Proactive, targeted benefits advice for older people in general practice: a feasibility study

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature

BACKGROUND

It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it.

PURPOSE OF STUDY

This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation.

METHODS

Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes.

RESULTS

Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs.

CONCLUSION

Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

International Evidence on the Impact of Health-Justice Partnerships: A Systematic Scoping Review

Background: Health-justice partnerships (HJPs) are collaborations between healthcare and legal services which support patients with social welfare issues such as welfare benefits, debt, housing, education and employment. HJPs exist across the world in a variety of forms and with diverse objectives. This review synthesizes the international evidence on the impacts of HJPs.

Methods: A systematic scoping review of international literature was undertaken. A wide-ranging search was conducted across academic databases and grey literature sources, covering OECD countries from January 1995 to December 2018. Data from included publications were extracted and research quality was assessed. A narrative synthesis approach was used to analyze and present the results.

Results: Reported objectives of HJPs related to: prevention of health and legal problems; access to legal assistance; health improvement; resolution of legal problems; improvement of patient care; support for healthcare services; addressing inequalities; and catalyzing systemic change. There is strong evidence that HJPs: improve access to legal assistance for people at risk of social and health disadvantage; positively influence material and social circumstances through resolution of legal problems; and improve mental wellbeing. A wide range of other positive impacts were identified for individuals, services and communities; the strength of evidence for each is summarized and discussed.

Conclusion: HJPs are effective in tackling social welfare issues that affect the health of disadvantaged groups in society and can therefore form a key part of public health strategies to address inequalities.

Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways

Poverty is positively associated with poor health; thus, some healthcare commissioners in the UK have pioneered the introduction of advice services in health service locations. Previous systematic reviews have found little direct evidence for a causal relationship between the provision of advice and physical health and limited evidence for mental health improvement. This paper reports a study using a broader range of types of research evidence to construct a conceptual (logic) model of the wider evidence underpinning potential (rather than only proven) causal pathways between the provision of advice services and improvements in health. Data and discussion from 87 documents were used to construct a model describing interventions, primary outcomes, secondary and tertiary outcomes following advice interventions. The model portrays complex causal pathways between the intervention and various health outcomes; it also indicates the level of evidence for each pathway. It can be used to inform the development of research designed to evaluate the pathways between interventions and health outcomes, which will determine the impact on health outcomes and may explain inconsistencies in previous research findings. It may also be useful to commissioners and practitioners in making decisions regarding development and commissioning of advice services.

Patients' perspective of financial benefits following head and neck cancer in Merseyside and Cheshire

The aim of this interview study was to ask patients with head and neck cancer in the Mersey region about their need for financial benefits, the advice they were given about benefits and financial matters, and the financial burden of the disease. Stratified quota sampling was by employment status, whether work had been affected by the cancer, and by sex. Of 51 interviewees (mean (SD) age 61(8) years) 20 were retired, 11 were unemployed, 13 worked full-time, and 7 worked part-time. Cancer had affected the work status of 24. Since diagnosis 57% had suffered financially; this was particularly high in those who had retired (65%), and in those whose work had been affected by cancer (79%). Quality of life had decreased in 53% as a result of the financial impact of the disease. This was most common in the unemployed (64%), and in those whose work was affected by cancer (83%). Only a quarter had been given adequate help and information about finance; this was lowest in the unemployed (18%) and highest in those who were fully employed (39%). One third (17/51) had never claimed benefits. The most common benefits were Disability Living Allowance and Incapacity Benefit. Two-thirds (21/31) had applied for benefits after diagnosis, 18 of these were directly as a result of the disease. The median (IQR) weekly income from benefits was £88 (£60-170). Patients and carers need better access to financial advice. We suggest that each multidisciplinary team should have a designated benefits or financial advisor who is readily available to patients in the clinic and on the ward.

Socioeconomic differences in service use, payment and receipt of illness-related benefits in the last year of life: findings from the British Household Panel Survey

BACKGROUND

Terminal illness presents a financial challenge to many households, but in Britain the situation should be eased by state benefits, such as attendance allowance, which is available to everyone in the last six months of life without means testing.

AIM

To investigate the use of health and social services, payments and benefit receipt by individuals in differing financial circumstances in the year before death.

METHODS

Analysis of individual level panel data for 1652 community-dwelling decedents from 12 waves of the British Household Panel Study (1991-2003).

RESULTS

In the year before death, over 90% of decedents saw their GP, and around one-third spent some time in hospital. More than 80% paid no fees for any services. Over a third of decedents aged over 65 reported financial strain, but only 13.9% of these were receiving attendance allowance. People who felt that they were having financial difficulties were more likely to be frequent attenders in primary care, taking age, health status and other factors into account (adjusted OR=1.9, 95% CI=1.3-2.6, P<0.001). Older age was associated with less use of primary, but not secondary care.

CONCLUSIONS

Financial strain was common, but benefit uptake low. Primary health care professionals saw nearly all decedents in their last year, and could play an important role in ensuring that the elderly and the less well off are aware of the services and benefits available to them.

Bridging the gap? A critical analysis of the development of the Patient Advice And Liaison Service (PALS)

PURPOSE

The creation of the Patient Advice and Liaison Service (PALS) was part of a range of measures to make the NHS more patient-centred. The purpose of this paper is to present a critical analysis of PALS through examining the impact on major stakeholder groups.

DESIGN/METHODOLOGY/APPROACH

The paper starts by examining the drivers for reform and the significance of PALS in the wider policy context. Key issues for implementation are then discussed including access to information, independence, cultural change in the health service and relationships with the voluntary sector. Research literature on the provision of advice in health care settings is drawn on.

FINDINGS

Taking a critical perspective, the paper argues that the current model of PALS can never succeed in bridging the gap between users and the health service and will end up merely defending service interests. It concludes by arguing for an alternative model of development based on fostering strong partnerships with the community and voluntary sector.

PRACTICAL IMPLICATIONS

This paper highlights critical issues for service development and delivery, including examining the impact on service users and the voluntary sector.

ORIGINALITY/VALUE

PALS is a very significant development in the health care provision, operating at the interface between the service and the public and yet its development has attracted little critical comment. This paper provides a comprehensive analysis of the new service and proposes an alternative model of development.

Exploring the relationships between provision of welfare benefits advice and the health of elderly people: a longitudinal observational study and discussion of methodological issues

Provision of welfare benefits advice to maximise financial benefit uptake is a shared goal for social and health policy in the UK. The study was designed to explore the wider impact on elderly people provided with specialist welfare benefits advice, in terms of their health and quality of life. This paper reports on a longitudinal postal survey of community dwellers aged 60 and over referred for specialist welfare benefits advice within social services and who were followed up at 5 months (over 2003-2004). Outcome measures included the Short Form-36 (SF-36), the General Health Questionnaire-12 (GHQ-12) and the Barthel Index (postal version), along with questions relating to chronic illness. We also report on the methodological issues that arise from conducting research of this nature. Out of 233 elderly people sent questionnaires, 77 (33%) returned a completed baseline questionnaire. Of the 156 who did not return questionnaires, 35 (22%) gave reasons of being 'too unwell' to participate. Between baseline and follow-up, 8 (10%) of the 77 respondents died; 52 of the 69 (75%) remaining participants completed follow-up questionnaires. Although low, these response rates are comparable with other similar questionnaire surveys examining the outcome of providing benefits advice to individuals. Elderly people (mean age = 80.3, SD = 8.6 years) receiving welfare benefits advice usually reported the presence of a longstanding illness or disability, and the use of healthcare services. Baseline SF-36 scores were extremely low and remained largely unchanged at follow-up; however, there were significant improvements in GHQ-12 scores (mean difference = -1.45, 95% CI = -2.63 to -0.27, P = 0.017). Significant increases in benefit income were identified in 65% of respondents with complete financial data sets (mean increase = pound14.73 per week; 95% CI = 5.27-24.18, d.f. = 39, P = 0.003). Participants were very vulnerable in their health status (compared with normative data for elderly people), and this may have contributed to the difficulty in engaging them in the research. There are methodological issues around establishing cause and effect in this type of study, which cannot be readily designed out on account of ethical issues. Extraction and analysis of financial status and benefit eligibility with a view to determining absolute changes in the material well-being of vulnerable individuals over time is a complex and challenging task. Use of suitable measures is essential. Innovative strategies are necessary to maximise survey response rates amongst the vulnerable elderly population.

Can primary care identify an 'at risk' group in the older population

The promotion of health and independence for older people through preventative strategies is rising up the public health agenda in many countries and has been made a government policy objective in the UK. Despite forty years of experimentation, community nursing and general practice involvement in this field has been characterized by a lack of evidence to support broad screening and surveillance programmes and a failure to reach consensus on the most effective approaches to health promotion in later life. One initiative brought together community nursing, general practice and the voluntary social welfare sector in an inner urban setting to proactively identify and address unmet need and promote health through short term case management in an older population. This paper reports on the ability of the primary care teams to identify 'at risk' groups in the older population, which can then be targeted for comprehensive assessment.

A systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings

BACKGROUND

Socio-economic variations in health, including variations in health according to wealth and income, have been widely reported. A potential method of improving the health of the most deprived groups is to increase their income. State funded welfare programmes of financial benefits and benefits in kind are common in developed countries. However, there is evidence of widespread under claiming of welfare benefits by those eligible for them. One method of exploring the health effects of income supplementation is, therefore, to measure the health effects of welfare benefit maximisation programmes. We conducted a systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings.

METHODS

Published and unpublished literature was accessed through searches of electronic databases, websites and an internet search engine; hand searches of journals; suggestions from experts; and reference lists of relevant publications. Data on the intervention delivered, evaluation performed, and outcome data on health, social and economic measures were abstracted and assessed by pairs of independent reviewers. Results are reported in narrative form.

RESULTS

55 studies were included in the review. Only seven studies included a comparison or control group. There was evidence that welfare rights advice delivered in healthcare settings results in financial benefits. There was little evidence that the advice resulted in measurable health or social benefits. This is primarily due to lack of good quality evidence, rather than evidence of an absence of effect.

CONCLUSION

There are good theoretical reasons why income supplementation should improve health, but currently little evidence of adequate robustness and quality to indicate that the impact goes beyond increasing income.

Establishing a welfare advice service in family practices: views of advice workers and primary care staff

BACKGROUND

The placement of welfare advice services in family practice to assist patients with health-related social and economic issues (e.g. disability benefits) has gathered momentum over the last decade in the UK. This expansion of primary care raises a number of issues for practices hosting these services.

OBJECTIVES

To gain the views of advice workers and primary care staff about the issues raised in hosting a welfare advice service across 30 practices in inner city Bradford.

METHODS

Views were obtained through focus groups with six advice workers, and primary care staff in 14 practices. A questionnaire was also posted to all practice managers asking their opinions about the service.

RESULTS

The focus groups highlighted a number of advantages for patients, including improvements in health and quality of life through increased income and reduced stress from social and economic issues. For practice staff, the service provided a resource to refer patients for welfare advice, reducing the time spent dealing with welfare issues, thereby reducing workload. This was confirmed in the questionnaire to practice managers where 72% said the service had saved time for GPs and reception/office staff. The advice workers raised concerns about the perceived level of commitment to the service from some staff at some practices. Practice staff were particularly concerned about the need for feedback about referrals.

CONCLUSION

Providing welfare advice in family practice can act as a valuable resource for primary care staff helping to address their patients health-related social and economic needs.

Welfare advice in general practice: a resource for community nurses

Recent policy guidance has recommended that community nurses address public health issues, suggesting that they play a role in assessing and addressing poverty, and ensuring patients claim the welfare benefits to which they are entitled. This article reports an evaluation of a welfare advice service catering for 30 general practices in inner-city Bradford. Community nurses, along with other members of the primary care team, were able to refer patients for advice about welfare issues, including benefits, housing, debt etc. A retrospective study was conducted of all patients referred for advice during 24 months of the project. The advice workers saw 2484 patients, dealt with over 4000 welfare advice issues, and raised over pounds 2 million in welfare benefit claims for patients, primarily through disability-related benefits. The contribution of community nurses is examined in terms of referrals and outcomes for patients.

Providing welfare advice in general practice: referrals, issues and outcomes

General practices in the UK are increasingly hosting welfare advice services on their premises to address patients' social and economic needs. In this paper, the authors present the outcomes of a service providing welfare advice across 30 general practices in inner-city Bradford. A retrospective study of all patients referred for advice during the initial 24 months of the project was conducted. The following information was collected: patient demographics, source of referrals, advice issues raised and income generated through benefit claims. The advice workers saw 2484 patients dealing with over 4000 welfare advice issues. Demand for the service varied widely across practices, reflecting practice list size and engagement with the service by practice staff. The main source of referrals was general practitioners (28%), and disability-related welfare benefits constituted the largest category of advice issues. Sixty-nine per cent of patients seen for advice were of south Asian ethnic origin. The advice workers raised pound sterling 2,389,255 in welfare benefit claims for patients, primarily through disability-related benefits. Approximately one in four patients referred for advice benefited financially. It is concluded that the service is an excellent strategy by which primary care organisations address the social, economic and environmental influences on the health of their population.

The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in 'at risk' older adults

Population ageing, escalating costs in pensions, health-care and long-term care have prompted a new policy agenda for active ageing and quality of life in old age across the European Union and other developed countries. In England, the National Service Framework for Older People (NSF OP) explicitly demands for the first time that the NHS and local authorities, in partnership, agree programmes to promote health ageing and to prevent disease in older people. These programmes are expected to improve access for older people to mainstream health promotion services and also to develop multiagency initiatives to promote health, independence and well-being in old age. This paper describes the evaluation of one interagency project team established to test out mechanisms for addressing health promotion for older people through primary care. A mixed methodology was used to understand the processes of service development, the impact of the team's intervention, and the primary and secondary outcomes for older people. The project demonstrated that multi-agency partnerships have the potential to improve the quality of the lives of older people deemed 'at risk' by their general practitioners, particularly through income generation but also in the identification of medical problems such as unrecognised hypertension, hearing loss and visual loss. It also offered some key learning points for other multi-agency groups developing similar services.