Has the new GP contract in Scotland reduced health inequalities? Qualitative evaluation of the views of general practitioners working in deprived areas.

Abstract

Background: Scotland has the widest health inequalities in western Europe and a well-documented inverse care law in general practice. Scotland introduced a new General Practitioner contract in 2018, reforming how care is delivered. Changes included expanding the primary care multidisciplinary team, and grouping practices into geographical clusters to improve quality of care for the local populations. A stated aim of the new contract was also to reduce inequalities in health. However, the effects of the reforms upon health inequalities have been little explored. This study aimed to analyse the views of General Practitioners working in deprived areas on the impact of the contract on health inequalities in Scotland.

Methods: This study involved a secondary analysis of qualitative data from one-to-one interviews with 11 GPs serving patients in deprived areas of Scotland. Thematic analysis was used to analyse the data.

Results: Despite some positive opinions on some aspects of the contract, GPs in deprived areas felt that the aim of reducing inequalities had not been achieved. Reasons for this were: (1) persisting barriers to engagement for patients in deprived areas (including poor access to services, lack of patient education about the reforms, centralisation of some services, and difficulties with remote consulting), (2) inadequate support to manage patients with complex problems (including difficulty in providing continuity of care, and limited resources for patients with specific comorbidities such as mental health and chronic pain), (3) clusters in areas of deprivation lacking capacity to address health inequalities (including lack of time, lack of training, and lack of data and evaluation), and (4) a lack of workforce and strategic planning in the new contract regarding deprivation (such as suitable resource allocation and recruitment of sufficient numbers of appropriate staff in practices in deprived areas). Two additional cross-cutting themes were identified, relating to lack of time and poor relationships.

Conclusions: The new Scottish General Practice contract has not achieved its aim of reducing health inequalities, according to General Practitioners working in deprived areas. Future iterations of the contract need to implement changes that will tackle the inverse care law and thus help reduce inequalities in health.