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

Discussion

Health inequalities relating to socioeconomic deprivation persist in Scotland, despite many decades of policy reform. As the ‘front door’ to the healthcare system primary care is an area where these inequalities can be exacerbated, but also has unique potential to respond. This review of literature on barriers faced by those experiencing disadvantage has shown that they arise at various points of engagement with primary care. Individually, the factors described through this report may not be experienced as a barrier in themselves, and for those in more affluent circumstances may be seen as an inconvenience. However, for those facing complex health and social issues these factors can compound, creating insurmountable barriers to successfully seeking, reaching and engaging with primary care. These difficulties intersect in different ways with related aspects of socioeconomic deprivation, including language, housing and cultural factors. Therefore, the broad barriers identified within the literature will be experienced differently by different groups of people, and by individuals.

As described, the causes of health inequalities go beyond primary care and the healthcare system. However, healthcare remains a recognised determinant of health, so can play an important role in mitigating the effects of societal inequalities on individual health. Below, findings from the literature review have been developed into three areas where primary care can counteract some of the barriers to access for those experiencing socioeconomic deprivation, and which should be considered as part of wider primary care reform.

Approachability and trust

Due to experiences of social isolation and low self-efficacy that can be felt by those living in the most challenging circumstances within Scotland, it is essential that primary care is seen as approachable by all. Firstly, this means accessible, ensuring that appointments are available, that they are attainable through systems that are easy to navigate, and that they can be attended by all, including those with employment and caring responsibilities. The report has shown that challenges to reaching care particularly affect those with limited access to flexible working and transport. Mobile health units are being used in the context of cancer screening bringing this service closer to local communities, with evidence on these beginning to grow⁷¹. Within general practice, changes to the appointments on offer are being tested and supported through the primary care access programme. This supports primary care teams to identify areas for change and improve aspects of access[119].

The everyday systems in place for communicating with primary care can pose a barrier to access. In this report, voices of lived experience and supporting organisations have highlighted that telephone systems can be challenging to navigate for those with mental health conditions, and that waiting on hold or for a callback is not always possible. Practice policies surrounding missed appointments can be inadequate to engage patients with the most complex needs. Outwith general practice, barriers to approaching pharmacy staff were linked to concerns about privacy. These issues present tangible barriers to access, and these points of entry to primary care should be considered as part of wider reform.

Approachability is also key in terms of anticipated interactions with primary care professionals, with prior encounters having the potential to discourage individuals from seeking care. This includes past experiences of prejudice, discrimination and racism. Experiences of racism and discrimination interact with socioeconomic inequality in complex ways. A recent statement from the Cabinet Secretary for Health and Social Care highlights racism as a significant public health challenge and contributor to health inequalities^[120]. To ensure services are approachable to all, anti-racism must be embedded within healthcare policies, practices and operations, along with a strengthening of data collection to better identify, monitor and address racialised inequalities[121].

Research focusing on more marginalised communities, including people who use drugs and those experiencing homelessness, has described patients being made to feel dehumanised and powerless following healthcare interactions. Factors contributing to these experiences include the stigmatisation of some communities, wider system pressures and insufficient understanding of the social challenges some patients face, such as food insecurity. Existing research therefore recommends improved professional practice in this area, including awareness of how to work effectively with other health and social care services to support those affected.

Empathy and trust were key themes within the literature and were also noted by the research advisory group. Better understanding of patient needs and the day-to-day challenges of socioeconomic difficulties can encourage more empathetic healthcare interactions¹⁰⁸. Trust in primary care services, and the expectation to be treated with dignity and respect, are essential to enable all patients to feel confident enough to seek healthcare. As some of the literature has demonstrated, seeking healthcare can be highly sensitive, particularly when health concerns are stigmatised or closely entwined with difficult life circumstances such as homelessness.

Adapting to needs and enabling patients

As demonstrated in the literature on candidacy, recognising a health need and seeing oneself as eligible for healthcare is not solely dependent on knowledge and education, but shaped by family and community settings, healthcare systems and personal situations. Those facing difficulties in other aspects of life may not position symptoms as a health need, or may de-prioritise health where they face challenges to daily living. Active outreach has been described within the literature as necessary for some populations to link individuals to the services they need58, to practically assist individuals without access to the technologies often necessary to reach primary care⁸³, or to provide tailored support to address contextual barriers, multi‐morbidity, health literacy and self‐efficacy⁵⁵. ‘Missing’ patients may also require active outreach tailored to issues that underlie non-attendance, which may include mental health needs or adverse childhood experiences⁸⁸. An appreciation of the overlapping causes of missingness and barriers to primary care more widely, and understanding of these as shaped by service provision and wider social factors rather than rooted in individual patient behaviour, is crucial.

Enabling patients to feel deserving of care is key. Due to factors described in this report, those experiencing deprivation may be less inclined to position themselves as eligible for care. This can be exacerbated by messaging from within the healthcare system that implies an individual’s health need must be an emergency, a feeling of ‘burdening’ the NHS, and some patients’ sense that during GP appointments they must “get in and out” as quickly as possible. These experiences are perhaps a legacy of the COVID-19 pandemic62. Nevertheless, such perceptions must be acknowledged within processes of wider primary care reform, and efforts made throughout the system to foreground the message that primary care is open to everyone and for all health concerns.

Empowering individuals to feel deserving ‘candidates’ for care, and able to access this, goes beyond primary care to wider policy areas and institutions. It requires improved health literacy, access to digital technologies and that the most vulnerable individuals feel safe and supported. However, the location of primary care at the heart of the community presents valuable opportunities for intervention. Creating links between primary care and communities, for example through community link workers, can be a powerful tool to enhance health literacy, and to ensure that care delivery is rooted within lived experience. This approach should continue to be supported within primary care reform, to deliver on its aim of providing holistic and person-centred care for physical and mental health²³.

Equity in access to primary care

As this report has shown, patients experiencing socioeconomic deprivation often have greater need, with multiple and more complex health issues. Their general practice consultations may require more time and ‘hidden work’ from practitioners¹¹². This imbalance can impact the delivery of care and patient experience, with those in deprived areas less satisfied with their experiences of general practice appointments⁹⁹. A 2024 report argues that more could be done to better distribute core general practice resource in Scotland according to the health needs associated with socioeconomic disadvantage[122]. That report, and others, advocate for the application of ‘proportionate universalism’ to help address inequity in healthcare provision[123]. For example, literature suggests that general practice appointments should better accommodate the complex needs of those in experiencing deprivation, and additional work this requires from GPs¹¹². An example of this is extended appointments for those patients with greatest need, which are offered within the Inclusion Health Action in General Practice project¹¹⁸.