Interventions to improve inclusion health in primary care: a realist review

People experiencing severe and multiple disadvantage (SMD)- including intersecting experiences of homelessness, substance misuse, poor mental health, and domestic violence and abuse- face high levels of unmet health need but encounter significant barriers to accessing general practice.

We aimed to explore how interventions or aspects of routine general practice care can improve access for people with SMD, examining what works, for whom, and under what circumstances.

We used a realist review approach as both general practice and access to services for people with SMD are complex; bringing them together required a nuanced understanding of underlying mechanisms. We developed an initial programme theory by consulting experts by experience, professional stakeholders, relevant literature and substantive theory. We searched databases and sought literature from relevant networks, including qualitative, quantitative, mixed-methods, and grey literature. We included full texts with relevant data that could inform programme theory development, and organised these into intervention components. We used a realist analytical approach to synthesise evidence and make conclusions. We collaborated with experts by experience and professionals supporting them throughout, to ensure findings and recommendations were relevant and applicable.

Themes of belonging, trust and power are key in improving access to primary care for and with people with SMD. Interventions to improve Inclusion Health in primary care include outreach, partnership working, peer involvement and advocacy, flexible access, specialist clinics, staff training, appointment systems, case management, co-design and challenging unjust systems.

Using actionable strategies, general practices can better include people with SMD.