Quantifying unmet need in General Practice: a retrospective cohort study of administrative data.

OBJECTIVES: To assess whether patients attending general practices (GPs) in socioeconomically (SE) deprived areas receive the same amount of care, compared with similar patients (based on age, sex and level of morbidity) attending GPs in less deprived areas. If not, to quantify the additional resource that would be required by GPs in deprived areas to achieve parity. DESIGN: Retrospective cohort study. SETTING: 150 GPs in Scotland, UK, divided into two groups: 80 practices in Scottish Index of Multiple Deprivation (SIMD) deciles 1-5 (more SE deprived); 70 practices in SIMD deciles 6-10 (less SE deprived). PATIENTS: 437 590 patients registered with a more SE deprived GP, and 333 994 patients registered with a less SE deprived GP, for the whole study period (2013-2016), who made at least one appointment. OUTCOMES: The number of contacts and total contact time between patients and clinical staff. RESULTS: Patients in more SE deprived areas had slightly more discrete contacts over 3 years (11.8 vs 11.4), but each patient had marginally less contact time (146.1 vs 149.5 min). Stratified by sex and age, differences were also small. Stratified by the number of long-term conditions (LTCs), practices in more SE deprived areas delivered significantly less contact time than practices in less SE deprived areas. Over 3 years, 8 fewer minutes for patients with no LTCs, and 24, 27, 38 and 28 fewer minutes for patients with 1, 2, 3-4 or 5+LTCs, respectively. CONCLUSION: If GPs in more SE deprived areas were to give an equal amount of direct contact time to patients with the same level of need served by GPs in less SE deprived areas, this would require a 14% increase in patient contact time. This represents a significant unmet need, supporting the case for redistribution of resources to tackle the inverse care law.

Communicating effectively with inclusion health populations: 2022 ICCH symposium.

OBJECTIVE: To describe communication strategies for clinical practice that allow practitioners to work more effectively with marginalised population groups and to discuss how to incorporate these into medical practice. METHODS: Active practitioners working in inclusion health and people with lived experience of homelessness and the asylum-seeking process shared their perspectives in the symposium at the 2022 International Conference on Communication in Healthcare (ICCH) and a subsequent conference on empathy in healthcare. The views of attendees were sought. SYMPOSIUM DISCUSSION: We describe the perspectives shared at the symposia under two main themes: communication needs in people experiencing homelessness and migrant populations, and trauma-informed practice. CONCLUSIONS: People experiencing homelessness have more communication challenges compared to the general adult population. Migrant, refugee, and asylum-seeking populations also face the complexity of negotiating unfamiliar healthcare, legal and social systems with the added burden of language barriers. Trauma-informed practice provides a useful framework that can improve communication with these groups.

Treatment burden for people experiencing homelessness with a recent non-fatal overdose: a questionnaire study.

BACKGROUND: People experiencing homelessness (PEH) who have problem drug use have complex medical and social needs, with barriers to accessing services and treatments. Their treatment burden (workload of self-management and impact on wellbeing) remains unexplored. AIM: To investigate treatment burden in PEH with a recent non-fatal overdose using a validated questionnaire, the Patient Experience with Treatment and Self-management (PETS). DESIGN AND SETTING: The PETS questionnaire was collected as part of a pilot randomised control trial (RCT) undertaken in Glasgow, Scotland; the main outcome is whether this pilot RCT should progress to a definitive RCT. METHOD: An adapted 52-item, 12-domain PETS questionnaire was used to measure treatment burden. Greater treatment burden was indicated by higher PETS scores. RESULTS: Of 128 participants, 123 completed PETS; mean age was 42.1 (standard deviation [SD] 8.4) years, 71.5% were male, and 99.2% were of White ethnicity. Most (91.2%) had >5 chronic conditions, with an average of 8.5 conditions. Mean PETS scores were highest in domains focusing on the impact of self-management on wellbeing: physical and mental exhaustion (mean 79.5, SD 3.3) and role and social activity limitations (mean 64.0, SD 3.5) Scores were higher than those observed in studies of patients who are not homeless. CONCLUSION: In a socially marginalised patient group at high risk of drug overdose, the PETS showed a very high level of treatment burden and highlights the profound impact of self-management work on wellbeing and daily activities. Treatment burden is an important person-centred outcome to help compare the effectiveness of interventions in PEH and merits inclusion in future trials as an outcome measure.

'A drive to make change' - exploring the views and experiences of medical students engaging in advocacy: a qualitative study in a UK medical school.

BACKGROUND: Advocacy is a recognised competency for medical graduates. Many medical students engage in advocacy, but research on this topic is limited. This study aimed to explore the views and experiences of medical student advocates. METHODS: Qualitative study using semi-structured interviews. Nine medical students from advocacy organisations were recruited by purposive sampling. Thematic analysis was used to generate codes and develop themes. RESULTS: There were five themes: triggers and enablers; barriers and disablers; knowledge, skills, and attributes; advocacy in the role of health professionals, and career aspirations; and teaching and assessment of advocacy. Triggers and enablers included internal drivers (e.g. experiencing injustice), and external drivers (e.g. role models). Obstacles included lack of institutional support, personal challenges, and discomfort around professionalism in advocacy. Student enhanced their knowledge of social issues and improved communication skills. Advocacy activities strongly influenced students' future plans. Most agreed that advocacy is an important topic in medical education, suggesting teaching it early in medical school via small-group tutorials and role-modelling. For assessment, a reflective approach was preferred over written exams. CONCLUSION: Medical students' engagement in advocacy has complex facilitators and barriers, and the relationship between advocacy and professionalism requires clarity. Benefits of advocacy include fostering empathy and other transferable skills required of future doctors. Advocacy teaching was welcomed by students, with suggested approaches proposed. The optimal learning and assessment strategy remains uncertain, and further research is needed.

Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx): a study protocol for a pilot randomised controlled trial.

INTRODUCTION: The number of people experiencing homelessness (PEH) is increasing worldwide. Systematic reviews show high levels of multimorbidity and mortality. Integrated health and social care outreach interventions may improve outcomes. No previous studies have targeted PEH with recent drug overdose despite high levels of drug-related deaths and few data describe their health/social care problems. Feasibility work suggests a collaborative health and social care intervention (Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx, PHOENIx) is potentially beneficial. We describe the methods of a pilot randomised controlled trial (RCT) with parallel process and economic evaluation of PEH with recent overdose. METHODS AND ANALYSIS: Detailed health and social care information will be collected before randomisation to care-as-usual plus visits from a pharmacist and a homeless outreach worker (PHOENIx) for 6-9 months or to care-as-usual. The outcomes are the rates of presentations to emergency department for overdose or other causes and whether to progress to a definitive RCT: recruitment of ≥100 participants within 4 months, ≥60% of patients remaining in the study at 6 and 9 months, ≥60% of patients receiving the intervention, and ≥80% of patients with data collected. The secondary outcomes include health-related quality of life, hospitalisations, treatment uptake and patient-reported measures. Semistructured interviews will explore the future implementation of PHOENIx, the reasons for overdose and protective factors. We will assess the feasibility of conducting a cost-effectiveness analysis. ETHICS AND DISSEMINATION: The study was approved by South East Scotland National Health Service Research Ethics Committee 01. Results will be made available to PEH, the study funders and other researchers. TRIAL REGISTRATION NUMBER: ISRCTN10585019.

Educational associations with missed GP appointments for patients under 35 years old: administrative data linkage study.

BACKGROUND: There is an evidence gap about whether levels of engagement with public services such as schools and health care affect people across the lifespan. Data on missed patient appointments from a nationally representative sample of Scottish general practices (GP) (2013-2016) were probabilistically linked to secondary school pupil data. We tested whether school attendance, exclusions (2007-2011) or lower educational attainment (2007-2016) was associated with an increased risk of missing general practice appointments. METHODS: School attendance data were classified into quartiles of possible days attended for years we had data. School exclusions were derived as a categorical variable of 'ever excluded'. Attainment data were categorised via the Scottish Credit and Qualifications Framework (SCQF) level 3 or 6; a cumulative measure of attainment on leaving school. The associations between school attendance, exclusions and attainment and risk of missing medical appointments were investigated using negative binomial models, offset by number of GP appointments made and controlling for potential confounders. RESULTS: 112,534 patients (all aged under 35) had GP appointment and retrospective school attendance and exclusion data, and a subset of 66,967 also had attainment data available. Patients who had lower attendance, had been excluded from school or had lower educational attainment had an increased risk of missing GP appointments (all rate ratios > 1.40). CONCLUSIONS: This study provides the first evidence from a population-representative sample in a high-income country that increased numbers of missed appointments in health care are associated with reduced school attendance, higher levels of school exclusion and lower educational attainment. Insights into the epidemiology of missingness across public services can support future research, policy and practice that aim to improve healthcare, health outcomes and engagement in services.

'Missingness' in health care: Associations between hospital utilization and missed appointments in general practice. A retrospective cohort study.

OBJECTIVES: Are multiple missed appointments in general practice associated with increased use of hospital services and missingness from hospital care? This novel study explores this in a population representative sample for the first time. DESIGN, SETTING, PARTICIPANTS: A large, retrospective cohort (n = 824,374) of patient records from a nationally representative sample of GP practices, Scotland, 2013-2016. Requested data were extracted by a Trusted Third Party for the NHS, anonymised and linked to a unique patient ID, in the NHS Safehaven for analysis using established NHS Scotland linkage. We calculated the per-patient number of GP missed appointments from individual appointments and investigated the likelihood of hospital appointment or admission outcomes using a negative binomial model offset by number of GP appointments made. These models also controlled for age, sex, Scottish Index of Multiple Deprivation (SIMD) and number of long- term conditions (LTCs). MAIN OUTCOME MEASURES: Hospital attendance: Outpatient clinic attendances; hospital admissions; Emergency Department (ED) attendances. Hospital missingness: 'Did not attend' (DNAs) outpatient clinic appointments, 'irregular discharges' from admissions, and 'left before care completed' ED care episodes. RESULTS: Attendance: Patients in the high missed GP appointment (HMA) category were higher users of outpatient services (rate ratio (RR) 1.90, 95% confidence intervals (CI) 1.88-1.93) compared to those who missed none (NMA) with a much higher attendance risk at mental health services (RR 4.56, 95% CI 4.31-4.83). HMA patients were more likely to be admitted to hospital; general admissions (RR 1.67, 95% CI 1.65-1.68), maternity (RR 1.24, 95% CI 1.20-1.28) and mental health (RR 1.23, 95% CI 1.15-1.31), compared to NMA patients. Missing GP appointments was not associated with ED attendance; (RR 1.00, CI 0.99-1.01). Missingness: HMA patients were at greater risk of missing outpatient appointments (RR 1.62, 95% CI 1.60-1.64) than NMA patients; with a much higher risk of non-attendance at mental health services (RR 7.83, 95% CI 7.35-8.35). Patients were more likely to leave hospital before their care plan was completed-taking 'irregular discharges' (RR 4.56, 95% CI 4.31-4.81). HMA patients were no more at risk of leaving emergency departments 'without care being completed' (RR1.02, 95 CI 0.95-1.09). CONCLUSIONS: Patients who miss high numbers of GP appointments are higher users of outpatient and inpatient hospital care but not of emergency departments, signalling high treatment burden. The pattern of 'missingness' is consistent from primary care to hospital care: patients who have patterns of missing GP appointments have patterns of missing many outpatient appointments and are more likely to experience 'irregular discharge' from in-patient care. Missingness from outpatient mental health services is very high. Policymakers, health service planners and clinicians should consider the role and contribution of 'missingness' in health care to improving patient safety and care.

Prescribing patterns for medical treatment of suspected prostatic obstruction: a longitudinal register-based study of the Scottish Health and Social Care Open Data.

BACKGROUND: The diagnosis of lower urinary tract symptoms related to suspected bladder outflow obstruction from benign prostate hyperplasia/enlargement in men is increasing. This is leading to high demand on healthcare services; however, there is limited knowledge of differences in pharmacotherapy prescribing for this condition based on geography. OBJECTIVE: To investigate potential variation in drug prescribing for suspected bladder outflow obstruction in Scotland, based on analysis of publicly available data, to identify trends and inform future prescribing. STUDY DESIGN: A longitudinal register-based data study of prescribing and patient data publicly available from Scottish registries. All information is available as monthly aggregates at the level of single general practices. SETTING AND PARTICIPANTS: 903 (97%) general practices in Scotland, over a 50-month period (October 2015 to November 2019). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We analysed numbers of daily doses of drugs for suspected bladder outflow obstruction prescribed per month using a Bayesian Poisson regression analysis, incorporating random effects to account for spatial and temporal elements. RESULTS: Prescriptions for suspected bladder outflow obstruction medications increased during the observation period (overall average rate of change 1.24±0.28, ranging from 0.893 in Orkney to 1.95 in Lanarkshire). While some determinants of health inequality regarding prescribing practices across health boards are consistent with those known from the literature, other inequalities remain unexplained after accounting for practice-specific and patient-specific characteristics such as deprivation and rurality. CONCLUSIONS: Inequalities in prescribing for suspected bladder outflow obstruction medications exist in Scotland, partially ascribable to accepted sociodemographic and geographic factors.

Comparing the Impact of Primary Care Practice Design in Two Inner City UK Homelessness Services.

Background: Specialist homeless primary health care services in the United Kingdom have arisen from the need for bespoke approaches to providing health care for people experiencing homelessness but descriptions of the design characteristics of homeless health services together with associated long-term condition (LTC) prevalence, health care utilization, and prescribing remain unexplored, thereby limiting our understanding of potential impact of service configuration on outcomes. Aim: Description of specialist homeless general practitioner services in Glasgow and Edinburgh, in terms of practice design (staff, skill mix, practice systems of registration, and follow-up); and exploration of the potential impact of differences on LTC prevalence, health care utilization, and prescribing. Method: Patient data were collected from computerized general practitioner records in Glasgow (2015, n = 133) and Edinburgh (2016, n = 150). Homeless health service configuration and anonymized patient data, including demographics, LTCs service utilization, and prescribing were summarized and compared. Results: Marked differences in infrastructure emerged between 2 practices, including the patient registration process, segmentation versus integration of services, recording systems, and the availability of staff expertise. Patient characteristics differed in terms of LTC diagnoses, health care utilization and prescribing. Higher rates of recorded mental health and addiction problems were found in Edinburgh, as well as higher rates of physical LTCs, for example, cardiovascular and respiratory conditions. There were significantly higher rates of consultations with nurses and other staff in Edinburgh, although more patients had consultations with pharmacists in Glasgow. Medication adherence was low in both cohorts, and attendance at referral appointments was particularly poor in Glasgow. Conclusion: Service design and professional skill mix influence recording of LTCs, service uptake, and identification and management of health conditions. Service configuration, professional skill mix, and resources may profoundly affect diagnoses, utilization of health care, and prescribing. Attention to homeless service design is important when providing care to this disadvantaged patient group.

General practice recording of adverse childhood experiences: a retrospective cohort study of GP records.

BACKGROUND: Adverse childhood experiences (ACEs) are linked to negative health outcomes in adulthood. Poor engagement with services may, in part, mediate the association between adverse outcomes and ACEs. While appointment recording is comprehensive, it is not yet known if or how ACEs are recorded in the GP clinical record (GPR). AIM: To investigate recording of ACEs in the GPR and assess associations between available ACE-related Read codes and missed appointments. DESIGN & SETTING: Retrospective cohort study of 824 374 anonymised GPRs. Nationally representative sample of 136 Scottish general practices; data collected 2013-2016. METHOD: Read codes were mapped onto ACE questionnaire and wider ACE-related domains. Natural language processing (NLP) was used to augment capture of non-Read-coded ACEs. Frequency counts and proportions of mapped codes, and associations of these with defined levels of missing GP appointments, are reported. RESULTS: In total, 0.4% of patients had a record of any code that mapped onto the ACE questionnaire, contrasting with survey-reported rates of 47% in population samples. This increased only modestly by including inferred ACEs that related to safeguarding children concerns, wider aspects of ACEs, and adult consequences of ACEs. Augmentation via NLP did not substantially increase capture. Despite poor recording, there was an association between ever having an ACE code recorded and higher rates of missing GP appointments. CONCLUSION: General practices would require substantial support to implement the recording of ACEs in the GPR. This study adds to the evidence that patients who often miss appointments are more likely to be socially vulnerable.

Morbidity, mortality and missed appointments in healthcare: a national retrospective data linkage study.

BACKGROUND: Recently, studies have examined the underlying patient and practice factors for missed appointments, but less is known about the impact on patient health. People with one or more long-term conditions who fail to attend appointments may be at risk of premature death. This is the first study to examine the effect of missed primary healthcare appointments on all-cause mortality in those with long-term mental and physical health conditions. METHODS: We used a large, nationwide retrospective cohort (n = 824,374) extracted from routinely collected general practice data across Scotland over a 3-year period from September 2013 until September 2016. This data encompasses appointment history for approximately 15% of the Scottish population, and was linked to Scottish deaths records for patients who had died within a 16-month follow-up period. We generated appointment attendance history, number of long-term conditions and prescriptions data for patients. These factors were used in negative binomial and Cox's proportional hazards modelling to examine the risk of missing appointments and all-cause mortality. RESULTS: Patients with a greater number of long-term conditions had an increased risk of missing general practice appointments despite controlling for number of appointments made, particularly among patients with mental health conditions. These patients were at significantly greater risk of all-cause mortality, and showed a dose-based response with increasing number of missed appointments. Patients with long-term mental health conditions who missed more than two appointments per year had a greater than 8-fold increase in risk of all-cause mortality compared with those who missed no appointments. These patients died prematurely, commonly from non-natural external factors such as suicide. CONCLUSIONS: Missed appointments represent a significant risk marker for all-cause mortality, particularly in patients with mental health conditions. For these patients, existing primary healthcare appointment systems are ineffective. Future interventions should be developed with a particular focus on increasing attendance by these patients.

A systematic review of interventions by healthcare professionals to improve management of non-communicable diseases and communicable diseases requiring long-term care in adults who are homeless.

OBJECTIVE: Identify, describe and appraise trials of interventions delivered by healthcare professionals to manage non-communicable diseases (NCDs) and communicable diseases that require long-term care or treatment (LT-CDs), excluding mental health and substance use disorders, in homeless adults. DESIGN: Systematic review of randomised controlled trials (RCTs), non-RCTs and controlled before-after studies. Interventions characterised using Effective Practice and Organisation of Care (EPOC) taxonomy. Quality assessed using EPOC risk of bias criteria. DATA SOURCES: Database searches (MEDLINE, Embase, PsycINFO, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA) and Cochrane Central Register of Controlled Trials), hand searching reference lists, citation searches, grey literature and contact with study authors. SETTING: Community. PARTICIPANTS: Adults (≥18 years) fulfilling European Typology of Homelessness criteria. INTERVENTION: Delivered by healthcare professionals managing NCD and LT-CDs. OUTCOMES: Primary outcome: unscheduled healthcare utilisation. SECONDARY OUTCOMES: mortality, biological markers of disease control, adherence to treatment, engagement in care, patient satisfaction, knowledge, self-efficacy, quality of life and cost-effectiveness. RESULTS: 11 studies were included (8 RCTs, 2 quasi-experimental and 1 feasibility) involving 9-520 participants (67%-94% male, median age 37-49 years). Ten from USA and one from UK. Studies included various NCDs (n=3); or focused on latent tuberculosis (n=4); HIV (n=2); hepatitis C (n=1) or type 2 diabetes (n=1). All interventions were complex with multiple components. Four described theories underpinning intervention. Three assessed unscheduled healthcare utilisation: none showed consistent reduction in hospitalisation or emergency department attendance. Six assessed adherence to specific treatments, of which four showed improved adherence to latent tuberculosis therapy. Three concerned education case management, all of which improved disease-specific knowledge. No improvements in biological markers of disease (two studies) and none assessed mortality. CONCLUSIONS: Evidence for management of NCD and LT-CDs in homeless adults is sparse. Educational case-management interventions may improve knowledge and medication adherence. Large trials of theory-based interventions are needed, assessing healthcare utilisation and outcomes as well as assessment of biological outcomes and cost-effectiveness.

Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis.

BACKGROUND: Addressing the causes of low engagement in health care is a prerequisite for reducing health inequalities. People who miss multiple appointments are an under-researched group who might have substantial unmet health needs. Individual-level patterns of missed general practice appointments might thus provide a risk marker for vulnerability and poor health outcomes. We sought to ascertain the contributions of patient and practice factors to the likelihood of missing general practice appointments. METHODS: For this national retrospective cohort analysis, we extracted UK National Health Service general practice data that were routinely collected across Scotland between Sept 5, 2013, and Sept 5, 2016. We calculated the per-patient number of missed appointments from individual appointments and investigated the risk of missing a general practice appointment using a negative binomial model offset by number of appointments made. We then analysed the effect of patient-level factors (including age, sex, and socioeconomic status) and practice-level factors (including appointment availability and geographical location) on the risk of missing appointments. FINDINGS: The full dataset included information from 909 073 patients, of whom 550 083 were included in the analysis after processing. We observed that 104 461 (19·0%) patients missed more than two appointments in the 3 year study period. After controlling for the number of appointments made, patterns of non-attendance could be differentiated, with patients who were aged 16-30 years (relative risk ratio [RRR] 1·21, 95% CI 1·19-1·23) or older than 90 years (2·20, 2·09-2·29), and of low socioeconomic status (Scottish Index of Multiple Deprivation decile 1: RRR 2·27, 2·22-2·31) significantly more likely to miss multiple appointments. Men missed fewer appointments overall than women, but were somewhat more likely to miss appointments in the adjusted model (1·05, 1·04-1·06). Practice factors also substantially affected attendance patterns, with urban practices in affluent areas that typically have appointment waiting times of 2-3 days the most likely to have patients who serially miss appointments. The combination of both patient and practice factors to predict appointments missed gave a higher pseudo R2 value (0·66) than models using either group of factors separately (patients only R2=0·54; practice only R2=0·63). INTERPRETATION: The findings that both patient and practice characteristics contribute to non-attendance of general practice appointments raise important questions for both the management of patients who miss multiple appointments and the effectiveness of existing strategies that aim to increase attendance. Addressing these issues should lead to improvements in provision of services and public health. FUNDING: Scottish Government Chief Scientist Office and Data Sharing and Linkage Service of the Scottish Government.

Interventions by healthcare professionals to improve management of physical long-term conditions in adults who are homeless: a systematic review protocol.

INTRODUCTION: People experiencing homelessness are at increased risk of, and have poorer outcomes from, a range of physical long-term conditions (LTCs). It is increasingly recognised that interventions targeting people who are homeless should be tailored to the specific needs of this population. This systematic review aims to identify, describe and appraise trials of interventions that aim to manage physical LTCs in homeless adults and are delivered by healthcare professionals. METHODS AND ANALYSIS: Seven electronic databases (Medline, EMBASE, Cochrane Central Register of Controlled Trials, Assia, Scopus, PsycINFO and CINAHL) will be searched from 1960 (or inception) to October 2016 and supplemented by forward citation searching, handsearching of reference lists and searching grey literature. Two reviewers will independently review titles, abstract and full-texts using DistillerSR software. Inclusion criteria include (1) homeless adults with any physical LTC, (2) interventions delivered by a healthcare professional (any professional trained to provide any form of healthcare, but excluding social workers and professionals without health-related training), (3) comparison with usual care or an alternative intervention, (4) report outcomes such as healthcare usage, physical and psychological health or well-being or cost-effectiveness, (5) randomised controlled trials, non-randomised controlled trials, controlled before-after studies. Quality will be assessed using the Cochrane EPOC Risk of Bias Tool. A meta-analysis will be performed if sufficient data are identified; however, we anticipate a narrative synthesis will be performed. ETHICS AND DISSEMINATION: This review will synthesise existing evidence for interventions delivered by healthcare professionals to manage physical LTCs in adults who are homeless. The findings will inform the development of future interventions and research aiming to improve the management of LTCs for people experiencing homelessness. Ethical approval will not be required for this systematic review as it does not contain individual patient data. We will disseminate the results of this systematic review via conference presentations, healthcare professional networks, social media and peer-reviewed publication. TRIAL REGISTRATION NUMBER: PROSPERO registration number: CRD42016046183.

Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data.

BACKGROUND: The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. METHODS: We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. RESULTS: Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices. CONCLUSIONS: Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled.