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.     

Who uses welfare benefits advice services in primary care?

There is considerable interest among organisations such as primary care trusts and health action zones in commissioning welfare benefits advice services in primary healthcare settings as part of local strategies to reduce health inequalities. However, very little is known about the contribution to health of such services or about the health status of those who use them. The present study reports on a longitudinal study of the contribution to individual health of welfare benefits advice in primary care that has gathered baseline demographic and health data on 345 research subjects. The average age of the subjects was 54 years, and they were likely to be unemployed or retired. Over 85% were advised to apply for welfare benefits or to appeal against the loss of a benefit, the most common benefit being Disability Living Allowance (over 50% of all subjects). Three-quarters reported a physical disability or long-term illness that limited their daily activity, and over half reported arthritis or rheumatism. Scores on the short form 36 (SF-36) which quantify self-reported physical and psychosocial aspects of health, were much lower than population norms, indicating poorer health. The burden of illness borne by users of these services is not surprising. However, reliable data has not previously been available. It appears that primary care provides good access to advice services for people in middle and old age, but not to other groups (e.g. families with young children, substance misusers or those with mental health problems). Better data collection by advice services, wherever located, would strengthen their understanding of the needs of those whom they serve, and help them to identify under-served groups. These data could be used to support requests for continued or extended funding.     

Welfare rights advice in primary care: prevalence,processes and specialist provision

BACKGROUND: Despite persistent poverty-related health inequalities, few sustained responses have been developed in primary care. Welfare rights provision has been proposed as one potential pathway to addressing health inequalities. OBJECTIVES: This study was set up to address the prevalence of welfare rights issues in general practice, and the practitioner response to unmet need. METHODS: A postal questionnaire was sent to practitioners in GP surgeries of an inner city health authority with high levels of deprivation. By means of a 'most recent case audit', data on welfare advice needs were collected. Practices with in-house welfare rights provision were compared with those surgeries with no such provision. RESULTS: Questionnaires were returned by 153 practitioners, describing their most recent case with a welfare rights need (mean 10.41 days ago). Of the respondents, 70.6% felt that there was a mental health element to this consultation, 49.8% of problems were described as urgent, and 65.8% of patients requested information or guidance. Those practitioners with specialist advisers in the surgery (n = 81) were significantly more likely to find referring patients to advisers easy, that quality of advice for patients was good, that welfare providers enhanced their ability to practice effectively and that such provision improves the health and well-being of patients. In those surgeries without provision (n = 72), patients were more likely to approach their practitioner for advice. GPs were more likely than nurses and other practising staff to see a case with welfare rights needs. Practitioners were more likely to raise the welfare issues if they had specialist advice in the surgery. CONCLUSIONS: A large amount of practitioner consultation time is spent on welfare rights-related issues. Although practitioners are skilled in detecting need, and their practice is enhanced by specialist support, expansion is needed to provide the advice which cannot be met by clinical consultation.     

Why do older people not get immunised against influenza? A community survey

Many older people who would benefit from influenza vaccine do not get immunised. We carried out a postal questionnaire survey of people aged 65 years and over living in the community to explore views about influenza vaccine and identify ways of improving uptake. Completed questionnaires were returned by 1468/2553 (57.5%). Vaccine coverage for 1998-1999 season was 50.5% (95% confidence interval (CI) 47.9-53.1%). Important predictor variables for non-uptake included absence of medical risk factors, perceived good health, lack of advice from a doctor or nurse, and negative views on vaccine efficacy and safety. Most people had to request vaccination, only one in five got a reminder from their general practitioner. There is scope for improving influenza vaccine coverage in older people by placing more emphasis in patient information materials on vaccine efficacy and safety and by greater use of reminders.     

Multidisciplinary guideline 'Recognition and treatment of chronic pain in vulnerable elderly people'

- Chronic pain in vulnerable elderly people is still poorly recognized and treated, both at home and in hospitals and care and nursing homes. - Vulnerable elderly people experience and express pain differently to relatively healthy adults, especially when they suffer from cognitive impairment or specific conditions. - Determining the nature and severity of the pain requires the use of pain assessment instruments that have been validated for use in vulnerable elderly people.- Effective treatment of pain demands careful diagnosis and pharmacological and non-pharmacological interventions that have proven effectiveness in vulnerable elderly people. - The combination of multiple morbidity and poly-pharmacy increases the chance of side-effects and complications. In addition, the pharmacokinetic and pharmacodynamic characteristics of many drugs are different in vulnerable elderly people. - The advice is to start with a lower dose of pain medication and gradually build up a level on the basis of pain relief and side-effects ('start low, go slow!').     

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.     

Evaluation of welfare rights advice in primary care: the general practice perspective

Income maximisation may reduce enduring poverty-related health inequalities. Specialist welfare rights advice in primary care has been proposed and, in some areas, implemented, but evaluation data from the general practice perspective is needed. The present study aimed to evaluate the impact on general practice of specialist welfare rights advice, comparing practices with and without in-house provision of welfare advice using a cross-sectional postal questionnaire. This study was conducted in general practice surgeries in an inner-London health authority with high indicators of deprivation. Questionnaires were sent to practice managers. Comparative data (according to whether specialist advice was currently offered) addressed processes of identifying and meeting welfare needs and outcomes in terms of efficiency of provision. Seventy-nine surgeries participated. Those with welfare rights advisers (n = 42) were significantly more likely to report that current provision was adequate, that it was easier for staff to access advice on their patients' behalf (and by patients themselves) and that the process of advice provision ran smoothly. Lack of funding and space were the principal reasons for not having in-house advice. Surgeries wish provision to be expanded within practices. Welfare rights advice in surgeries improves ability to meet welfare needs via specialist advisers. Referral processes are simplified, enabling general practitioners to ensure that relevant advice is provided without the need for welfare knowledge themselves. General practices welcome the expansion of provision, with the proviso that adequate resources are identified. The current lack of basic information in surgeries must be addressed (e.g. information on local providers, printed information detailing range and eligibility criteria of welfare benefits).     

Factor structure and internal consistency of the 12-item General Health Questionnaire (GHQ-12) and the Subjective Vitality Scale (VS), and the relationship between them: a study from France

Background  

The objectives of this study were to test the factor structure and internal consistency of the 12-item General Health Questionnaire (GHQ-12) and the Subjective Vitality Scale (VS) in elderly French people, and to test the relationship between these two questionnaires.     

"Done more for me in a fortnight than anybody done in all me life." How welfare rights advice can help people with cancer

Background  

In the UK many people with cancer and their carers do not have easy access to the welfare benefits to which they are entitled adding further strain to the process of dealing with cancer. It is estimated that nine out of ten cancer patients' households experience loss of income as a direct result of cancer, which, due to its socio-economic patterning disproportionately affects those most likely to be financially disadvantaged. In the UK proactive welfare rights advice services accessed via health care settings significantly increase benefit entitlement among people with health problems and this paper reports on a qualitative study examining the impact of a welfare rights advice service specifically designed for people affected by cancer and their carers in County Durham, North East England (UK).     

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.