Title: Reducing Health Inequalities through General Practice: A Realist Review (EQUALISE)
Funder: Department of Health and Social Care

Abstract: Health inequalities are unfair differences in health between two groups of the population. The health inequality gap in life expectancy between the richest and poorest is increasing. There is currently a 9.4 year gap between richest and poorest men and 7.4 year gap in richest and poorest women. National statistics show that the gap in life expectancy is caused mostly by differences in cancer, cardiovascular disease and respiratory conditions, such as Chronic Obstructive Pulmonary Disease (COPD). Previous research has found that NHS inequalities generally arise in care provided through doctors’ surgery, such as delays in getting tests or referred to a specialist, rather than during hospital treatment. All doctors’ surgeries in England are grouping together into organisations called Primary Care Networks (PCNs). These networks will be asked to help tackle NHS health inequalities, but there is a lack of evidence and guidance to suggest what they can do to narrow the health gap. For example, previous research suggests services that are hard to navigate because of complicated booking systems tend to increase inequalities._x000D_ _x000D_ The aim of this research is to explore the types of general practices services which increase or decrease inequalities in cancer, cardiovascular disease (including risk factors such as diabetes) and COPD, under what circumstances and how. These may include routine monitoring for people with long term conditions or encouraging doctors to give healthy lifestyle advice when seeing patients. We want to develop guidance which can be used in general practice to reduce inequalities and improve services for patients and carers._x000D_ _x000D_ We will undertake a review of the literature using what is called a realist review. This type of review helps us understand the different contexts or settings in which interventions work or not, rather than taking a one-size-fits-all approach. We will first start by asking expert doctors, health care professionals and commissioners what they think increases or decreases health inequalities in their services. After that we will search the published literature. There are a lot of published literature reviews about general practice. These papers may or may not include information about health inequalities. We will use the existing reviews to find the full papers for the original studies to see if they report their results by measures of inequality. We will primarily focus on socio-economic status (e.g. income, occupation, education), but will also collect data on other categories of inequality (e.g. ethnicity). We will look at a range of outcomes including prevention, diagnosis, follow-up and treatment. We will then develop guidance and a toolkit through a workshop with a diverse group of patients, carers, GPs, health care managers and researchers. _x000D_ _x000D_ The results will provide us with guidance about how the NHS can reduce health inequalities through doctors’ surgeries and PCNs. We will work with NHS England and Cambridgeshire and Peterborough Clinical Commissioning Group to ensure that the NHS can make best use of the findings. We will also work with our team-members who are patients to ensure that the research is person-centred and the findings are effectively shared with the public.

Lay abstract: Background _x000D_ The gap in life expectancy between least and most deprived areas of England has increased in recent years to 9.4 years for men and 7.4 years for women. This gap is primarily driven by cancer, cardiovascular disease (and its risk factors, such as diabetes) and, respiratory conditions, such as Chronic Obstructive Pulmonary Disease (COPD). The NHS has an important role in reducing this gap in life expectancy, but some health care interventions can inadvertently increase inequalities. Previous research has found that inequalities generally arise in general practice, rather than secondary care. The last systematic review looking broadly at health service interventions to reduce inequalities was published 23 years ago. The NHS is asking general practice to address health inequalities through Primary Care Networks. Despite these asks, the NHS lacks evidence or broad guiding principles to inform more equitable decision making in general practice. Identifying and disseminating broad principles is likely to deliver considerable impact because they can be applied across all general practice services. _x000D_ _x000D_ Research question _x000D_ What types of interventions or aspects of routine care in general practice increase or decrease inequalities in cardiovascular disease, cancer, diabetes or COPD, for whom, in what circumstances, why and how? _x000D_ _x000D_ Methods _x000D_ Our realist review will follow Pawson’s five iterative stages – namely: 1) locate existing theories; 2) search for evidence; 3) select articles; 4) extract and organise data and; 5) synthesise evidence and draw conclusions. We will start by developing an initial programme theory based on existing theories and discussions with stakeholders. To identify the broad types of interventions, we will identify the existing systematic reviews published across cardiovascular disease, cancer, diabetes and COPD for interventions delivered in general practice. We will examine the full-text primary studies included within each systematic review to identify those which report or comment on inequalities. We will focus on socio-economic inequalities, but also collect data on other types of inequalities (e.g. ethnicity). Where needed, we will undertake more searches for relevant data. We will collect data on a range of clinical outcomes including prevention, diagnosis, follow-up and treatment. Articles will then be described, categorised and synthesised using a realist logic of analysis. The findings will be a description and explanation of the general practice interventions which are likely to increase or decrease inequalities across the major conditions. We will then develop guiding principles and a toolkit through a deliberative workshop with a diverse group of patients, GPs, commissioners and researchers. _x000D_ _x000D_ Outputs and dissemination _x000D_ Working with patients we will produce a set of guiding principles for the NHS and an associated toolkit for NHS organisations, such as NHS England, Clinical Commissioning Groups, Primary Care Networks and Integrated Care Systems. These will be disseminated through policy briefings and user-friendly summaries targeted at different audiences.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;RESPIRATORY