Reducing Health Inequalities through General Practice: A Realist Review (EQUALISE)

Background

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. Research question

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? Methods

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. Outputs and dissemination

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.