Bridging Gaps: Improving access to primary care for and with marginalised patients- “it’s quite joyful for us. It’s really improved our work”

Problem

People who experience severe and multiple disadvantage (SMD- combinations of homelessness, substance misuse, domestic abuse and poor mental health) have high health needs and poor access to primary care. The priorities and abilities of patients with SMD and the organisation of primary care are poorly aligned and inequalities in access are worsening, exacerbating vulnerabilities.The aim of this research was to collaborate with people with lived experience, a charity that supports them and general practice staff to co-produce interventions to improve access to primary care for people with SMD. We sought to explore the perspectives of marginalised patients, those who support them, and general practice staff participants on ways to improve access, and their experience of co-producing and implementing the service improvements.

Approach

We used a co-production approach where people with lived experience are involved in decision-making throughout the process. The co-production group (Bridging Gaps) was started by LP and women with lived experience of SMD who had been supported by One25 (a Bristol women’s charity which reaches out to some of the city’s most marginalised women). We contacted general practices identified by the co-production group and collaborated with their staff to co-develop service-improvements together.We used qualitative methods to explore professional and lived experience perspectives on this complex issue. Six collaborative meetings were observed at three general practices with documentary analysis of minutes. Nine practice staff and four lived experience participants were interviewed. Three lived experience participants and one staff member who supports them participated in a focus group. Data was analysed inductively and deductively using thematic analysis.

Findings

We focus on the answers to two practical questions in our findings:• What are the key issues and challenges in improving access to primary care for people with SMD?• What are the potential strategies to improve access to primary care for people with SMD?Enabling motivated general practice staff with time and funding opportunities, galvanised by lived experience involvement, resulted in sustained service changes. These included using Care Coordinators and patient lists to prioritise access to patients in greater need and an information sharing tool. A key focus was shifting ways of working to provide proactive continuity of care from trusted professionals.

Consequences

This work describes co-produced strategies to prioritise access to patients in greater need, in addition to rich contextual information on how to shift ways of working to better serve marginalised patients. This is a unique example of highly inclusive research and service-improvement work for and with highly marginalised patients, with practical tools that can be used and adapted in practice now. Investing in this different way of working may improve inclusion of marginalised patients, health equity and staff wellbeing.