote consultations were more commonly offered. Though remote care removes barriers for some, including those with mobility issues[85], for others it can reduce face-to-face contact resulting in lower satisfaction with healthcare interactions. A recent UK study of 1,462 adults found that those with fewer educational qualifications may require additional support to improve their experience of remote consultations and ensure equitable care[86]. Remote care can also be inaccessible or ineffective for those experiencing homelessness, those requiring an interpreter, and those without access to up-to-date smartphones and credit or WiFi⁶². Poor access to WiFi is often experienced in rural areas of Scotland, and can amplify health inequalities in these regions[87].

Missingness in healthcare

Despite making contact or being eligible for healthcare services, some patients with experience of deprivation may subsequently find it difficult to engage with care, exemplified by ‘missed’ appointments (sometimes called ‘did not attend’s or DNAs). Ongoing research in general practice settings from the University of Glasgow has defined ‘missingness’ as “the repeated tendency not to take up offers of care, such that it has a negative impact on the person and their life chances” ^[88], with missingness more prevalent among those experiencing socioeconomic deprivation[89]. Patients with multiple long term-conditions have an increased risk of missing GP appointments, are more likely to be admitted to hospital[90], and are at significantly greater risk of all-cause mortality. Those experiencing mental health conditions who miss more than two appointments per year have an 8-fold increase in risk of premature death [91].

Research on missingness indicates that healthcare settings and systems are not accessible to some patients, and that universal procedures may contribute to widening inequalities. For example, where a text message reminder may be effective for those who miss a single appointment, this may not promote attendance for an individual with complex needs⁹¹. Missingness is complex, encompassing social, structural and health-related causes as demonstrated throughout this report. It must therefore be seen as rooted within service design and wider social structures, rather than individual behaviours. Efforts to improve access to primary care must be sensitive to this complexity and include tailored and targeted interventions⁸⁸.

Other recommendations and interventions to improve service access include community-based, physical spaces serving as ‘hubs’ with access to the internet and digital equipment[92]; the simplification of systems to make an appointment with a GP; or the introduction of shorter pre-bookable ‘review’ appointments [93]. The Chance 2 Change peer-support group also recommended clearer lines of communication for long-term health conditions, including mental health, and improved continuity of care²⁹.

Encounters with Primary Care

Two of the four principles for access to general practice formed by a Scottish Government Short Life Working Group state that care should be ‘person-centred and based on what matters to the individual’, and that services should be ‘approachable, sensitive, compassionate and considerate to need’³³. However, current healthcare processes and structures, and the quality of interpersonal relationships between professionals and patients, may mean that those principles may not be fully embedded in practice. This, in turn, perpetuates barriers to involvement with primary care.

Capacity to equitably meet demand

Primary care across Scotland is under pressure with rising demand from an ageing population^[94], impacting service capacity, resource and workloads. This has significant implications for remote and rural communities, as well as deprived areas due to higher rates of multiple long-term conditions and complex social needs. A 2022 interview study with 21 general practice staff about experiences of multidisciplinary team working found that in deprived areas, staff reported insufficient resources to deal with high numbers of patients with complex morbidity [95]. Secondary analysis of survey data from 2,465 GPs found lower job satisfaction and higher job stressors among GPs working in deprived areas [96]. Higher or more intense workloads may also impede professional development within deprived practices, despite there being particular training needs to best serve these populations [97].

Higher demand within these practice populations can be felt by patients. Secondary analysis of the 2017/2018 national Health and Care Experience survey, which returned 132,972 questionnaires, found lower satisfaction with access and consultation quality in areas of higher deprivation compared with lower deprivation96. The finding relating to consultation quality is reflected in results from Quality of care experience analysis of the 2023/24 national Health and Care Experience survey (107,538 respondents), which found that those living in deprived areas were less likely to rate the overall quality of care provided by their GP practice as Excellent or Good (63%) compared to those from the least deprived areas (71%)^[98]. The results of a 2022 postal survey (1,053 responses) support this, finding that while patients in deprived areas have the greatest health needs, including higher multimorbidity and complex presentations, they also have the poorest experience of consultations [99]. Indeed, one qualitative study with patients facing financial hardship noted a feeling of “hav[ing] to get in and get out as quick as possible” [100]. Some of these studies discuss inequalities in access to and quality of healthcare with reference to the ‘inverse care law’. This is the observation first described over 50 years ago that ‘the availability of good medical care tends to vary inversely with the need for it in the population served’[101]. Though the literature reviewed concentrates on general practice, the inverse care law has also been described with reference to NHS dentistry[102].

The time and resource constraints faced within primary care can mean that in the context of the most complex conditions and life circumstances such as homelessness, it may be difficult to ascertain or discuss particular health concerns[103]. Limited practitioner awareness can also mean that wider social and economic impacts on health may not be addressed¹⁰⁰. Though national initiatives to incentivise better care have been introduced such as the quality and outcomes framework, now discontinued in Scotland, these may not have a positive impact on those with greatest health needs[104].

Health professional understanding and empathy

Several studies discuss practitioner experiences of the needs of those affected by socioeconomic deprivation. Some found little professional awareness of the challenges faced by these patients, for example around food insecurity. Health professionals, particularly those without experience of treating food insecure patients, may not recognise this issue or could find it a sensitive topic to discuss^[105]. Negative attitudes, lack of understanding or discomfort with discussing circumstances such as homelessness and drug use were also described in research with general practice staff[106] and pharmacists[107].

Alongside perceptions of patients, professionals’ perceptions of the factors contributing to health status influence the delivery of care. In two interview studies with practitioners working in socioeconomically deprived areas, those who emphasised wider social issues such as material deprivation and adverse living conditions when discussing health inequality were more understanding towards the difficulties patients faced in adopting healthy behaviours ^[108]. Perceived empathy is known to improve patient outcomes[109], whereas a lack of empathy can lead to an ‘othering’ of patients experiencing complex health needs[110] and negative views about their ability or motivation to improve their health[111].

Though increased practitioner understanding of the wider social contexts contributing to poor health may facilitate empathetic interactions with affected patients, it is important to acknowledge the emotional labour involved for practitioners working with patients with complex health and social needs. This work is often not recognised or resourced within the wider healthcare system ^[112], and is situated within a context of workforce pressures within primary care.

Patient trust and practitioner-patient relationships

Some studies have pointed to interactions with staff negatively influencing patient experience. This can include with those who patients may perceive as ‘gatekeepers’ to primary care (See Box 6).

Box 6

Voices of experience: reflections from Voluntary Health Scotland member organisations

Some VHS members emphasised the need to understand at-risk population groups more fully. The lack of widely captured data on patient characteristics to fully understand unmet need was highlighted as a concern. They also raised the need for additional training for staff including receptionists, to better understand how to engage and empathise with certain population groups. They hoped this would lead to more informed approaches and could reduce stigma and bias against patients, such as those whose first language is not English.

One interview study with practitioners and charities delivering Hepatitis C treatment found that those who use drugs can feel judged by GPs, affecting their confidence and self-worth[113]. Participants experiencing homelessness interviewed for a different qualitative study reported previous encounters of public services which made them feel humiliated and powerless. These did not all concern primary care, but provoked anxiety about future interactions with professionals⁶⁸.

Anxiety and feelings of powerlessness shape the extent to which those facing disadvantage can be and feel involved in healthcare and treatment decision-making. Due to factors described above, patients with reduced access to material and social resources are less well-positioned to access and navigate the healthcare system. They can therefore be or feel less able to influence healthcare interactions[114], contributing to a lack of participation in clinical decisions. However, as reported in an interview study with GPs, lower confidence with the healthcare system and a feeling of overwhelm may also mean some patients reject taking a role in decision-making¹¹².

Patient satisfaction and trust has been shown to influence medication adherence^[115] amongst those experiencing disadvantage. Some of the most marginalised groups, such as those experiencing homelessness, already find engaging with treatment difficult, because of impacts on wellbeing and daily activities[116]. Challenges to accessing and taking medications therefore have the potential to further entrench health inequality.

The research reviewed suggests that there may be a lack of fit between the standard work of general practice, which focuses on illness management, and the needs of socioeconomically disadvantaged patients¹¹². This research argues that the complexity of health and social issues they face are not accounted for in the single disease approach to consultations, which is reflected in consultation length, and that care for these patients requires an individualised and responsive approach. Existing research suggests this might be achieved through tailored support, such as the community health workers service for the Gyspy/Traveller community77, or specialist training for GPs focused on deprived areas and marginalised groups⁹⁷.

A recognition of additional resource needs amongst practices serving communities with high levels of poverty and disadvantage has shaped the Scottish Government’s Inclusion Health Action in General Practice project^[117], which targets additional funding to practices in highly deprived areas within the NHS Greater Glasgow and Clyde health board. The project enables practices to undertake community engagement, participate in training related to health inequalities, and offer longer consultations targeted to those with the most complex needs. This work has seen positive early outcomes [118].