Supporting practices

The first approach implicitly assumes the issue is one of motivation and resources at the general practice level. Practices with lower quality of care may be more likely to be in socioeconomically deprived areas and have fewer resources, more competing demands, higher volume of patients with chronic disease and more complex health and social needs.13 14 Recently, Ashworth and colleagues have argued that healthcare funding structures in the UK entrench health inequities and that QOF payments should be weighted for deprivation.15 There is also some evidence that certain types of incentives targeting primary care are associated with increased engagement with prevention programmes at the provider level. A recent study, also based on the NHS DPP, found that outcome incentives (ie, payments linked to the number of patients referred) were associated with statistically significant increases in referrals and attendances.16 Structural incentives (ie, lump sum payments to support necessary infrastructure) and process incentives (ie, payments linked to actions taken in the process of generating referrals) did not appear to stimulate participation in the DPP.

However, in the study by Parkinson and colleagues,10 practices were already part of QOF (a financial incentive scheme), and staff resources were not significantly associated with DPP referral rates, suggesting other factors may be the key drivers of the documented gaps. Few studies examining disease prevention in primary care have considered the influence of organisational context (eg, working relationships, organisational readiness, implementation culture, leadership support and programme champions, and ethos within the practices and their relative priorities) on the extent to which services are delivered.17 Future research is needed to develop and test implementation strategies to address some of these provider-level and organisational barriers to implementation. For example, at the provider level, the documented barriers to referral suggest that practices may need support to protect provider time to screen, discuss and refer. Providers and leadership may benefit from information about the benefits for different patient groups or focused training on how to conduct risk assessment and to effectively counsel patients to attend DPP. At the organisational level, implementation strategies such as audit and feedback18 may help by highlighting referral rates, patterns and the profile of patients referred to DPP, as compared with other practices. Strategies that enhance organisational readiness and synergise existing infrastructure to implement the DPP may also prove fruitful.19 However, these strategies make assumptions about the nature of the breakdown in referrals and as mentioned, further research with providers and patients is needed to understand the reasons for referral patterns and to inform strategy selection and development.

Supporting patients

The second solution put forward by Parkinson and colleagues is to explore alternative methods of recruitment and greater engagement of patients (external to provider referral) to address inequities. When selecting alternative methods of recruitment, it is important to consider how to better engage patients who are socially vulnerable or experience health inequities as they may be less likely to be reached by such systems and programmes.

Online self-referral has been introduced in the NHS DPP. There is limited evidence on the potential impact of such self-referral pathways on programme referrals and reach, that is, differences in the types of patients accessing a programme via self-referral versus other referral pathways, and whether the referral mode exacerbates or reduces disparities. In studies that have explored the impact of self-referral on disparities, the results have been mixed. For example, a study comparing different referral pathways to psychological support services in the UK reported fewer disparities via a self-referral pathway as compared with general practitioner (GP) referral.20 In contrast, a study exploring self-referral to cancer specialists in the USA21 reported that this pathway could reinforce inequities in care; people who were white, or with higher income and educational attainment are more likely to self-refer. These findings may reflect differing healthcare contexts, trust and trustworthiness of healthcare systems, and payment models (USA vs UK) along with differences in disease progression (people with existing mental health problems or cancer diagnosis). However, the limited evidence base does suggest that the impact of self-referral warrants further exploration and should be implemented with caution, paying heed to whether it might further compound inequities.

Using self-referral alongside other approaches—and monitoring how these approaches may enhance the reach and recruitment of a wide range of participants—may be the most pragmatic way forward. Other programmes, for example, in Australia22 have introduced a variety of recruitment pathways to enter the DPP. While the role of GPs remains central in the Australian DPP (they need to assess patients to exclude pre-existing diabetes), a referral to get to that stage can be mediated by other health professionals (eg, pharmacists), and through a consumer-led process (ie, social media campaign prompting people to visit the programme website or helpline and initiate referral). They report that approximately 20% of participants are recruited via the latter consumer-led process.