Reducing health inequalities through general practice

TL;DR: The authors conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice.

Abstract: Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice. Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice. Inequalities in health are “systematic differences in health between different socioeconomic groups within a society. As they are socially produced, they are potentially avoidable and widely considered unacceptable in a civilised society.”1Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (216) Google Scholar Although these differences are driven by inequalities in the wider social determinants of health, which shape our circumstances from before our birth and during the life course,2Dahlgren G Whitehead M The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows.Public Health. 2021; 199: 20-24Crossref PubMed Scopus (58) Google Scholar health-care services have a substantial role to play.3NHS EnglandCore20PLUS5 (adults)—an approach to reducing healthcare inequalities 2021.https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/Date: Nov 1, 2021Date accessed: March 29, 2023Google Scholar General practitioners especially can mitigate the effect of social determinants of health because they deal with the psychosocial aspects of patients’ health.4Starfield B Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012.Gac Sanit. 2012; 26: 20-26Crossref PubMed Scopus (220) Google Scholar, 5Maguire D Buck D Inequalities in life expectancy—changes over time and implications for policy. King's Fund, London2015Google Scholar, 6Exworthy M Morcillo V Primary care doctors' understandings of and strategies to tackle health inequalities: a qualitative study.Prim Health Care Res Dev. 2019; 20: e20Crossref PubMed Scopus (6) Google Scholar, 7Allen M Allen J Hogarth SMM Working for health equity: the role of health professionals. UCL Institute of Health Equity, London2013Crossref Google Scholar However, inequalities in health and health care are often intertwined.8Ford J Sowden S Olivera J et al.Transforming health systems to reduce health inequalities.Future Healthc J. 2021; 8: e204-e209Crossref PubMed Google Scholar, 9Hart JT The inverse care law.Lancet. 1971; 1: 405-412Summary PubMed Scopus (2208) Google Scholar For example, in the UK, general practices in the most deprived areas have 2·5 days less general practitioner time per week compared with their counterparts in the least deprived areas.10Ford J Nussbaum C Primary care workforce inequalities remain as wide as ever.https://www.phpc.cam.ac.uk/pcu/research/research-groups/crmh/research/crmh-health-inequalities/primary-care-workforce-inequalities-remain-as-wide-as-ever/Date: Nov 4, 2022Date accessed: March 29, 2023Google Scholar In such practices, patient experience is worse and the identification and management of long-term conditions, such as hypertension, is generally more challenging11Wu AS Dodhia H Whitney D Ashworth M Is the rule of halves still relevant today? A cross-sectional analysis of hypertension detection, treatment and control in an urban community.J Hypertens. 2019; 37: 2470-2480Crossref PubMed Scopus (0) Google Scholar, 12Curtis HJ Walker AJ MacKenna B Croker R Goldacre B Prescription of suboptimal statin treatment regimens: a retrospective cohort study of trends and variation in English primary care.Br J Gen Pract. 2020; 70: e525-e533Crossref PubMed Scopus (0) Google Scholar because of increased multimorbidity and risk factors.13Head A Fleming K Kypridemos C Schofield P Pearson-Stuttard J O'Flaherty M Inequalities in incident and prevalent multimorbidity in England, 2004–19: a population-based, descriptive study.Lancet Healthy Longev. 2021; 2: e489-e497Summary Full Text Full Text PDF PubMed Google Scholar Evidence for what is effective at reducing inequalities in health and health care in general practice is inconclusive.14Arblaster L Lambert M Entwistle V et al.A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health.J Health Serv Res Policy. 1996; 1: 93-103Crossref PubMed Scopus (101) Google Scholar A systematic review of the evidence on health-service interventions that can reduce inequalities in health showed that successful interventions include a systematic, intensive, and multidisciplinary approach, enhanced access, the utilisation of services, tailoring to patient needs, and community involvement.14Arblaster L Lambert M Entwistle V et al.A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health.J Health Serv Res Policy. 1996; 1: 93-103Crossref PubMed Scopus (101) Google Scholar Additional evidence indicates that shared decision making in primary care might reduce socioeconomic inequalities by particularly benefiting disadvantaged groups through increased knowledge, informed choice, and participation.15Durand M-A Carpenter L Dolan H et al.Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis.PLoS One. 2014; 9e94670Crossref Scopus (300) Google Scholar On the contrary, primary prevention for cardiovascular disease that is focused only on individuals at high risk has been found to increase socioeconomic inequalities in health and care outcomes.16Capewell S Graham H Will cardiovascular disease prevention widen health inequalities?.PLoS Med. 2010; 7e1000320Crossref PubMed Scopus (232) Google Scholar Studies on general-practice interventions have been unable to establish the differential effect of such interventions across multiple interacting aspects of disadvantage and rarely interrogate the role of structural and systemic factors.17Attwood S van Sluijs E Sutton S Exploring equity in primary-care-based physical activity interventions using PROGRESS-Plus: a systematic review and evidence synthesis.Int J Behav Nutr Phys Act. 2016; 13: 60Crossref PubMed Scopus (36) Google Scholar, 18Terens N Vecchi S Bargagli AM et al.Quality improvement strategies at primary care level to reduce inequalities in diabetes care: an equity-oriented systematic review.BMC Endocr Disord. 2018; 18: 31Crossref PubMed Scopus (9) Google Scholar, 19Scott-Samuel A Smith KE Fantasy paradigms of health inequalities: utopian thinking?.Soc Theory Health. 2015; 13: 418-436Crossref Scopus (41) Google Scholar, 20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar Most of the evidence comes from controlled trials that do not address the effect of the social determinants of health.14Arblaster L Lambert M Entwistle V et al.A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health.J Health Serv Res Policy. 1996; 1: 93-103Crossref PubMed Scopus (101) Google Scholar, 15Durand M-A Carpenter L Dolan H et al.Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis.PLoS One. 2014; 9e94670Crossref Scopus (300) Google Scholar, 16Capewell S Graham H Will cardiovascular disease prevention widen health inequalities?.PLoS Med. 2010; 7e1000320Crossref PubMed Scopus (232) Google Scholar However, inequalities in health and health care are produced across multiple interacting dimensions beyond socioeconomic status (eg, gender and ethnicity) and are contingent on structural factors, such as policies on housing, the labour market, or education.20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar Therefore, there will not be a one-size-fits-all solution. Still, general practitioners are left with little guidance on how to address health inequalities driven by structural factors.1Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (216) Google Scholar, 6Exworthy M Morcillo V Primary care doctors' understandings of and strategies to tackle health inequalities: a qualitative study.Prim Health Care Res Dev. 2019; 20: e20Crossref PubMed Scopus (6) Google Scholar, 21Nussbaum C Massou E Fisher R Morciano M Harmer R Ford J Inequalities in the distribution of the general practice workforce in England: a practice-level longitudinal analysis.BJGP Open. 2021; 5 (BJGPO.2021.0066.)Crossref PubMed Scopus (16) Google Scholar Researchers and policy makers should prioritise identifying the principles of equitable health-care services that will be achievable, not despite social determinants of health, but rather by addressing them. To identify such principles, we synthesised the evidence on interventions and routine care in general practice that decrease or increase inequalities in health and health care and, on the basis of this evidence, we produced an action framework for health-care professionals and decision makers. The Review was guided by evidence on cardiovascular disease, cancer, diabetes, or chronic obstructive pulmonary disease or their risk factors, as the main drivers of inequalities in life expectancy.22Waterall J Health matters: preventing cardiovascular disease. Public Health England, London2019Google Scholar We adopted a definition of health inequalities that includes social inequalities in health outcomes (eg, morbidity) and health care at the patient level (eg, access) and system level (eg, funding).8Ford J Sowden S Olivera J et al.Transforming health systems to reduce health inequalities.Future Healthc J. 2021; 8: e204-e209Crossref PubMed Google Scholar Our conceptual framework put the social determinants of health at the centre of the analysis, allowing us to draw on theories that suggest that health inequalities result from the unequal distribution of social determinants of health, which in turn result from economic and political structures23Raphael D A discourse analysis of the social determinants of health.Crit Public Health. 2011; 21: 221-236Crossref Scopus (0) Google Scholar and inequalities in power.23Raphael D A discourse analysis of the social determinants of health.Crit Public Health. 2011; 21: 221-236Crossref Scopus (0) Google Scholar, 24Babbel B Mackenzie M Hastings A Watt G How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care.Crit Public Health. 2017; 29: 168-180Crossref Scopus (22) Google Scholar, 25Brassolotto J Raphael D Baldeo N Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: a qualitative inquiry.Crit Public Health. 2014; 24: 321-336Crossref Scopus (56) Google Scholar Adopting an intersectional understanding of power20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar, 26Crenshaw K Mapping the margins: identity politics, intersectionality, and violence against women.Stanford Law Rev. 1991; 43: 1241-1299Crossref Google Scholar, 27Collins PH The difference that power makes: intersectionality and participatory democracy.in: Hankivsky O Jordan-Zachery JS The Palgrave handbook of intersectionality in public policy. Palgrave Macmillan, London2019: 167-192Crossref Google Scholar, 28Collins PH Bilge S Intersectionality. Polity Press, Cambridge2020Google Scholar enabled us to approach health inequalities as the outcome of multiple disadvantages or privileges that people experience simultaneously according to their socioeconomic position, gender, race, ethnicity, sexuality, disability, and other identities.20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar, 29Weber L Parra-Medina D Intersectionality and women's health: charting a path to eliminating health disparities. Gender perspectives on health and medicine. Emerald Group Publishing, Bingley2003Google Scholar Intersectionality offered us a theoretical tool to capture the ways that interventions and care can increase or decrease inequalities by having a differential effect on individuals according to their circumstances. Because of this approach we were able to interrogate the effect of both universal and targeted interventions on health inequalities within and between groups.30Rose GA Khaw K-T Marmot M Rose's strategy of preventive medicine: the complete original text. Oxford University Press, Oxford2008Crossref Google Scholar We integrated Collins’ framework of power organisation27Collins PH The difference that power makes: intersectionality and participatory democracy.in: Hankivsky O Jordan-Zachery JS The Palgrave handbook of intersectionality in public policy. Palgrave Macmillan, London2019: 167-192Crossref Google Scholar, 28Collins PH Bilge S Intersectionality. Polity Press, Cambridge2020Google Scholar to organise inequalities in general practice across four domains: structural (ie, policies and institutional structures), cultural (ie, beliefs about inequalities, their causes, and solutions), disciplinary (ie, organisational practices emerging whenever a policy or programme is implemented), and interpersonal (ie, personal experiences and relationships). Finally, we built on Levitas’ theory of utopia as a method31Levitas R Utopia as method: the imaginary reconstitution of society. Palgrave Macmillan, London2013Crossref Scopus (430) Google Scholar and fantasy paradigms in health inequalities19Scott-Samuel A Smith KE Fantasy paradigms of health inequalities: utopian thinking?.Soc Theory Health. 2015; 13: 418-436Crossref Scopus (41) Google Scholar to imagine what equitable general practice looks like and identify relevant guiding principles. We conducted a realist review32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar based on Pawson and colleagues’33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar five iterative steps (appendix p 1): (1) locating existing theories; (2) searching for evidence; (3) selecting articles; (4) extracting and organising data; and (5) narratively synthesising the evidence, combining steps 3 and 4 to increase efficiency. In contrast to systematic reviews that assess the effectiveness of distinct interventions, realist reviews focus on the mechanisms that link contexts with specific outcomes and identify which groups are the most and least likely to be affected by these outcomes and in what circumstances.32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar The logic of a realist review and evidence synthesis is based on the formation of causal statements between contexts, mechanisms, and outcomes (CMOs).32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar The literature review was registered with PROSPERO (CRD42020217871) and the protocol is available elsewhere.34Ford JA Gkiouleka A Kuhn I et al.Reducing health inequalities through general practice: protocol for a realist review (EQUALISE).BMJ Open. 2021; 11e052746Crossref Scopus (1) Google Scholar Building on our conceptual framework, we identified key theories about how general practice might increase or decrease health inequalities and integrated them into a broad theoretical explanation known as an initial programme theory.32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar We identified these theories through (1) an exploratory background literature search using informal methods (ie, snowballing and citation tracking);32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar (2) a panel discussion with content experts; and (3) iterative discussions within the project team. The initial programme theory covered a broad range of elements of context (ie, social, geographical, or other features affecting the implementation of interventions and care), mechanisms (ie, forces that cause things to happen), and outcomes (ie, the results of mechanisms). The initial programme theory served as an evaluative framework to guide our formal literature search and evidence collection,33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar with the areas that were then populated with evidence available in the appendix (p 2). Documents for the evidence synthesis were selected according to the extent to which they contained relevant data for the development and refinement of the programme theory.32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar AG classified studies in groups in this order: (1) studies which focused on inequalities in the UK were deemed of the highest relevance; (2) studies discussing interventions targeted at disadvantaged groups in the UK; (3) studies on interventions in the UK controlling for one or more PROGRESS-Plus (Cochrane Equity Methods Group) criteria35O'Neill J Tabish H Welch V et al.Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health.J Clin Epidemiol. 2014; 67: 56-64Summary Full Text Full Text PDF PubMed Scopus (509) Google Scholar in their analysis; (4) studies on inequalities outside the UK; (5) studies on interventions targeted at disadvantaged groups outside the UK; and (6) studies on interventions outside the UK controlling for one or more PROGRESS-Plus criteria in their analysis. Quality-assessment checklist criteria were not used as is conventionally the case in realist reviews;33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar rather, the rigour of the extracted data was considered during the coding and synthesis phase. Conforming with realist methodology, studies that contributed to the refinement of the programme theory were used in data synthesis even if they were of poor rigour.36Wong G Westhorp G Pawson R Greenhalgh T Realist synthesis: RAMESES training materials.https://www.ramesesproject.org/media/Realist_reviews_training_materials.pdfDate: July, 2013Date accessed: March 29, 2023Google Scholar To increase efficiency, article selection and data extraction were combined. Characteristics of all the included studies were extracted with an Excel sheet by AG and a research assistant. AG uploaded the included studies in QSR Nvivo (QSR International: Burlington, MA, USA) from most to least relevant and alphabetically by title, and coded relevant data with feedback from the research team. JF independently coded a random sample of approximately 5% of the articles to check for systematic errors. Articles were removed from the Nvivo sources list if they contained no relevant data. Data extraction stopped when no further data contributing to the programme theory were consistently identified (ie, thematic saturation).32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar Relevant text was searched manually in the full text of the included studies. Data were extracted by use of these questions: (1) does the text refer to any of the elements included in the initial programme theory? Or (2) does the text refer to the unequal effectiveness of care services or interventions? Codes were deductive (ie, created from the initial programme theory and identified with question 1), inductive (ie, created to categorise data reported in included studies and identified with question 2), or retroductive (ie, created on the basis of an interpretation of data to infer to what the hidden causal forces might be for outcomes and identified with both questions).32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar They were refined regularly throughout the data analysis and organised across 14 broader themes: access to care, communication, community engagement, competing priorities, cultural understanding, differences between general practices, interprofessional cooperation, patient education and behaviour change, patient enablement, patient perceived risk, resources distribution, the role of the general practitioner in intervention success, time constraints, and workforce.33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar We formed CMO configurations (CMOCs)32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar within and across themes. When necessary, we used questions about the relevance, rigour, and interpretation of data in line with previous work.37Wong G Brennan N Mattick K Pearson M Briscoe S Papoutsi C Interventions to improve antimicrobial prescribing of doctors in training: the IMPACT (IMProving Antimicrobial presCribing of doctors in Training) realist review.BMJ Open. 2015; 5e009059Crossref Scopus (28) Google Scholar Our synthesis aimed to elicit common patterns and generalisable messages across contexts and health conditions. Therefore, we focused on the underlying principles of care and interventions and CMOCs were abstracted to a high degree to reflect the principles of care and interventions that are likely to decrease or increase inequalities in general practice. We identified 7998 reviews of which 251 met the inclusion criteria. From the included reviews, we retrieved 6555 primary studies of which we included 325 (figure 1). The included primary studies covered a period from 1989 until 2021 and most were conducted in the USA (n=143) and the UK (n=102). 56 studies focused primarily on inequalities, 137 on an intervention or care targeted at specific disadvantaged groups, and 132 just controlled for at least one PROGRESS-Plus criterion (usually age or sex). More details about the characteristics of the included studies are available in the appendix (p 3). We coded 159 studies (appendix pp 55–80) before reaching thematic saturation. The evidence on interventions in general practice that address inequalities is disparate as it involves different kinds of interventions, settings, and populations. Moreover, although interventions seem to focus on single aspects of care (eg, invitations to screening programmes), their effectiveness is subject to other aspects (eg, availability of patient contact details). This finding stresses how inequalities are produced through context-specific, inter-related processes. Therefore, producing a list of distinct well defined interventions effective in reducing inequalities in health or care would have been impractical, given the length of such a list, and of little use given that interventions are context-specific. However, there is transferrable evidence about common qualities that inform successful interventions, which was the subject of our focus. We produced 21 CMOCs, which we organised across the four domains of power organisation in line with our conceptual framework. This way, we captured how inequalities are produced across different aspects of care while producing transferrable conclusions, resulting in an action framework for equitable general practice (figure 2). The framework identifies key areas of action for the reduction of health and care inequalities in general practice across the structural, cultural, disciplinary, and interpersonal domains and suggests five principles that should inform relevant action. We discuss the identified action areas with some examples of the CMOCs included in each domain and the meaning of each suggested principle in the context of the reviewed evidence. An elaborated account of the evidence synthesis and CMOCs production from the reviewed evidence is available in the appendix (pp 4–28). In the structural domain, key areas include funding and workforce distributions, which are often unable to account for differences in needs within and between practices (figure 2; appendix p 7).38Fullwood C Doran T Reeves D The effect of financial incentives on inequalities in the quality of primary care.J Epidemiol Community Health. 2008; 62: A21Google Scholar, 39Laverty AA Bottle A Majeed A Millett C Blood pressure monitoring and control by cardiovascular disease status in UK primary care: 10 year retrospective cohort study 1998–2007.J Public Health. 2011; 33: 302-309Crossref Scopus (0) Google Scholar, 40McLean G Sutton M Guthrie B Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework.J Epidemiol Community Health. 2006; 60: 917-922Crossref PubMed Scopus (0) Google Scholar, 41Calvert M Shankar A McManus RJ Lester H Freemantle N Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study.BMJ. 2009; 338b1870Crossref PubMed Scopus (126) Google Scholar, 42Dalton AR Alshamsan R Majeed A Millett C Exclusion of patients from quality measurement of diabetes care in the UK pay-for-performance programme.Diabet Med. 2011; 28: 525-531Crossref PubMed Scopus (25) Google Scholar, 43McGovern MP Williams DJ Hannaford PC et al.Introduction of a new incentive and target-based contract for family physicians in the UK: good for older patients