Evaluations of advice services in primary health care settings

The Acheson report and the subsequent White Paper “Saving Lives: Our Healthier Nation” recognised the extent to which material deprivation and poverty impact on people’s health. The Acheson report concluded that: “Policies which increase the income of the poorest are likely to improve their living standards, such as nutrition and heating, and so lead to improvements in health.”

“Saving Lives: Our Healthier Nation” recognised that: “Health inequality is widespread: the most disadvantaged have suffered from the poorest health” and that: “poor health… springs from a range of wider factors – including poverty and low wages…”

One of the key challenges set by government for the NHS, in particular for Primary Care Groups/Trusts, is to is to reduce health inequalities.

Health Action Zones have been established in order to develop innovative ways to address the causes of ill health. The emphasis is on targeting communities suffering the most disadvantage and on working in partnerships with statutory, voluntary and community organisations.

Welfare rights and other advice services have sprung up all over the country in response to the new health agenda. There is evidence to suggest that advice services are effective and cost efficient ways to meet these challenges. This may be particularly the case for older people who are both frequent users of health services and the most likely to miss out on their full benefit entitlements.

Advice services in primary health

Exploring the qualities and health outcomes of a Citizens’ Advice Bureau (CAB) in primary care in the West Midlands – Judith Emmanuel and Shanaz Begum (2000). Faculty of Education, University of Manchester, Oxford Rd, Manchester M13 9PL. Tel: 0161 275 3686.

 E-mail: Margaret.Crawford@man.ac.uk.

This evaluation focussed on a CAB adviser attached to a primary health care team (PHCT) with a practice population of over 12000 in a town in the West Midlands. There are high levels of economic deprivation in the area.

The evaluation considered:

• the processes and content of CAB advice work
• the appropriateness of the Hospital Anxiety and Depression Scale (HADS) and the Measure Your Own Medical Outcome Profile (MYMOP) as ways to measure health impacts on CAB service users
• the use of primary health care by users and non users of the CAB service
• the views of PHCT staff regarding the CAB service

10 CAB service users and 10 PHCT staff were interviewed. The CAB service receives mainstream NHS funding and the adviser was integrated into the PHCT.

CAB service users expressed high levels of satisfaction with the service. PHCT staff were more aware of and better able to address the socio-economic needs of their patients.

HADS and MYMOP scores improved at 9 months after seeing the adviser but the scores were not statistically significant. Similarly, positive health outcomes were not statistically significant. This may be due to the small numbers involved.

The report concluded that the CAB service is:

• a model of good advice practice and of inter-agency working
• an appropriate way to tackle health inequalities
• an effective way of increasing the take up of benefit entitlements
• increased the ability of PHCT staff to address patients’ socio-economic needs.

An evaluation of the Health and Advice Project (HAP): its impact on the health of those using the service – Stephen Abbott and Lindsay Hobby (1999). Health and Community Care Unit, Liverpool University, Thomas Yates Building, Quadrangle, Brownlow Hill, Liverpool L69 3GB. Tel: 0151 794 5503

The HAP is a CAB project (similar to the above) based in 7 primary care venues in the economically deprived Speke/Garston area of the city.

The evaluation considered:

• the health profile (SF-36) of 68 CAB service users, who were interviewed shortly after seeing an adviser and again after 6 and 12 months
• their use of primary health care services before and after seeing the adviser
• the views of PHCT staff regarding the CAB service

The 68 research subjects had an average age of 57 and reported high levels of chronic morbidity. At least one third reported one or more of the following conditions: arthritis, physical disability, poor heart health, asthma or sensory impairment.

48 respondents who had an increase in income as a result of the CAB service reported improvements in their health related quality of life.

There were statistically significant improvements in 3 of the SF-36 measures: the limits which emotional problems put on the range and extent of all types of work; degrees of nervousness/calmness and happiness/sadness; levels of energy and tiredness. In the case of the last 2, there were statistically significant differences between those who whose income had increased and those whose income had not changed.

Although not statistically significant, there were reductions in GP consultations, prescriptions in general and prescriptions of drugs among those whose income increased compared with those whose income did not change. One GP and many other members of the PHCT’s expressed their great appreciation of the CAB service.

The evaluation also found evidence that locating the CAB service in primary care venues improved access to advice services particularly for older people. Some of the respondents said that they would never have sought advice had it not been recommended by a member of the PHCT.

Prescribing Citizens Advice: an evaluation of the work of the CAB with health and social service in Birmingham – Debbie Veitch (1995).  Birmingham District CABx, Dr Johnson House, Bull St, Birmingham B4 6AJ. Tel: 0121 643 3456

Birmingham District CABx have pioneered the delivery of advice services in primary care, with the support the local health authority’s Public Health Director, since 1989. The service is based in health centres/GP practices, social services mental health sites and in an HIV/AIDS centre.

The evaluation considered:

• the pattern of previous medical history of CAB service users
• the subjective health status of  advice service users before and after seeing a CAB adviser

The survey used a questionnaire for both GP practice based and mental health advice service users. Respondents were contacted immediately after receiving advice and again after 6 months. The survey incorporated the Nottingham Health Profile and established background information about the respondents and their satisfaction with the advice service. These were compared with a control group who had not used the CAB service.

The results showed the following:

• users of health based advice services were older than users of mainstream CAB services, more likely to be disabled or long term sick, heavily dependent on benefits for their income and were less likely to have accessed advice services based in other venues
• 119 respondents reported a total of 223 illnesses between them, 31% of which included ‘psychiatric’ illnesses (notably depression and anxiety)
• although not statistically significant, there was evidence that advice service users, particularly those whose income had increased, perceived an improvement in their own health (particularly in respect of the categories social isolation and emotional reaction)
• income generation was significant for advice service users – mental health clients in particular were found to be underclaiming by an average of almost £50 per week.

Income generation through welfare rights and debt advice

The most obvious and immediate link between poor health and socio-economic deprivation is low income. The poorest people in the country tend to be heavily dependent on social security benefits for part or all of their income. Therefore helping people to access their full legal benefit entitlement is a key strategy for tackling health inequalities. Advice services are uniquely placed to a provide service which delivers that outcome.

Welfare rights advice helps people to claim and retain all the social security benefits to which they are legally entitled. Debt advice helps people to maximise their incomes and stabilise their financial circumstances so that essential living needs can be met while arranging repayment of arrears for both priority and non priority items.

There is considerable evidence of the effectiveness of advice services to maximise people’s income.

For example:

• one local authority WRO was attached to 3 GP practices in North Derbyshire. Between 1996 and 1998, the WRO delivered advice sessions in GP practices and sent targeted mail-shots to pensioners. The WRO was able to generate £1,292,406 of annualised social security benefits and arrears. This was from a total gross investment of £54,414 – an output of £24 for every £1 invested.

(Welfare Rights in Primary Care – North Derbyshire RDA Project, Nigel Godfrey, Cenetary Lane, Ripley, DE5 3HY. Tel: 01773 728272)

• A pilot project in rural Derbyshire provided by High Peak CAB in advice in GP practices – in one year (1995) one generalist adviser (ie broader than just benefits advice) was able to generate an extra £38,646 benefit income

It is also likely that extra benefit income will be spent locally thereby helping with local economic regeneration initiatives such as New Deal for Communities and SRB. (See attached case studies for an illustration of the impact that advice can have on a household’s financial circumstances).

Key evaluation issues for advice services based in primary health care

Consideration of the above reports of advice services in health settings, along with government’s wider agenda for the new NHS, suggest that some or all of the following issues need to be addressed in future evaluations:

• income generation – monitoring should use an agreed and valid formula for annualised benefit take-up, payments of arrears and the financial impact of debt advice (this could also be linked to evaluation of regeneration efforts as it is likely that extra benefit income will be spent locally)
• health improvement for advice service users – health researchers must identify appropriate methodologies but it seems valid to include service users’ self assessments and to focus on mental health issues (and not to expect miracles!)
• use of primary health care services by advice service users – before and after using advice services and taking account of whether the advice generated additional income for particular respondents
• quality of advice services – service users’ satisfaction surveys and other advice service measures of quality
• partnership working – integration of advice services into the PHCT in day to day, practical working relationships
• views of PHCT members – regarding the advice service and changes in their own awareness of/ability to address patients’ socio-economic concerns
• improved access to advice services – evidence of reaching people who would not otherwise access advice (particularly elderly people, people with mental health problems and people from black and minority ethnic communities)

Further research into the range of funding sources for existing primary health care based advice services would also be useful. If advice is to become part of the landscape in the new NHS, long term funding streams and key decision makers must be identified. The emerging Primary Care Trusts, Healthy Living Centres and partnership working between health authorities, local authority social services/community services departments and voluntary sector agencies are likely to be significant in this respect.