Addressing Inequalities in the Primary and Secondary Outpatient Interface: A Policy-Focused Evidence Brief

In the UK, an estimated 15 million primary care appointments are used every year dealing with issues between primary and secondary care. A dysfunctional primary-secondary care interface impacts on patient experience, safety and staff workload, and is likely to widen health inequalities by disproportionately impacting underserved populations. Health care systems globally have implemented numerous initiatives to improve this interface. While the aim is often to increase efficiency, short-term efficiency gains may be outweighed by populations missing out on care and subsequently presenting late and acutely. Here we explore what works to address inequalities in the primary-secondary care interface. Most evidence describes the problem of inequalities at the primary-secondary care interface, rather than identifying solutions. We identified five points at which inequalities can arise, and action should be considered: 1) referral from primary care, 2) navigating the health and care system, 3) integration of care, 4) follow-up after initial appointment and 5) policies when patients miss appointments. Evidence exists for the use of care coordinators, co-location of services, culturally tailored services, and appointment reminder systems. Patient-initiated follow-up should be used with caution. Policymakers should consider programmes that include support mechanisms to help attendance at specialist appointments, care coordinators, inclusive and culturally competent communication, flexibility, co-location where possible and using patient-initiated follow up on a case-by-case basis. Improved evaluation and monitoring are also needed to understand the current and evolving impact of health care interface policy across different communities. • Health inequalities arise at multiple points in the primary-secondary care interface, including referral, care navigation, integration, follow-up, and missed appointments. • Care coordinators, co-located services, culturally competent communication, and targeted reminder systems improve access for disadvantaged groups. • Patient-initiated follow-up (PIFU) may increase inequalities if used without consideration of patient health literacy or resources. • Targeted interventions such as text reminders and proactive outreach improve attendance among socioeconomically disadvantaged groups.