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

How co-locating public mental health interventions in community settings impacts mental health and health inequalities: a multi-site realist evaluation

BACKGROUND

Public mental health interventions are non-clinical services that aim to promote wellbeing and prevent mental ill health at the population level. In England, the health, social and community system is characterised by complex and fragmented inter-sectoral relationships. To overcome this, there has been an expansion in co-locating public mental health services within clinical settings, the focus of prior research. This study evaluates how co-location in community-based settings can support adult mental health and reduce health inequalities.

METHODS

A qualitative multi-site case study design using a realist evaluation approach was employed. Data collection took place in three phases: theory gleaning, parallel testing and refining of theories, and theory consolidation. We collected data from service users (n = 32), service providers (n = 32), funders, commissioners, and policy makers (n = 11), and members of the public (n = 10). We conducted in-depth interviews (n = 65) and four focus group discussions (n = 20) at six case study sites across England, UK, and two online multi-stakeholder workshops (n = 20). Interview guides followed realist-informed open-ended questions, adapted for each phase. The realist analysis used an iterative, inductive, and deductive data analysis approach to identify the underlying mechanisms for how community co-location affects public mental health outcomes, who this works best for, and understand the contexts in which co-location operates.

RESULTS

Five overarching co-location theories were elicited and supported. Co-located services: (1) improved provision of holistic and person-centred support; (2) reduced stigma by creating non-judgemental environments that were not associated with clinical or mental health services; (3) delivered services in psychologically safe environments by creating a culture of empathy, friendliness and trust where people felt they were being treated with dignity and respect; (4) helped to overcome barriers to accessibility by making service access less costly and more time efficient, and (5) enhance the sustainability of services through better pooling of resources.

CONCLUSION

Co-locating public mental health services within communities impacts multiple social determinants of poor mental health. It has a role in reducing mental health inequalities by helping those least likely to access services. Operating practices that engender inter-service trust and resource-sharing are likely to support sustainability.

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.

Addressing financial strain through a peer-to-peer intervention in primary care

BACKGROUND

Financial strain is a key social determinant of health. As primary care organizations begin to explore ways to address social determinants, peer-to-peer interventions hold promise.

OBJECTIVE

Our objective was to evaluate a peer-to-peer intervention focussed on financial empowerment delivered in primary care, in partnership with a social enterprise.

METHODS

This intervention was hosted by a large primary care organization in Toronto, Canada. Participants were recruited within the organization and from local services. We organized three separate groups who met over 10 weekly in-person, facilitated sessions: millennials (age 19-29) no longer in school, precariously employed adults (age 30-55) and older adults near retirement (age 55-64). We applied principles of adult education and peer-to-peer learning. We administered surveys at intake, at exit and at 3 months after the intervention, and conducted three focus groups.

RESULTS

Fifty-nine people took part. At 3 months, participants had sustained higher rates of optimism about their financial situation (54% improved from baseline), their degree of control (55% improved) and stress around finances (50% improved). In focus groups, participants reported greater understanding of their finances, that they were not alone in struggling with finances, and that it was useful to meet with others. One group continued to meet for several months after the intervention.

CONCLUSIONS

In this study, a peer-to-peer intervention helped address a key social determinant of health, likely through reducing stigma, providing group support and creating a space to discuss solutions. Primary care can host these interventions and help engage potential participants.

Randomised controlled trial with economic and process evaluations of domiciliary welfare rights advice for socioeconomically disadvantaged older people recruited via primary health care (the Do-Well study)

Background

Welfare rights advice services are effective at maximising previously unclaimed welfare benefits, but their impact on health has not been evaluated.

Objective

To establish the acceptability, cost-effectiveness and effect on health of a domiciliary welfare rights advice service targeting older people, compared with usual practice.

Design

A pragmatic, individually randomised, parallel-group, single-blinded, wait-list controlled trial, with economic and process evaluations. Data were collected by interview at baseline and 24 months, and by self-completion questionnaire at 12 months. Qualitative interviews were undertaken with purposive samples of 50 trial participants and 17 professionals to explore the intervention’s acceptability and its perceived impacts.

Setting

Participants’ homes in North East England, UK.

Participants

A total of 755 volunteers aged ≥ 60 years, living in their own homes, fluent in English and not terminally ill, recruited from the registers of 17 general practices with an Index of Multiple Deprivation within the most deprived two-fifths of the distribution for England, and with no previous access to welfare rights advice services.

Interventions

Welfare rights advice, comprising face-to-face consultations, active assistance with benefit claims and follow-up as required until no longer needed, delivered in participants’ own homes by a qualified welfare rights advisor. Control group participants received usual care until the 24-month follow-up, after which they received the intervention.

Main outcome measures

The primary outcome was health-related quality of life (HRQoL), assessed using the CASP-19 (Control, Autonomy, Self-realisation and Pleasure) score. The secondary outcomes included general health status, health behaviours, independence and hours per week of care, mortality and changes in financial status.

Results

A total of 755 out of 3912 (19%) general practice patients agreed to participate and were randomised (intervention,n = 381; control,n = 374). In the intervention group, 335 participants (88%) received the intervention. A total of 605 (80%) participants completed the 12-month follow-up and 562 (75%) completed the 24-month follow-up. Only 84 (22%) intervention group participants were awarded additional benefits. There was no significant difference in CASP-19 score between the intervention and control groups at 24 months [adjusted mean difference 0.3, 95% confidence interval (CI) –0.8 to 1.5], but a significant increase in hours of home care per week in the intervention group (adjusted difference 26.3 hours/week, 95% CI 0.8 to 56.1 hours/week). Exploratory analyses found a weak positive correlation between CASP-19 score and the amount of time since receipt of the benefit (0.39, 95% CI 0.16 to 0.58). The qualitative data suggest that the intervention was acceptable and that receipt of additional benefits was perceived by participants and professionals as having had a positive impact on health and quality of life. The mean cost was £44 per participant, the incremental mean health gain was 0.009 quality-adjusted life-years (QALYs) (95% CI –0.038 to 0.055 QALYs) and the incremental cost-effectiveness ratio was £1914 per QALY gained.

Conclusions

The trial did not provide sufficient evidence to support domiciliary welfare rights advice as a means of promoting health among older people, but it yielded qualitative findings that suggest important impacts on HRQoL. The intervention needs to be better targeted to those most likely to benefit.

Future work

Further follow-up of the trial could identify whether or not outcomes diverge among intervention and control groups over time. Research is needed to better understand how to target welfare rights advice to those most in need.

Trial registration

Current Controlled Trials ISRCTN37380518.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 3. See the NIHR Journals Library website for further project information. The authors also received a grant of £28,000 from the North East Strategic Health Authority in 2012 to cover the costs of intervention delivery and training as well as other non-research costs of the study.

A novel income security intervention to address poverty in a primary care setting: a retrospective chart review

OBJECTIVE

To examine the development and implementation of a novel income security intervention in primary care.

DESIGN

A retrospective, descriptive chart review of all patients referred to the Income Security Heath Promotion service during the first year of the service (December 2013-December 2014).

SETTING

A multisite interdisciplinary primary care organisation in inner city Toronto, Canada, serving over 40 000 patients.

PARTICIPANTS

The study population included 181 patients (53% female, mean age 48 years) who were referred to the Income Security Health Promotion service and engaged in care.

INTERVENTION

The Income Security Health Promotion service consists of a trained health promoter who provides a mixture of expert advice and case management to patients to improve income security. An advisory group, made up of physicians, social workers, a community engagement specialist and a clinical manager, supports the service.

OUTCOME MEASURES

Sociodemographic information, health status, referral information and encounter details were collected from patient charts.

RESULTS

Encounters focused on helping patients with increasing their income (77.4%), reducing their expenses (58.6%) and improving their financial literacy (26.5%). The health promoter provided an array of services to patients, including assistance with taxes, connecting to community services, budgeting and accessing free services. The service could be improved with more specific goal setting, better links to other members of the healthcare team and implementing routine follow-up with each patient after discharge.

CONCLUSIONS

Income Security Health Promotion is a novel service within primary care to assist vulnerable patients with a key social determinant of health. This study is a preliminary look at understanding the functioning of the service. Future research will examine the impact of the Income Security Health Promotion service on income security, financial literacy, engagement with health services and health outcomes.

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background

This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.

Aims

The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.

Methods

We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.

Findings

Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.

Future Research

Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

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.

Psychiatric morbidity and people's experience of and response to social problems involving rights

Psychiatric morbidity has been shown to be associated with the increased reporting of a range of social problems involving legal rights ('rights problems'). Using a validated measure of psychiatric morbidity, this paper explores the relationship between psychiatric morbidity and rights problems and discusses the implications for the delivery of health and legal services. New representative national survey data from the English and Welsh Civil and Social Justice Survey (CSJS) surveyed 3040 adults in 2007 to explore the relationship between GHQ-12 scores and the self reported incidence of and behaviour surrounding, rights problems. It was found that the prevalence of rights problems increased with psychiatric morbidity, as did the experience of multiple problems. It was also found the likelihood of inaction in the face of problems increased with psychiatric morbidity, while the likelihood of choosing to resolve problems without help decreased. Where advice was obtained, psychiatric morbidity was associated with a greater tendency to obtain a combination of 'legal' and 'general' support, rather than 'legal' advice alone. The results suggest that integrated and 'outreach' services are of particular importance to the effective support of those facing mental illness.

Towards an integrated service response to the link between legal and health issues

International research that confirms links between health issues and legal needs and the prevalence of non-legal services as the first port of call for assistance with legal problems has reinvigorated interest in providing integrated legal and health services. This article details research that indicates experiencing ‘justiciable events’ (problems for which there is a potential legal remedy) leads to stress, anxiety and deterioration in physical or mental health problems. Health consequences are identified for those that do not obtain appropriate and timely legal assistance. People often experience clusters of legal and non-legal problems that require a range of responses. For those that seek assistance with their justiciable event, most seek this assistance from non-legal sources. Within the legal aid sector, these research findings are considered compelling reasons to integrate legal, health and welfare services. However, the co-ordination and collocation of legal and non-legal services (particularly for disadvantaged communities) is not a straightforward solution. Drawing on the experience of several examples of integrated approaches in legal, health and welfare service delivery including the longstanding arrangements between the West Heidelberg Community Legal Service, which is collocated with Banyule Community Health, a range of challenges facing those agencies wishing to develop relationships to provide integrated legal, health and welfare services are identified.

Cancer and disability benefits: a synthesis of qualitative findings on advice and support

Following the Supportive and Palliative Care Guidance, a call was made for a meta-ethnography on social support services for people affected by cancer. We responded by focusing on the topic of financial advice and support. After a scoping exercise revealed little qualitative evidence, we adopted the chief aim of identifying issues for research. Over 50 keywords relating to patient finances, cancer and qualitative research were entered into electronic search databases and combined. Because of the nature of the literature found, we synthesized primary data into themes and discussion, rather than second-order constructs into third-order constructs, as is common in meta-ethnography. Most of the literature found serves pragmatic, campaigning and/or service-development objectives. Also, most relates to disability benefits rather than insurance, tax and other issues. Five themes emerged: patients' struggles to obtain financial advice and benefits; tests/rules for disability benefits; issues relating to 'Special Rules'; intervention by benefit advisers; and intervention by health/social-care professionals. Struggles with the benefit system emerged as the fundamental theme. We conclude that patients need sensitive, proactive services to assist with benefit claims, and a benefit system that seems supportive rather than obstructive. Numerous under-researched topics were identified, including the need for general financial advice, help for carers, and cultural issues.

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.

Family caregivers: Russian-speaking Australian women's access to welfare support

In Australia, rapid population ageing, and government efforts to support people who are chronically ill, elderly or with disabilities to live in their own homes, has led to the primary responsibility of care being undertaken by families. Through its social policies, the Australian government provides income and other types of support to informal caregivers. This article explores how Australian social policy and women's understanding of their roles impact on their access to welfare support. Qualitative research was conducted in Melbourne between February and June 2006. In-depth interviews were undertaken with eight Russian-speaking women involved in caregiving, purposively recruited through ethnic associations, and with four community service providers. Women based their expectations of the gendered and private nature of their role on the social policies in countries of their origin and, hence, did not attempt to access welfare support unless they were referred by health and welfare professionals. In addition, poor referral by professionals, influenced by past societal attitudes that caregiving is a gendered role, contributed to women's limited access to welfare benefits. Changes in the implementation of social policy are proposed to increase caregivers' access to welfare support and efficient utilisation of existing resources.

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.