- Julia Burrows
- Susan Baxter
- Wendy Baird
- Julie Hirst
- Elizabeth Goyder
School of Health and Related Research, Regent Court, Regent Road, Sheffield S1 4DA
Corresponding author:
Julia Burrows Email: j.burrows@sheffield.ac.uk Telephone: 0114 2221722
Abstract
Background
The potential to improve health by reducing poverty, debt and other social problems has been suggested. Research indicates that the provision of welfare advice in general practice can secure additional income for patients and help manage debt.
Aim
To examine the views of primary care staff and users of advice services located in general practices, and to identify key factors perceived as contributing to the intervention’s success or difficulties.
Design of Study
A qualitative interview study
Setting
Two General Practices (one urban and one rural) in the UK
Methods
Semi-structured interviews (n=22) with five primary care and practice staff, five CAB advisors and twelve service users.
Results
Key positive service features were seen by all groups as the confidential and familiar GP surgery environment; ability to make appointments; experienced advisor availability and continuity. Outcomes for service users were described as financial gain and managed debt, along with beneficial social and mental health impacts. Staff benefits were perceived to be appropriate referral, and better use of GP consultation time.
Conclusion
Welfare advice in primary care provides financial benefit and was perceived by participants to offer health and other benefits to patients and staff. However, while perceptions of gain from the intervention were evident, demonstration of measurable health improvement and wellbeing presents challenges. Further empirical work is needed in order to explore these complex cause-effect links and the cost-effectiveness of the intervention.
How this fits in
Welfare advice in primary care is known to be an effective way to help patients to secure financial benefits and manage debt and some (uncontrolled) studies suggest health gains. This study reports the views of clinicians, advisors and service users of a service delivery model used across rural and urban settings. The study is particularly relevant at a time when clinicians are likely to be increasingly dealing with patients in financial hardship. With the anticipated changes in UK commissioning arrangements, GP consortia will need appropriate evidence to support their commissioning decisions, and this will include the decision about whether or not to invest in welfare advice services in primary care.
Keywords
Citizens advice; welfare advice; welfare benefits; primary care; general practice; poverty.
Introduction
Welfare advice in primary care has been suggested as a promising approach to tackling poverty as a determinant of ill-health1 23. Previous studies have demonstrated positive outcomes for patients including financial gain4 and improvements in measures of mental health and wellbeing56. Although there is a strong theoretical argument for improving health by tackling financial hardship3, evidence of health gain from welfare advice in health settings has been elusive78. To date, the provision of advice in primary care has tended to be implemented as scattered projects throughout the United Kingdom (UK)3.
The locality examined in this study has pioneered welfare advice as a key strategy to tackle health inequality for over ten years. Citizens Advice Bureaux (CAB) are charitable organisations, staffed by paid employees and volunteers, with offices in most towns throughout the UK. CAB were chosen for this initiative as they provide free, independent and confidential advice related to any issue9, rather than specific benefits advice or debt counselling services that have been explored in other studies10-12.
During the period under investigation, 50% of the locality’s general practices offered an in-house CAB service to their patients. A trained CAB advisor was available at each practice for one half-day each week. The CAB advisor had access to a telephone and computer. The advisor spent a further half-day at bureau headquarters doing follow-up work, such as writing to creditors and attending tribunals. The service was open access, with self-referral and referral from primary health care team members. Appointments of 45 minutes duration were made with the practice receptionist. The service cost £8850 per practice/year and was funded by the Primary Care Trust (PCT) as a public health intervention.
Data collected for the 2009-10 period indicate that 3,490 clients were seen. Of these, one in four (27%) received additional income as a result of that advice. Additional income totalling £4,545,623 was secured for clients and £7,660,593 of debt was managed. For every £1 invested in the project it secured £6.97 in additional income for its users and managed £11.75 of their debts. This study sought to gain understanding of this welfare advice provision beyond the financial outcomes. It sought to explore perceptions of service delivery, including identified benefits to patients and staff.
Methods
Selection and recruitment of participants
We invited a range of stakeholders to participate, including patients, CAB advisors, primary care clinicians, practice managers and commissioners from two practices, one rural and one urban, that had hosted the service for over five years. Professionals were invited by letter. In order that anonymity was not breached, users were identified via the CAB service by purposive selection of a sample of users to achieve a range of gender and age. Letters of invitation with information sheets and postage-paid envelope and reply slip were sent by the CAB service to 90 users. A poor response rate led to a change in strategy, with advisors handing out the packs. A further 40 invitations to participate were distributed via this method.
Interviews
Interviews took place in early 2010 and lasted 30-50 minutes. Topic guides were devised following a review of the literature and consultation with key stakeholders. Three topic guides were developed: one for users; one for primary care staff and one for CAB advisors. Interviews were carried out by two members of the research team who are experienced qualitative researchers. Interviews with staff took place in their office or practice. Service user interviews took place at their home or in their GP surgery according to their preference.
Analysis
Interviews were tape-recorded with consent and transcribed verbatim. The transcripts were read on a line-by-line basis with codes assigned to perceptions or ideas. Data within and between codes were retrieved for comparison and consistency checking in an iterative process to develop key recurring themes13 supported by the NVivo 814 software. The initial analysis was undertaken by the second author, with subsequent discussion with the first author of code structure as findings emerged. The stage at which data saturation occurred was agreed between these two members of the research team.
Findings
Sample
We interviewed ten staff and twelve service users. Tables I and II describe participant characteristics. The staff group included five CAB advisors, one GP, one Health Visitor, one PCT commissioner and two practice managers. All had five or more years’ experience of working with CAB in primary care.
The response rate for CAB advisors was 100% and 50% for practice staff. Three service users replied from the initial mailing (of 40) and four from the second mailing (of 50). Three further responses were obtained from advisors handing out the information. Two couples responded, both agreeing to be interviewed, giving the final sample of twelve service users. Data analysis occurred in parallel with data collection, with no new themes emerging by the 11th and 12th user interviews. The researchers considered that at this point saturation15 had been reached, therefore further recruitment attempts ceased.
Analysis of the data highlighted a number of themes relating to process and outcomes for users and staff (see Figure 1).
1. Process
Referral
An important means of accessing the service was by referral or suggestion from a staff member at the health centre/surgery.
“So the doctor recommended, you know, go and see citizen’s advice so I did” (User 7)
“So a lot of the referrals come from the docs, the docs saying that it would be a good idea if you had a word with CAB” (Advisor 2)
“(A) good number are self-referrals, but all the health professionals here are aware of the CAB and will refer them to them if necessary” (Staff 5)
There was the suggestion that the recommendation coming from a doctor could make a difference as to whether the service was accessed.
“A lot of people see the posters at GP surgeries but often it’s the GP who says specifically you need to go and get help with this” (Advisor 1)
While referrals (particularly from GPs) were reported to be important in users accessing the service, there was some suggestion in the data that the potential for referral was not always fully realised.
“He didn’t mention that they were there to me, but I never mentioned that I had money problems to him anyway. But maybe just making people more aware there is a worker there to help” (User 10)
Some participants suggested that rather than relying on individual professionals to instigate referral, a more proactive system could be beneficial, such as a trigger system or automatic referral in response to particular life events.
“One year I was able to add a little paragraph to their flu shot letter saying you know if you’re over 60 please come in for a benefits check just to see that you’re getting everything that you’re entitled to and we got a really good response to that” (Advisor 4)
Word of mouth
Another important source of access to the service was reported to be via ‘word of mouth’ locally. There were examples in the data of service users telling friends and relatives about the service or having heard about it from these sources rather than from professionals.
“Now the word has spread and a lot of people are accessing the service directly as well, they’ve heard from a neighbour or a friend or what have you” (Staff 3)
Speed of access
Staff reported that the GP-based service offered a choice for users in which service they could access. There was a perception that the outreach service could offer earlier or speedier access to help which was beneficial in terms of resolving problems at an early stage.
“We can nip things in the bud much earlier and allow people to kind of start to resolve things much more easily I think by having a local service” (Advisor 1)
However, this perception was not described by all, with some reports that it took longer to access a GP surgery appointment than the town centre ‘drop-in’ service.
“That’s the only problem. I think we had to wait sort of two weeks was it”? (User 2)
A drop-in system, while potentially offering the opportunity for an early appointment was not always viewed as easier to access however.
“So you pass it many times, but it’s closed….” (Staff 5)
Drop in versus timed appointment
Generally the preference amongst users seemed to be for a timed appointment rather than drop-in, a perception that was shared by staff.
“If you go to the doctors and you know there’s a Citizens Advice Bureau worker there, then you can just ask to make an appointment” (User 10)
“I think people get a better deal if they come to an appointment and they get 45 minutes guaranteed time” (Advisor 1)
In addition to the ‘appointment versus drop-in difference’, GP-based services were also reported to offer a range of options for receiving input.
“Citizens Advice will visit people in their own homes if they can’t get down to the practice” (Staff 4)
Ease of travelling
A key advantage highlighted was the ease of travelling to a local surgery, particularly for a rural area with poor public transport.
“I think they would be less likely to go to the drop in because they’d have to travel” (Advisor 4)
“If we didn’t get the CAB which was local then we couldn’t get the time to go here” (User 3)
Confidentiality and anonymity
The most commonly described advantage of the service was that it offered greater confidentiality and anonymity, thus overcoming the perceived stigma associated with seeking help. Although the service offered advice on a wide variety of issues there seemed to be a perception of a CAB service user as being someone in financial hardship. Users perceived that attending a service in a general practice obscured the reason for their visit and did not publicly declare that they were a service user.
“I would have thought twice if it was on the main road where… you can be spotted walking in” (User 2)
“I suppose the main one is confidentiality because everybody is at the doctors for something and they don’t know who you’re going to see.” (User 5)
“(Y)ou go in the doctors and nobody sort of takes much notice, do they? Whereas if you were walking into a Citizens Advice Bureau right in Main Street, that’s what you are going for, isn’t it?” (User 12)
Continuity
Another key difference was the continuity or personalised service that was offered.
“People find it’s more personalised in a GP surgery. I tend to find that people like coming back to the same person because they don’t have to start telling the story all over again” (Advisor 3)
Somewhere people know
After confidentiality and anonymity, the second most frequently occurring theme related to the importance of services being somewhere that people know.
“I feel safer in an environment because I know she’s in the doctors. I know that’s a bit daft” (User 10)
“People who don’t really know what’s out in the community to help them, but they always know the doctor” (Staff 4)
“I would have gone because the doctor suggested it or it was part of the National Health Service rather than an independent body. I know [it’s] independent from the doctor’s surgery but it doesn’t feel like that. It feels like it’s part of the doctors” (User 12)
2. Outcomes
Outcomes for service users
Financial benefits
The service was reported to have achieved financial gains for users not only through increased or additional benefits, but also by resolving consumer problems and giving debt advice.
“That’s £200 back in the kitty that we can start paying some of the debts off” (User 3)
In addition to financial benefits participants described the impact that input could have in terms of relationship and social gains and improvements to daily living.
“At least we [husband and wife] can talk about these things now” (User 2)
“I suppose better quality of care, better eating, better food and being able to provide the necessary equipment” (Staff 2)
“They can pay for some extra help coming in that can take quite a burden off for carers so you might be improving the health outcome for the actual individual, the patient, but also their wider family or caring network as well” (Staff 3)
Mental wellbeing gains
Many of the users talked about the benefits to their mental health which they attributed not only to the practical outcome of the advice, but also to the support they received from the advisors.
“I mean I’m sleeping too. We are not having stuff like these like little panic attacks.” (User 2)
“[CAB] was invaluable….I’d have killed somebody, or killed myself if I hadn’t got it sorted out because it was just going downhill” (User 12)
“It [CAB] does ease my worries, that’s the main thing. I’ve got depression anyway…it’s just knowing that there’s somebody there to talk to” (User10)
Several of the service users reported how experiences with government agencies had led to feelings of frustration, lack of self worth and powerlessness when coming into conflict with these large bureaucracies.
“It makes me feel that nobody cares … the total mess that they [Job Centre Plus] are in, I was given all sorts of conflicting advice… …I’ve never dealt with such an inefficient organisation…It takes you at least half an hour to get through to them.
It’s very depressing to be spoke to the way they [Job Centre Plus] speak to you and it definitely puts barriers up to trying to apply and wade through all the mountains that they want and hoops to jump through. (User 5)
Outcomes for staff
A resource
Staff described the CAB service as supporting their own work, a resource and a somewhere to refer to.
“A valuable resource for our clinicians to refer them to” (Staff 1)
“A good tool to help me do my job” (Staff 2)
There was discussion of the different roles that CAB and health professionals fulfilled, with perceptions of different or complementary functions.
“GPs can’t sort out the practicalities and we can” (Advisor 1)
“So the doctor is dealing with one aspect of mental health … and we help with the other bits” (Advisor 4)
Time-saving
The benefit mentioned most frequently was that it was time-saving for doctors.
“Before I’ve actually had to fill the forms in with the parents, or help them and it can take hours” (Staff 2)
“The GP … probably did spend some time with that patient but probably would have spent a lot more if CAB hadn’t been in their practice” (Staff 4)
“I just think it’s a good idea to keep the doctor’s surgeries flowing” (User 4)
While being perceived as saving time during consultations, the link between having a CAB service and less contact with a doctor however was not supported by all participants. Some users saw the service as “an extra” rather than instead of consulting their GP.
“I’ve actually made appointments to go and see my doctor, because I’m there” (User 10)
“I can’t think of anyone who’s come to me instead of going to the GP … as yet” (Advisor 3)
However, some users identified that, without the CAB service, they may have continued seeing the doctor when in fact they needed a different type of help.
“He knew he needed to get me somewhere else. So [without CAB] he was going to be seeing me week after and week after and I was slowly going to just deteriorate” (User 12)
Discussion
Summary of main findings
The study examined perceptions of staff and service users to identify process and outcome factors associated with a welfare advice service in primary care. The familiar and confidential environment of a GP surgery, the ability to make appointments and the continuity of advisor were seen as key positive aspects of this service. There were also perceptions of financial gain, together with a positive impact on daily living, social relationships and mental health. The main benefits for staff were reportedly: a resource to refer to; and the potential for saving GP time.
A key benefit for service users related to avoiding the stigma16 perceived to be associated with accessing welfare advice services. The reluctance to be publicly identified as needing this type of help was a strong feature of the data. This perceived stigma has been described in previous studies17 18. The perception of needing welfare advice as an undesirable characteristic is potentially a key barrier to vulnerable people accessing help. This seems worthy of further study.
Other work has suggested that users of welfare advice services in primary care may differ from services sited elsewhere, such as having more complex problems19or being older5. While advisors in this study reported no particular trends in demographics, some suggested a much broader range of issues being covered in their primary care caseload, such as consumer and legal advice, contrasting with the almost exclusively ‘debt and benefit’ problems they dealt with in mainstream advice services. The positive aspects regarding access and delivery potentially could widen the service user population. This would be important to explore in further work, particularly in regard to reaching those most in need.
Comparisons with existing literature
Poverty is a significant driver of health inequalities, with the potential for interventions tackling the financial hardship of patients theoretically to improve health3. Previous studies have provided evidence of financial benefit for patients through the provision of welfare advice in primary care, with some (mainly uncontrolled) studies indicating the potential for health gains4. It has been suggested that provision of welfare advice, particularly to older people, is an effective intervention to identify people who are eligible for benefits but are unlikely to have claimed them20.
This study was designed as preliminary work to gain further insights into the use and potential benefits of the service, with a view to carrying out a larger quantitative evaluation21. It provides data regarding aspects that enable access and optimise delivery. The study confirms previous work reporting financial benefit and suggests how financial benefits may have a wider positive impact, for example on mental health and social relationships. It found the perception that CAB in primary care can result in more appropriate use of health services, for example by providing an alternative route of referral for health professionals, and by supporting individuals in addressing the cause of health issues resulting from financial hardship.
This study contributes to the knowledge base from qualitative and quantitative research in suggesting that there may be a wide range of potential impacts, some more easily measured than others. For most of the potential benefits there is a plausible causal pathway between advice, change in an individual’s circumstances and health benefits, even where these impacts are difficult to quantify. A promising future approach to studying this area may be to use the existing quantitative and qualitative evidence-base to develop a logic model of the pathways between intervention and outcomes which could be used to inform commissioning decisions22.
Strengths and limitations of the study
The study is timely given the current economic situation and increasingly difficult financial circumstances some patients are likely to experience with the potential for a negative impact on their health. The study explored a range of views from service users and staff working in primary care, both those directly providing the service and those commissioning it or referring patients to it. The findings enhance the current evidence of financial benefits resulting from investment in the initiative.
The UK seems to be one of only a small number of countries (including Israel and Ireland) offering local in-person consultations on health and welfare matters. Other countries offer predominantly website and telephone hotline services, for example the Federal Citizen Information Center and Medicare Rights Center (USA), and Community Legal Centres in Australia which offer casework assistance generally by telephone. Socioeconomic determination of health, both at an individual and population level, is a firmly established global phenomenon. The placing of advice services in a healthcare setting may give important acknowledgement of this link.
The sample of participants recruited for this study could be considered unrepresentative of service users since those who had positive experiences of the service may have been more likely to respond as a way of “giving something back” for a service they appreciated. A reluctance to be identified as someone who needed outside help or who was in financial hardship may have precluded participation for some23. The study highlights the difficulty in recruiting research participants; particularly in an area where there may be embarrassment about using the service under scrutiny, and the preservation of user anonymity precludes direct contact by researchers. Future studies could consider including an invitation from the GP in the pack, or offering a financial incentive, such as a shopping voucher, to take part.
A range of primary care staff were interviewed from two practices in different settings (rural and urban). Both practices had substantial experience of hosting the CAB service. However, other than practice managers, only one staff member from each professional group was interviewed. This small sample offers the possibility that staff who agreed to be interviewed had different views from those of their colleagues.
Implications for future research or clinical practice
Key service features perceived to be beneficial have been identified. These elements are important to consider when planning any similar service initiatives. Welfare advice sessions in general practice can give financial benefit to patients and is perceived by staff and service users to offer health, social and other benefits. Further empirical work is needed in order to explore these complex cause-effect links.
Funding
This work was supported by NHS Derbyshire County.
Ethics
Ethical approval was received from the Derbyshire NHS Research Ethics Committee. REC 09/H0401/56 The change in recruitment procedure was approved as an amendment.
Competing interests
One of the authors (JH) is employed by the funding body and has been actively involved in the project, including participating in the study.
Acknowledgements
Grateful thanks are due to all the service users and staff who took part and to the Citizens Advice Bureaux and Primary Care Trust for support in undertaking the research, including participating on the steering group and in recruiting participants
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