Interventions to improve access to primary care for inclusion health groups in England: a scoping review.

BACKGROUND: Everyone in England has the right to primary care without financial charges. Nevertheless, evidence shows that barriers remain for inclusion health populations such as vulnerable migrants, people experiencing homelessness, Gypsy, Roma, and Traveller (GRT) communities, and people who sell sex. There is little evidence for what works to improve access. This study was a scoping review of interventions to improve access to mainstream primary care for inclusion health groups in England. METHODS: In this scoping review, we searched databases (Embase, Medline, APA PsychInfo, the Cochrane Collaboration Library, Web of Science and CINAHL) and grey literature sources, including the National Health Service and National Institute for Clinical Excellence, for articles published in English between Jan 1, 2010, and Dec 31, 2020, with no limit on study design. Data were extracted according to inclusion criteria, including interventions taking place in England and targeting people with insecure immigration status, people who sell sex, people experiencing homelessness, and GRT communities. Results were presented in a narrative synthesis. FINDINGS: 39 studies describing one or more interventions were included: four peer-reviewed articles (one randomised trial, two quality improvement projects, and one mixed-methods study protocol) and 25 grey literature items (38 interventions in total). Interventions mostly targeted people with insecure immigration status (17/38, 45%), and a majority (12/38, 32%) took place in London. The most common types of intervention were training, education, and resources (such as leaflets or websites) for patients or staff (25/38, 66%), and most interventions targeted GP registration processes (28/38, 74%). Interventions commonly involved voluntary and community sector organisations (16/38, 42%). Most interventions were not evaluated to understand their effectiveness (23/38, 61%). Sources with evaluations identified staff training, direct patient advocacy, and involvement of people with lived experience as effective elements. INTERPRETATION: Interventions to improve access to primary care for inclusion health groups in England were heterogeneous, commonly undertaken at community level, and developed to serve local inclusion health groups. Considerations for policymakers and practitioners include groups and geographical areas less commonly included in interventions, the elements of positive practice identified in evaluations, and the need for evaluation of future interventions. FUNDING: National Institute for Health and Care Research (NIHR 202050).

The experiences of a regional Aboriginal community accessing primary health care during times of crisis.

INTRODUCTION: The importance of primary health care (PHC) to Aboriginal Australians is widely acknowledged, as is the underservicing of the Aboriginal Australian population. Aboriginal People continue to face significant obstacles when accessing and using health care services. OBJECTIVE: This study identifies environmental factors (beyond personal and service delivery) that functioned as barriers and enablers to Aboriginal Australians' experiences accessing PHC during crises and recommends approaches during future events. DESIGN: This research utilised a case study approach. Data were collected through in-depth interviews and analysed using thematic analysis. The study was set in Lakes Entrance, a regional Victorian locality with a sizable Aboriginal community, which was affected by bushfires during 2019/2020 and COVID-19 restrictions during 2020-2021. Participants were 18 Aboriginal People over the age of 18 living in the locality during either bushfires or COVID-19. FINDINGS: The barriers identified included the impact on PHC access of priorities other than health, including housing; financial constraints; difficulties with transport; medical bureaucracy and the physical environment of the health care setting, including appointment-making processes; interactions with medical reception staff; and waiting room environments. Enablers identified included the supportive role of the local Aboriginal Community Controlled Health Organisations (ACCHO) and their staff, which was highlighted in participant responses. DISCUSSION: The preference of many Aboriginal people to access PHC via their local ACCHO, rather than mainstream health care services, appears even more salient during crises than in normal times. This research identified that ACCHOs are ideally placed to promote and protect the health of Aboriginal communities during crises. CONCLUSION: Results may help direct interventions to improve PHC access and experiences for regional Aboriginal communities both during and outside periods of crisis.

Disparities in access to primary care, a key site for HIV prevention services, among gay and bisexual men in the United States.

U.S. HIV diagnoses disproportionately affect Non-Hispanic Black (NHB) and Hispanic gay and bisexual men. Using data from the National Health Interview Survey (2013-2018), we examined race and ethnicity and primary care access, an HIV prevention resource, among gay and bisexual men. The explanatory variable was NHB, Hispanic or Non-Hispanic White (NHW). Outcomes were primary care-specific usual place of care (potential access) and saw general doctor <12 months (realized access). We used multivariable logistic regression, adjusting for individual sociodemographic characteristics, health status, and care barriers. In sensitivity analysis, we examined general access (any place/doctor) and subgroups (1) NHB (2) has usual place of care. The sample included 1,858 adult, gay and bisexual men (unweighted). Nearly one-third self-identified as NHB or Hispanic. Compared to NHW men, NHB and Hispanic men were younger, with lower household income, and more care barriers (p < 0.05). NHB and Hispanic men had lower realized access (aOR 0.7058, p = 0.030) than NHW men. Potential access was lower for NHB only (versus NHW) and, among those with any usual place of care, NHB and Hispanic men versus NHW men. Lower primary care access for NHB or Hispanic, rather than NHW, gay and bisexual men, may reduce HIV prevention access.

Trauma-informed co-production: Collaborating and combining expertise to improve access to primary care with women with complex needs.

INTRODUCTION: Health, social care, charitable and justice sectors are increasingly recognising the need for trauma-informed services that seek to recognise signs of trauma, provide appropriate paths to recovery and ensure that services enable people rather than retraumatise. Foundational to the development of trauma-informed services is collaboration with people with lived experience of trauma. Co-production principles may provide a useful framework for this collaboration, due to their emphasis on lived experience, and intent to address power imbalances and promote equity. This article aims to examine trauma-informed and co-production principles to consider the extent to which they overlap and explore how to tailor co-production approaches to support people who have experienced trauma. METHODS: Bridging Gaps is a collaboration between women who have experienced complex trauma, a charity that supports them, primary care clinicians and health researchers to improve access to trauma-informed primary care. Using co-production principles, we aimed to ensure that women who have experienced trauma were key decision-makers throughout the project. Through reflective notes (n = 19), observations of meetings (n = 3), interviews with people involved in the project (n = 9) and reflective group discussions on our experiences, we share learning, successes and failures. Data analysis followed a framework approach, using trauma-informed principles. RESULTS: Co-production processes can require adaptation when working with people who have experienced trauma. We emphasise the need for close partnership working, flexibility and transparency around power dynamics, paying particular attention to aspects of power that are less readily visible. Sharing experiences can retrigger trauma. People conducting co-production work need to understand trauma and how this may impact upon an individual's sense of psychological safety. Long-term funding is vital to enable projects to have enough time for the establishment of trust and delivery of tangible results. CONCLUSIONS: Co-production principles are highly suitable when developing trauma-informed services. Greater consideration needs to be given as to whether and how people share lived experiences, the need for safe spaces, honesty and humility, difficult dynamics between empowerment and safety and whether and when blurring boundaries may be helpful. Our findings have applicability to policy-making, funding and service provision to enable co-production processes to become more trauma-informed. PUBLIC CONTRIBUTION: Bridging Gaps was started by a group of women who have experienced complex trauma, including addiction, homelessness, mental health problems, sexual exploitation, domestic and sexual violence and poverty, with a general practitioner (GP) who provides healthcare to this population, alongside a support worker from the charity One25, a charity that supports some of the most marginalised women in Bristol to heal and thrive. More GPs and healthcare researchers joined the group and they have been meeting fortnightly for a period of 4 years with the aim of improving access to trauma-informed primary care. The group uses co-production principles to work together, and we aim to ensure that women who have experienced trauma are key decision-makers throughout our work together. This article is a summary of our learning, informed by discussion, observations and interviews with members of the group.

From idea to systems solution: enhancing access to primary care in Malawi.

Malawi, like many other countries, faces challenges in providing accessible, affordable, and quality health services to all people. The Malawian policy framework recognizes the value of communities and citizens, as co-creators of health and leaders of localized and innovative initiatives, such as social innovations.Social innovations involve and include communities and citizens, as well as bring about changes in the institutions responsible for care delivery. In this article, we describe the institutionalization process of a citizen-initiated primary care social innovation, named Chipatala Cha Pa Foni, focused on extending access to health information and appropriate service-seeking behavior.An interdisciplinary multi-method qualitative case study design was adopted, drawing on data collected from key informant interviews, observations, and documents over an 18-month period. A composite social innovation framework, informed by institutional theory and positive organizational scholarship, guided the thematic content analysis. Institutional-level changes were analyzed in five key dimensions as well as the role of actors, operating as institutional entrepreneurs, in this process.A subset of actors matched the definition of operating as Institutional Entrepreneurs. They worked in close collaboration to bring about changes in five institutional dimensions: roles, resource flows, authority flows, social identities and meanings. We highlight the changing role of nurses; redistribution and decentralization of health information; shared decision-making, and greater integration of different technical service areas.From this study, the social innovation brought about key institutional and socio-cultural changes in the Malawi health system. These changes supported strengthening the system's integrity for achieving Universal Health Coverage by unlocking and cultivating dormant human-based resources. As a fully institutionalized social innovation, Chipatala Cha Pa Foni has enhanced access to primary care and especially as part of the Covid-19 response.

Nurse Practitioners Are Stepping Up to Meet Access to Primary Care Services Across the United States: A Time for Policy Change.

This month's column highlights the need for access to primary care services across the United States and how nurse practitioners (NPs) have risen to meet this need. The authors discuss the modernization of licensure laws that will remove unnecessary barriers to full and direct access to NP healthcare services.

Timely access to primary care in New Brunswick: Variability across health regions.

OBJECTIVE: To examine the factors that influence variation in timely access to primary care across the different health regions in New Brunswick. DESIGN: Descriptive and comparative study of organizational practices in primary care practices based on speed of access. Data were collected from December 2019 to March 2020 using semistructured interviews conducted by telephone, in person, or online, according to participants' preferences. SETTING: New Brunswick. PARTICIPANTS: Participants were primary care providers. Two types of regions were targeted: those with a higher proportion of citizens with timely access to primary care (regions with faster access) and those with less timely access (regions with slower access). A sample of 27 participants was used. MAIN OUTCOME MEASURES: Organizational practices (ie, new technologies, team-based health services, performance measurement, method of appointment booking, and physician remuneration model) according to prevalence of timely access. RESULTS: Participants in regions with faster access measured their performance more often (45.5% vs 12.5%, P=.046), did not use mixed compensation models (0.0% vs 31.3%, P<.001), and managed more patients (average of 2157 patients vs 950, P=.025), compared with participants from regions with slower access. CONCLUSION: This study found that performance measurements and other organizational practices are favourably linked to timely access to primary care.

Disparities in access to primary care are growing wider in Canada.

Canadian provinces and territories have undertaken varied reforms to how primary care is funded, organized, and delivered, but equity impacts of reforms are unclear. We explore disparities in access to primary care by income, educational attainment, dwelling ownership, immigration, racialization, place of residence (metropolitan/non-metropolitan), and sex/gender, and how these have changed over time, using data from the Canadian Community Health Survey (2007/08 and 2015/16 or 2017/18). We observe disparities by income, educational attainment, dwelling ownership, recent immigration, immigration (regular place of care), racialization (regular place of care), and sex/gender. Disparities are persistent over time or increasing in the case of income and racialization (regular medical provider and consulted with a medical professional). Primary care policy decisions that do not explicitly consider existing inequities may continue to entrench them. Careful study of equity impacts of ongoing policy reforms is needed.

The best defence is a good offence: Ensuring equitable access to primary care in Canada.

Ensuring access to primary care is a persistent challenge in Canada, and the COVID-19 pandemic exacerbated existing gaps. Public policy reform that only partially addresses these access issues, technological opportunities, workforce desires, or patient preferences creates an opportunity for private, investor-owned corporations to take ownership of primary care delivery systems. This article summarizes the history of the "public-private" conversation as it pertains to primary care, with a particular focus on investor-owned corporations. We outline how profit-driven, corporate healthcare impacts equitable access to care, increases spending on low-value services, and undermines the underlying values of Canadian healthcare systems. All of healthcare delivery requires rapid regulation and oversight by policy-makers, which would increase transparency of corporate care. There also must be parallel efforts placed on addressing the long-standing issues in publicly funded delivery of primary care that created the space for corporate care to grow.

Racial and ethnic disparities in access to primary care during COVID-19.

Context: Early evidence suggests that many patients chose to forgo or delay necessary medical care during the COVID-19 pandemic. Existing and well-documented racial and ethnic disparities in access to care were exacerbated by the pandemic for many reasons, potentially including the additional barriers involved in a rapid shift to telehealth for certain groups of patients. Objectives: 1) Examine changes in primary care visit volume and telehealth during the COVID-19 pandemic. 2) Test for racial and ethnic differences in primary care in-person and telehealth visits during the pandemic relative to pre-pandemic levels. Study design: Longitudinal. Datasets: EHR data including patient visits, procedures, and demographics captured in the American Board of Family Medicine's PRIME Registry. Population studied: 2,966,859 patients seeing 1,477 primary care clinicians enrolled in the PRIME Registry. Outcome measures: 7-day average of weekly visits per clinician, both in-person and telehealth, tracking trends in the volume of care provided before and during the pandemic by patient race/ethnicity. We defined telehealth conversion ratio (TCR) as the number of telehealth visits during the pandemic divided by the total number of pre-pandemic visits. We calculated TCR and visit volume changes from March 15 through the end of 2020 relative to the same period in 2019. Results: During the pandemic we observed decreases of 12% and 22% in the average number of total and in-person visits, respectively, as well as a 10% TCR. Total visits reached a nadir in April 2020 with a 29% decrease from the same point in 2019. Telehealth visits peaked the following week with 23% of that week's total visits, and 139 times more than 2019. Total visits decreased and telehealth visits increased for patients of all races/ethnicities. The magnitude of these changes differed, with Black (5% decline, 15% in-person decline, 10% TCR) and Hispanic (9%, 24%, 15%) patients seeing less of a decrease in total visits than White (12%, 21%, 9%) and Asian (16%, 30%, 14%) patients. Conclusion: Declines in primary care visits during the pandemic were partially offset by an increase in telehealth use. Utilization in our sample suggests less decline in Black and Hispanic patient primary care utilization during the pandemic than expected, in contrast to Asian patients, who demonstrated the largest declines. This metric and these results are novel and foundational for ongoing & further study using other data sources.

Access to primary eye care for people living with dementia: a call to action for primary care practitioners to 'think vision'.

Access to allied health services offers significant benefits for people living with dementia, yet access is currently fragmented and inconsistent. The 2023-2024 budget allocated AU$445million to further enable general practice-led, multidisciplinary teams, with integrated care located within practices, including employment of allied health professionals. Such team care models are recognised by The Royal Australian College of General Practitioners as vital to delivery of high-quality care for older adults. They are especially relevant for over 250,000 Australians who live with dementia in the community. However, not all allied health professionals are currently based within general practices. Future, sustainable general practice-led models of multidisciplinary care that connect patients with external allied health providers could be considered for a comprehensive and collaborative approach to care. Our focus is on people living with dementia, who are at greater risk of preventable vision impairment. Poor vision and/or ocular health can be detected and managed through regular eye examinations, which are predominantly delivered by community-based optometrists in Australia, in a primary care capacity. However, people living with dementia are also less likely to have regular eye examinations. In this paper, we highlight the value of ensuring access to primary eye care services as part of post-diagnosis dementia care. We illustrate the important role of primary care practitioners in building and sustaining connections with allied health professions, like optometry, through effective referral and interprofessional communication systems. This can help break down access barriers to dementia-friendly eye care, through promoting the importance of regular eye tests for people living with dementia.

Understanding intersectional inequality in access to primary care providers using multilevel analysis of individual heterogeneity and discriminatory accuracy.

BACKGROUND: Despite the Canadian healthcare system's commitment to equity, evidence for disparate access to primary care (PC) providers exists across individual social identities/positions. Intersectionality allows us to reflect the realities of how social power shapes healthcare experiences at an individual's interdependent and intersecting social identities/positions. The objectives of this study were to determine: (1) the extent to which intersections can be used classify those who had/did not have a PC provider; (2) the degree to which each social identity/position contributes to the ability to classify individuals as having a PC provider; and (3) predicted probabilities of having a PC provider for each intersection. METHODS AND FINDINGS: Using national cross-sectional data from 241,445 individuals in Canada aged ≥18, we constructed 320 intersections along the dimensions of gender, age, immigration status, race, and income to examine the outcome of whether one had a PC provider. Multilevel analysis of individual heterogeneity and discriminatory accuracy, a multi-level model using individual-level data, was employed to address intersectional objectives. An intra-class correlation coefficient (ICC) of 23% (95%CI: 21-26%) suggests that these intersections could, to a very good extent, explain individual variation in the outcome, with age playing the largest role. Not all between-intersection variance in this outcome could be explained by additive effects of dimensions (remaining ICC: 6%; 95%CI: 2-16%). The highest intersectional predicted probability existed for established immigrant, older South Asian women with high income. The lowest intersectional predicted probability existed for recently immigrated, young, Black men with low income. CONCLUSIONS: Despite a "universal" healthcare system, our analysis demonstrated a substantial amount of inequity in primary care across intersections of gender, age, immigration status, race, and income.

[How to ensure the accessibility of primary care]. / Hoe houden we de huisartsenzorg toegankelijk?

The accessibility of primary care is under pressure, because more and more responsibilities and tasks are being shifted to general practitioners. Changes will have to take place to safeguard the core values of primary care: person-oriented, medical-generalistic and continuous. The increase in chronic diseases and multimorbidity forces general practitioners to delve deeper into complex care and maintain their management role in healthcare. Because of their guiding function, general practitioners must orientate themselves on problem areas that were previously discussed less prominently, such as questions related to gender identity and diversity. The time required for this may become available through the disposal and delegation of tasks and through further digitization. Digital interdisciplinary consultation in particular may improve the efficiency and quality of care. Finally, patients must be better informed about the nature of their complaints and the indications for an assessment by the GP.

'Getting it write' in a new era of patient online access to primary care health records.

AIM: To explore how to help make online consultation notes easier for patient audiences to understand. BACKGROUND: Most patients in England will soon be able to access all new prospective entries (including free-text) within their online primary care health record via the NHS App or other online services. METHOD: We conducted interviews and focus group discussions with 26 patients from underserved communities. Participants responded to vignettes about fictional patient consultation scenarios and assessed the clarity of corresponding simulated records. Participants were then asked to identify potential comprehension issues, offensive content, or anxiety triggers. RESULTS: Most participants struggled to understand a large proportion of simulated notes, particularly medical acronyms, clinician shorthand, and non-clinical abbreviations. Participants also identified issues that may cause unintended offence or additional anxiety. Participants considered that most patients will struggle to fully understand the content of their consultation notes in their current format. They made a number of suggestions about how this service may be improved to meet the needs of patient audiences and maintain positive patient-clinician relationships. CONCLUSION: Opening up online record access to include patient audiences necessitates a significant cultural shift in the way that consultation notes are written and used. To maximise NHS investment in this policy and avoid worsening health inequalities, it is essential to ensure that all patients can understand and access the benefits of online access to their notes. To do this, clinicians need to be supported to manage the challenges of writing for patient audiences, while continuing to maintain effective clinical care.

Investigation of the role of perceived access to primary care in mediating and moderating racial and ethnic disparities in chronic disease control in the veterans health administration.

OBJECTIVE: To examine the role of patient-perceived access to primary care in mediating and moderating racial and ethnic disparities in hypertension control and diabetes control among Veterans Health Administration (VA) users. DATA SOURCE AND STUDY SETTING: We performed a secondary analysis of national VA user administrative data for fiscal years 2016-2019. STUDY DESIGN: Our primary exposure was race or ethnicity and primary outcomes were binary indicators of hypertension control (<140/90 mmHg) and diabetes control (HgbA1c < 9%) among patients with known disease. We used the inverse odds-weighting method to test for mediation and logistic regression with race and ethnicity-by-perceived access interaction product terms to test moderation. All models were adjusted for age, sex, socioeconomic status, rurality, education, self-rated physical and mental health, and comorbidities. DATA COLLECTION/EXTRACTION METHODS: We included VA users with hypertension and diabetes control data from the External Peer Review Program who had contemporaneously completed the Survey of Healthcare Experience of Patients-Patient-Centered Medical Home. Hypertension (34,233 patients) and diabetes (23,039 patients) samples were analyzed separately. PRINCIPAL FINDINGS: After adjustment, Black patients had significantly lower rates of hypertension control than White patients (75.5% vs. 78.8%, p < 0.01); both Black (81.8%) and Hispanic (80.4%) patients had significantly lower rates of diabetes control than White patients (85.9%, p < 0.01 for both differences). Perceived access was lower among Black, Multi-Race and Native Hawaiian and Other Pacific Islanders compared to White patients in both samples. There was no evidence that perceived access mediated or moderated associations between Black race, Hispanic ethnicity, and hypertension or diabetes control. CONCLUSIONS: We observed disparities in hypertension and diabetes control among minoritized patients. There was no evidence that patients' perception of access to primary care mediated or moderated these disparities. Reducing racial and ethnic disparities within VA in hypertension and diabetes control may require interventions beyond those focused on improving patient access.

Access to primary care for children and young people (CYP) in the UK: a scoping review of CYP's, caregivers' and healthcare professionals' views and experiences of facilitators and barriers.

OBJECTIVES: To examine children and young people's (CYP), caregivers' and healthcare professionals' (HCPs) views or experiences of facilitators and barriers to CYP access to UK primary care services to better understand healthcare inequity. To explore differences across CYP subpopulations with greater health needs from deprived areas, identifying as ethnic minorities, with experiences of state care, special educational needs or disabilities, chronic conditions or mental health problems. DESIGN: Scoping review. ELIGIBILITY CRITERIA: Included studies were in English, published 2012-2022 and reported: the views/experiences of CYP (0-25 years), caregivers or HCPs about accessing UK primary care; using quantitative or qualitative empirical methods. DATA SOURCES: PubMed, CINAHL, Web of Science, PsycINFO and Scopus. RESULTS: We included 47 reports (46 studies). CYP/caregivers' decision to access care was facilitated by CYP/caregivers' or their family/friends' ability to identify a health issue as warranting healthcare attention. Barriers to accessing care included perceived stigma (eg, being seen as a bad parent), embarrassment and discrimination experiences. CYP and caregivers believed longer opening hours could facilitate more timely access to care. Caregivers and HCPs reported that delayed or rejected referrals to secondary or adult care were a barrier to having needs met, especially for CYP with poor mental health. CYP and caregivers in numerous studies emphasised the importance of communication and trust with HCPs, including taking their concerns seriously, being knowledgeable and providing continuity of care for CYP. Common barriers reported across high-need subpopulations were caregivers needing knowledge and confidence to advocate for their child, gaps in HCP's knowledge and a lack of connectedness between primary and secondary care. CONCLUSIONS: Connecting general practices and community health workers/services, improving CYP/caregivers' understanding of common childhood conditions, addressing HCP's knowledge gaps in paediatric care and integrated approaches between primary and secondary care may reduce inequity in access.

Cardiovascular risk and access to primary care: Comparisons among Chinese documented and undocumented immigrants.

AIMS: The aim of this study was to examine main risk factors of undocumented Chinese migrants living in Italy when compared with Chinese migrants registered with National Health Service (NHS). METHODS: A cohort of 3435 Chinese first-generation immigrants living in Prato underwent blood pressure (BP) measurement and blood tests. Hypertension was diagnosed for BP ≥ 140/90 mmHg at 2 visits, and/or antihypertensive drug use; type 2 diabetes (T2DM) for fasting glucose ≥ 126 mg/dL at 2 visits, and/or use of hypoglycemic drugs; hypercholesterolemia (HC) for cholesterol ≥ 240 mg/dL and/or statins use. Subjects diagnosed with hypertension, T2DM, or HC unaware of their condition were considered newly diagnosed. Comparisons were performed using multivariable adjusted logistic regression analysis. RESULTS: A large proportion of Chinese migrants were undocumented (1766, 51 %); newly diagnoses of risk factors were performed especially among undocumented migrants; registration with NHS was associated with higher level of awareness for hypertension and T2DM and with 6 times higher rate of treatment for T2DM. Only a small minority of subjects with high cholesterol were treated with statins. CONCLUSIONS: Undocumented immigrants had high prevalence of risk factors with lower levels of awareness than migrants registered with the NHS. Health policies targeting this hard-to-reach population needs to be improved.