Project objectives

Background

The project aims to evaluate the impact of co-located welfare advice services in primary healthcare settings. Services offered in two London boroughs are included in the evaluation; Haringey and Camden.

Funded by the local Clinical Commissioning Group (CCG), Haringey Citizens Advice Bureau provides weekly information and advice sessions at five general practices (including two health centres) in deprived areas of the borough. Trained advisers see six clients per session. Advice sessions last approximately 30 minutes per client, with repeat appointments available for ongoing casework. The focus of advice is welfare benefits and debts and the majority of issues are health-related benefits enquiries; for example, linked to Employment and Support Allowance (ESA). Other types of issues are advised on, but this is more commonly signposting work. Sessions are walk-in, first come first served - individuals registered with any practice in the borough could access the service but the service is mainly used by residents living in the vicinity of the practice (even if they are not registered there).

Also CCG funded, Camden CAB services provide GP outreach in 12 practices in the borough. Trained advisers see six clients per session, for 30 minutes each. Clients are seen by appointment only, and all clients seen at a practice are registered with that practice. The majority of clients are informally referred by their General Practitioner (GP), and book appointments with GP reception staff. Some patients, most commonly those who have seen the adviser before, also self-refer and book an appointment direct with the reception staff. The majority of advice issues are linked to health-related benefits and debt, and to a lesser extent housing. Advisers in Camden also provide advice on a much broader range of health related welfare queries, including wills, Power of Attorney, travel/transport and so on; and, are also able to support clients appealing ESA decisions to tribunal.

Aims and objectives

The project addresses the following primary and secondary objectives:

Primary objective:

• To estimate the impact of GP-located welfare advice service provision on the mental health and well-being of those who use the service

Secondary objectives:

• To examine any changes in GP consultation frequency following access to co-located welfare advice services.
• To assess whether the receipt of advice impacts upon perceived financial strain
• To assess whether the provision of GP-located welfare advice service influences future support- seeking behaviours.
• To understand GP staff (clinical and non-clinical) and welfare adviser perceptions of GP-based welfare advice services in more detail.
• To explore aspects of service delivery, context and individual characteristics which might influence implementation and outcomes.

Study design

The study uses a quasi-experimental before-and-after design with an embedded qualitative study. The quantitative component will include two groups – those receiving welfare advice at GP services during the study period (the welfare advice group); and, those who are similar to the welfare advice group in terms of their socio-demographic characteristics and financial status, but who have not sought advice in the past three years (the comparison group). Data will be collected at two time points (prior to receiving advice -baseline - and three-four months later).

Brief Summary

Methods

Quantitative

Prospective, controlled quasi-experimental study in eight intervention and nine comparator sites across North Thames. Changes in the proportion meeting criteria for common mental disorder (CMD, 12-item General Health Questionnaire); well-being scores (Shortened Warwick and Edinburgh Mental Well-being Scale), three-month GP consultation rate, and financial strain were measured alongside funding costs and financial gains.

Qualitative

We aimed to develop an initial programme theory for how the provision of co-located advice supports specific practice outcomes; and, to identify salient barriers and enabling factors. 24 semi-structured interviews with general practice staff, advice staff and service funders in two UK urban localities were conducted between January and July 2016. Data were thematically analysed and a modified Realist Evaluation approach informed the topic guide, thematic analysis and interpretation.

Results (including findings in relation to the objectives):

Quantitative

Relative to controls, CMD reduced among females (ratio of odds ratios (rOR) 0.37, 95% CI: 0.20-0.70) and Black advice recipients (rOR 0.09, 95% CI: 0.03-0.28). Individuals whose advice resulted in positive outcomes demonstrated improved well-being scores (β coefficient 1.29, 95% CI: 0.25-2.32). Reductions in financial strain (rOR 0.42, 95% CI: 0.23-0.77) but no changes in three-month consultation rate were found. Per capita, advice recipients received £15 per £1 of funder investment.

Qualitative

Two outcomes are described linked to participant accounts of the impact of such non-health work on practices: reduction of GP consultations linked to non-health issues and reduced practice time spent on non-health issues. We found that individual responses and actions influencing service awareness were key facilitators to each of the practice outcomes, including proactive engagement, communication, regular reminders and feedback between advice staff, practice managers and funders. Facilitating implementation factors were: not limiting access to GP referral; offering booked appointments and advice on a broader range of issues responsive to local need. Key barriers included pre-existing socio-cultural and organisational rules and norms largely outside of the control of service implementers, which maintained perceptions of the GP as the ‘go-to-location’.

Conclusions

Quantitative

Co-located welfare advice improves short term mental health and well-being; reduces financial strain and generates considerable financial returns.

Qualitative

Co-location of welfare advice services alone is unlikely to enable positive outcomes for practices and suggest several factors amenable to intervention that could enhance the potential for co-location to meet desired objectives.

Plain English summary

In recent NHS surveys General Practitioners (GP) reported increased demands on their time from patients requiring support for social, non-clinical needs. GPs also felt that patients’ health was being negatively affected by increasing financial strains and the impact of welfare reforms such as the cap on overall benefits.

Placing welfare advice services in GP practices (co-location) is one approach to supporting people whose health is affecting, or affected by, such problems. It is also hoped that such services will ease pressures on practices. For example, by supporting patients to fill out welfare benefit forms that might otherwise be brought to GPs.

Previous evaluations of these services provided limited information about whether they improve patient health or reduce pressure on GP practices. A lack of such evidence can affect continued funding of welfare advice services.

We evaluated co-located welfare advice services in two London boroughs. Through surveys and interviews with patients, medical professionals and advisers, we examined whether and how such services could support patients and GP practices. We compared changes in mental health, financial strains and help-seeking behaviours, to a group that had not received such advice. This meant we could be more certain that any improvements were due to the co-located advice.

Among patients receiving advice we found improved mental health and well-being, and reduced financial strain. They gained £15 per £1 of funder investment, in welfare income that they were entitled to but missing out on previously, and reorganised debts. However, there was no change in how often people receiving advice visited their GP. Our interviews revealed the potential for co-located advice to reduce GP pressures. They also identified key enablers and barriers to whether or not this would happen, such as a lack of awareness of the service amongst GP staff.

Our findings suggest co-located welfare advice improves short-term mental health and well-being, reduces financial strains and supports people to receive financial support they are entitled to. Our findings also suggest that co-location alone is unlikely to enable positive outcomes for practices. We suggest several ways to increase the potential for co-location to reduce GP pressures. For example, regular reminders to practice staff and feedback from the service about how it supports patients, and more clarity about how advisers can support GP work. Providing a wider range of advice (e.g. housing) would help ensure the service meets the needs of people who might otherwise go to their GP.

Dissemination

Journal articles

Woodhead C, Collins H, Lomas R, Raine. Co-located welfare advice in general practice: A realist qualitative study. Health & Social Care in the Community. 2017;00:1–11 DOI: 10.1111/hsc.12453

Woodhead C, Khondoker M, Lomas R, Raine R. The impact of co-located welfare advice in healthcare settings: a prospective quasi-experimental controlled study (under review BJPsych).

Reports (Full & Summary)

An evaluation of co-located welfare advice services in Haringey

Academic conferences

Woodhead C. The impact of co-located welfare advice in primary health settings on mental health and service use: a prospective quasi-experimental controlled study. Health Services Research Network UK, July 2017.

Woodhead C The impact of co-located welfare advice in primary health settings on mental health and service use: a prospective quasi-experimental controlled study. Society of Social Medicine, September 2017

Non-academic dissemination

• Report as above
• Newsletter to participants, participating practices, GP newsletter and intranet.
• Face to face meetings - Lindsay Poole, Director Advice Services Alliance (4th April 2017)
• Websites – link to be added once quantitative paper accepted for publication.
• Webcast of qualitative findings to be made available via project and institution website
• Twitter - CLAHRC North Thames and Department of Applied Health Research (UCL), Health Inequalities Research Network (HERON, KCL).

Public involvement

Working as an ‘embedded researcher’ has enabled and facilitated opportunities for PPI while increasing our understanding of the context in which the service runs so that we can provide tailored feedback to individual partners. PPIE this year has focussed on Involvement in interpreting findings and identifying implications, and Engagement via dissemination activities. Specifically, we worked with Haringey Citizens Advice to understand and interpret findings from the qualitative study in terms of implications for amending future service delivery. A Citizens Advice volunteer who had been involved throughout the study (study design, data collection) was also a co-author on the two main papers arising from the study. Engagement activities include presenting and discussing findings locally within the public health team and CCG, and those at other geographical areas. In addition, we are working with the Advice Services Alliance, an umbrella organisation for Information, advice and guidance organisations (including Citizens Advice, Advice UK etc) to disseminate the findings through their communication channels.

Impact

In Haringey the co-located welfare advice service was initially funded by Haringey Public Health Directorate, and later by the CCG. The service was re-commissioned over two consecutive years as a result of initial and interim evaluation findings. The summative evaluation findings have been fed back to the CCG and PH team. In the context of financial savings requirements, the CCG have reviewed the service and decided to maintain co-located welfare advice provision in the borough (although at fewer locations) and reorganise to deliver part of the service co-located within secondary mental health services. In addition, learning from the qualitative evaluation findings have been used to inform planning & implementation of other co-located services in the borough.

 

This project was funded by the National Institute for Health Research School for Public Health Research (SPHR-UCL-EWP-WAH) 

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Public Health Research, NIHR, NHS or the Department of Health.