What works: Addressing inequalities in the primary and secondary care interface

Problem

A dysfunctional primary-secondary care interface impacts on patient experience, patient safety and staff workload, and is likely to widen health inequalities by disproportionately impacting underserved populations. An estimated 15 million GP appointments are used every year dealing with issues between primary and secondary care. Most evidence examining strategies at this interface overlook the impact on disadvantaged groups.

Approach

We used our Living Evidence Map (www.heec.co.uk) to identify relevant literature and complemented it by grey literature searches. Our Living Evidence Maps use machine learning within EPPI-Reviewer software to efficiently map interventions to address inequalities in primary care. Articles examining the outpatient primary-secondary care interface and inequalities were identified from these Living Evidence Maps and synthesised with grey literature. Furthermore we augmented the literature base with equity-focused guiding principles from the EQUALISE study, a realist review examining what worked to address inequalities.

Findings

We identified six points at which inequalities can arise in the outpatient primary-secondary care interface. In all areas, there was relatively little evidence around interventions specifically to reduce inequalities. Schemes developed within the UK and internationally to improve primary care referral reduced variation and may in turn improve equity. There was some evidence for care coordination, improved patient communication and targeted prehabilitation to reduce inequalities for patients navigating the interface and awaiting care. Co-location and integration of care have shown improvements in patient experience and outcomes, including projects focussed on disadvantaged groups. There is limited evidence of Patient-initiated follow-up (PIFU) on inequalities, but evidence from the EQUALISE study suggests PIFU may worsen inequalities because it takes more patient effort. Did not attend (DNA) rates are disproportionately high in lower socio-economic status groups. Interventions to reduce DNA rates have been successfully implemented, including text message, telephone and letter reminders, but the impact has in general not been disaggregated across different patient groups.

Consequences

There are multiple points across the primary-secondary care interface which could worsen inequalities; however the evidence base is weak. Policy makers and practitioners include consider use of appointment reminders in secondary care, especially for disadvantaged groups, targeted support for patients with language barriers, digital exclusion, caring responsibilities and care coordinators for patients with poor health literacy. More research is needed to better describe how, when and where inequalities arise and effective interventions to reduce inequalities.