How does equitable general practice look like? A realist review and action framework
Problem
Health inequalities have been in the public agenda for decades. Researchers and public health bodies agree that these are driven by the circumstances in which people are born and live. However, there is an increasing consensus that healthcare services and especially general practice can play a significant role in reducing health inequalities. Still, what is missing is effective and transferable guidance regarding how this can be achieved. In this study, we synthesised the evidence on interventions and routine care in general practice that decrease or increase inequalities. Our aim was to produce a series of guiding principles and an action framework for equitable general practice for healthcare professionals and decision makers.
Approach
We conducted a realist review based on Pawson’s five steps. We searched MEDLINE, EMBASE, CINAHL, PsychINFO, the Web of Science, and the Cochrane Library for systematic reviews of health inequalities interventions in general practice from 2010 to March 2022. We focused on studies on cancer, diabetes, cardiovascular or chronic obstructive pulmonary disease as the main drivers of inequalities in mortality. We screened the primary studies in the included systematic reviews and included those that reported on clinical or care related outcomes by socio-economic status or other PROGRESS-Plus categories.
Findings
325 studies met the inclusion criteria and 159 were included in the evidence synthesis. Robust evidence on the impact of general practice on health inequalities is limited. Inequalities in general practice result from complex processes that involve structures, ideas, everyday bureaucracies, and interpersonal relationships. Focusing on common qualities of effective interventions, we found that to reduce inequalities in health and healthcare, general practice needs to be: • Connected so that interventions are coordinated across the system.• Intersectional to account for differences within groups of (disadvantaged) patients.• Flexible to meet patients’ different needs and preferences.• Inclusive so that it does not exclude people because of who they are. • Community-centred so that everyone involved in general practice engages with its design and delivery.
Consequences
A vision of equitable general practice involves coordinated action and care that is connected, intersectional, flexible, inclusive, and community-centred. Future work should focus on how these five principles can be better used to shape the organisational development of future general practice.