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

Health and Social Care in the Community

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© 2002 Blackwell Science Ltd

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Abstract

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).

Keywords:

general practice, health inequalities, poverty, primary care, welfare rights

Accepted for publication

27 May 2002

Blackwell Science, LtdOxford, UKHSCHealth and Social Care in the Community0966-0410Blackwell Science Ltd 2002November 2002106Original ArticleWelfare rights adviceR. Harding et al.

Evaluation of welfare rights advice in primary care: the general

practice perspective

Richard Harding

BSc(Hons) MSc

1

, Lorraine Sherr

BA(Hons) DipClinPsych PhD

1

, Surinder Singh

BM MRCGP MSc

1

, Avrom Sherr

PhD

2

and Richard Moorhead

LLB(Hons)

2

1

Department of Primary Care and Population Sciences, Royal Free University College Medical School, London, UK and

2

Institute of Advanced Legal Studies, London, UK

Correspondence

Richard Harding Department of Primary Care and Population Sciences Royal Free University College Medical School Rowland Hill Street London NW3 2PF UKE-mail: [email protected]

Introduction

Low income and poverty are recognised to be key deter-minants of an individual’s health. This link has beenfound to be consistent across studies, and universalaccess to healthcare does not reduce inequalities(Marmot

et al

. 1997). Among British men, low individualand household income are related to poor health after

adjusting for employment status, education and socialclass (Rahkonen

et al

. 2000). Fifty per cent of the healthdisadvantage of British lone mothers is accounted forby the mediating factors of poverty and joblessness(Whitehead

et al

. 2000).The socio-economic predictors of increased general

practitioner (GP) consultation rates are living in publichousing, being from an ethnic minority, coming from a

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© 2002 Blackwell Science Ltd, Health and Social Care in the Community

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(6), 417–422

single-parent family (Balarajan

et al

. 1992), and beingpermanently sick or unemployed (Carr-Hill

et al

. 1996).Among young mothers, relative deprivation has beenassociated with both greater morbidity and increasedGP consultations for stress-related conditions such asdepression, headache and anxiety (Baker & Taylor2001). Elevated patient deprivation scores have beenassociated with both higher scores of psychologicaldistress and shorter GP consultation time, thereforereducing the likelihood of detection and discussion forthose with greatest welfare needs.

Interventions aiming to reduce health inequalitiesmay be difficult to undertake, and despite the researchevidence linking poverty to poor health outcomes, therehave been few practical interventions (Syme 1998). Theinfluence of socio-economic deprivation is initiallyapparent in primary care, and it is in general practicethat we may be most able to provide solutions to UKhealth inequalities (Beale 2001). The formulation of anadequate response may be the greatest current chal-lenge to British general practice (Smeeth & Heath 2001).

Income maximisation is an effective tool for GPs topromote health, and there appears to be an assumptionon the part of patients that GPs (Ennals 1990) andmental health professionals (Pacitti & Dimmick 1996)will automatically inform them of their entitlement.However, it is unrealistic for clinical staff to maintainaccurate knowledge since the range, eligibility criteriaand value of benefits are constantly changing (Ennals1990). Therefore, the specialist provision of welfare rightsis needed in primary care settings. Although the timespent with patients in consultation is increasing, thepressures caused by increased roles (e.g. health pro-motion) create extra stress for GPs, and may only berelieved through the reconfiguration of practice ser-vices (Mechanic 2001).

Primary-care-based interventions to reduce povertyand health inequalities will depend on practices recog-nising the relevance and potential impact of specialistwelfare rights providers within practices, and viewingthem as part of the wider primary care team. Thegeneral practice perspective of how they currently meetwelfare rights needs, how they view the importance ofprovision of welfare rights advice, and how and wherethey would like to see such specialist provision devel-oped is not yet known. Although the provision ofspecialist welfare rights information in primary caresettings is seen to be an appropriate and effective inter-vention for reducing health inequalities, provision ispatchy and not necessarily encouraged by clinical staff.Under current arrangements, practice managers have arole in broad strategy development and implementa-tion, and for identifying the cost implications of in-house providers (Dornan & Pringle 1991). They reflect

the vision of the surgery, and the views of GPs asemployers. The present study aimed to assess thecurrent level of provision, and satisfaction with, specialistprofessional welfare rights advice in general practicesurgeries, and to establish if and how specialist provi-sion could be expanded in primary care.

Subjects and methods

Setting

The present study was conducted in surgeries amongthe six primary care groups (PCGs) of an inner-LondonUK health authority, with a high level of deprivation.The overall male life expectancy in this area is lower thanthe average for England and Wales, and a number ofother indicators are higher, including the birth rate,the rate of termination, the proportion of babies withlow birth weights, the still birth rate, the rates ofteenage pregnancy, perinatal mortality, and deaths fromaccidents, respiratory and cerebrovascular disease(Director of Public Health 2001).

Procedure

All practice managers in general practice surgeriesacross the six PCGs were identified (

n

= 140), and cir-culated with a postal questionnaire in December 2000.Practices not responding after 2 weeks were sentreminders.

The questionnaire addressed current practice,surgery size, specialist welfare rights advice provisionand referrals to local providers. Satisfaction with existingwelfare rights advice provision in-house and locally,and general effectiveness of provision were measuredusing a 10-point Likert attitudinal scale from (1)‘strongly disagree’ to (10) ‘strongly agree’. Absence ofcurrent provision was explored by identification of theprincipal and secondary reasons, each of which wasidentified during piloting with PCGs, GPs and practicemanagers. Ethical approval for this study was grantedby the local research ethics committee of the Royal FreeHospital and Medical School, London.

Data were analysed using non-parametric tests (theMann–Whitney

U

-test for ordinal data and the chi-square test for binary data), with the significance levelset at

P

< 0.05, using the SPSS Version 9.0 computerprogram.

Results

Out of the 140 surgery practice managers to whomquestionnaires were sent, 79 returned completed ques-tionnaires (response rate = 56.4%). The mean practice


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size was 6322 patients (median = 6000, range = 1400–17 000). Welfare rights providers were available in 42surgeries (53%), providing between 30 minutes and30 hours of client contact time per week (median =3 hours). Seventy-two surgeries (91%) informed patientsof other welfare provider organisations and 63 (82%)made referrals on patients’ behalf to other organisations.

The nearest welfare rights facility to the surgery wasidentified as within walking distance by 20 surgeries(27%; mean walking distance = 10 minutes), and a busride away by 34 (45%). The nearest facility could not beidentified by 22 respondents (29%).

Attitudinal responses to the availability, accessibil-ity and adequacy of welfare rights information arepresented in Table 1. Those practices with specialistwelfare rights provision were more likely to agree with

the statements ‘We have adequate welfare and adviceservices available within our practice’, ‘We are ableadequately to access services for patients’, ‘Patients canaccess advice services without difficulty’ and ‘The pro-cess of obtaining advice runs smoothly’. They were lesslikely to agree with the statement ‘We lack informationon appropriate services’.

The reasons for not having a specialist in-houseservice are presented in Table 2. The lack of funding byPCGs was cited as the most common reason, followedby lack of space. Other reasons were of roughly equalimportance. No alternative reasons were presented byrespondents under the category ‘other’.

In terms of future provision, the formats whichsurgeries would prefer to see are described in Table 3.All formats which were suggested in the questionnaire

Table 1 Availability, accessibility and adequacy of welfare rights provision

Advice service provision

Chi-square test Mann–Whitney

No, we haveno service

Yes, we havea service U-test P-value

We have adequate welfare and advice services available within our practice 2.67 5.98 232.5 0.001We have adequate services available locally 2.47 2.43 539.5 0.065We are able adequately to access services for patients 4.24 5.54 465.5 0.017We lack information on appropriate services 6.8 5.15 494.5 0.018Patients can access advice services without difficulty 3.97 5.53 437.5 0.008Advice services are over-stretched 2.59 3.22 629.0 0.991The process of obtaining advice runs smoothly 3.71 5.75 395.5 0.001

Table 2 Reasons for not currently having in-house provision (percentages shown in brackets)

ReasonMajor reason

Minor reason

Combined reason(major + minor) Not a factor

Not funded by a primary care group 22 (71%) 4 (13%) 26 (84%) 5 (16%)Lack of space 14 (42%) 3 (8%) 17 (52%) 16 (49%)Patients rarely demand such a service 5 (19%) 8 (31%) 13 (50%) 13 (50%)This practice has other priorities 3 (12%) 9 (36%) 12 (48%) 13 (52%)There are adequate alternatives 4 (17%) 7 (29%) 11 (46%) 13 (54%)This practice has never considered providing this type of service 6 (24%) 5 (20%) 11 (44%) 14 (56%)Lack of need from this practice 2 (8%) 7 (27%) 9 (35%) 17 (65%)

Table 3 Preferred arrangements for future provision of advice (percentages shown in brackets)

Arrangement ‘More’ ‘As is’ ‘Less’Combined (‘as is’ + ‘less’)

Within practice-specific service 52 (80%) 13 (20%) 0 (0%) 13 (20%)System of referrals to other specialist agencies 50 (76%) 15 (23%) 1 (2%) 16 (24%)Additional funding for welfare provision 58 (84%) 11 (16%) 0 (0%) 11 (16%)Availability of patient information leaflets 50 (69%) 21 (29%) 2 (3%) 23 (32%)Internet provision 39 (67%) 17 (29%) 2 (3%) 19 (33%)Outreach service 49 (82%) 10 (17%) 1 (2%) 11 (19%)Targeted provision for excluded/vulnerable groups 55 (82%) 12 (18%) 0 (0%) 12 (18%)Training for surgery staff 51 (72%) 17 (24%) 3 (4%) 20 (28%)


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were supported by at least 67% of practice managers,although there was particularly strong support forfunded provision of welfare rights services and referralsystems.

Printed welfare rights information was provided inwaiting areas by 52 surgeries (67%), and among thosewho provided printed material, 33 (66%) provided thisin languages other than English. Among those withwelfare rights providers, 17 (49%) offered interpretersand 20 (51%) offered home visits for welfare rightsadvice. Training and information for staff to update onbenefit eligibility and changes in payments was pro-vided in six of the surgeries (8%). Practice size was notfound to be related to whether or not specialist advicewas available in-house (

t

=

−

1.37, d.f. = 69,

P

= 0.182), orwhether they knew the location of the nearest provider(

t

= 0.480, d.f. = 66,

P

= 0.589).Current specialist provision was not associated with

knowledge of the nearest provider (

χ

2

= 1.342, d.f. = 1,

P

= 0.247), whether they refer to outside agencies (

χ

2

=0.185, d.f. = 1,

P

= 0.667), provision of printed informa-tion in waiting areas (

χ

2

= 0.643, d.f. = 1,

P

= 0.423), orwhether information and training was given to staff(

χ

2

= 0.379, d.f. = 1,

P

= 0.538). A chi-square binary ana-lysis of those wanting more provision with those want-ing static or less provision for each of the proposedmodels of specialist information revealed that there wasno association between current provision and wishesfor future provision. Therefore, those with currentspecialist in-house welfare rights advice were as likely asthose with none to want to increase advice in all forms.

Surgeries with printed information available ratedsignificantly more highly the adequacy of advice ser-vices available in the practice (

U

= 450.0,

P

= 0.046)and the ability to access services for patients (

U

= 402.5,

P

= 0.037).Those practices who knew the distance to the nearest

welfare rights provider were more likely to agree onthe adequacy of welfare advice services available withinthe practice (

P

< 0.05), ease of access to advice servicesfor patients (

P

< 0.05) and that the process of obtainingadvice was smooth (

P

< 0.01).In-house provision was not related to whether or not

they referred to outside agencies.

Discussion

The response rate is modest, reflecting the problemsof undertaking research in general practice (Myerson1993), and the present response rate is in line with thatof other general practice research (Hannay

et al

. 1992).Although comparison data for non-responders is

not available, the present study was able to secureresponses from surgeries both with and without

specialist advice provision, enabling useful comparisonto be made. The data was collected in an area with highdeprivation, and therefore, the high level of need may notbe generalisable. It also may be that non-respondentsdiffered from the sample in that they were less likelyto recognise the relevance of welfare interventions inprimary care. The impact of this potential bias mayhave been that non-responders were less likely toknow the location of local providers, to refer patients tothem and to want increased information provision intheir setting. Nonetheless, the data gives useful insightinto the impact of specialist provision on the quality of,and access to advice for patients.

Specialist welfare rights advice is well integratedinto primary care provision with 53% of surgerieshaving provision and 91% of surgeries actively referring.The need and pathway are clearly established. How-ever, the quality needs evaluation. The time availablefor specialist advice is low (median = 3 hours perweek), and since surgeries report the service to be oper-ating at capacity, it seems likely that the decision wasled by resources and not needs. Despite the low numberof available hours, the service has a significant impacton the perceived quality of welfare rights informationprovision. Despite the high level of satisfaction reportedfrom the practice perspective, it is likely that such a lowavailability of advisers may create frustration anddissatisfaction among potential service users.

Among those who do not currently offer specialistin-house welfare rights provision, the lack of fundingby their PCG was the most common reason. While thiscan be remedied through allocation of funding, thesecond most common reason (lack of space) cannot.Alternative solutions may need to be considered, suchas cluster provision for a group of local surgeries, creativeuse of space or dedicated links with existing welfareproviders. When the categories of ‘major reason’ and‘minor reason’ are combined, all other reasons for nothaving provision are of approximately equal import-ance. This includes four reasons which represent a lackof prioritising/interest in the service: ‘There are ade-quate alternatives’, ‘This practice has other priorities’,‘Patients rarely demand such a service’ and ‘This prac-tice has never considered providing this type of service’.

The data suggest that these practices may beunlikely to offer such a service, whether or not it is facil-itated through the provision of finance or space. Thesefindings point to a lack of awareness of the need forsuch a service and its potential health benefits, and alsoto the fact that any patient population will undoubtedlyhave unmet need in terms of benefits advice and incomemaximisation. Provider goodwill, endorsement andbacking are crucial if extended welfare service provi-sion is to be made available. Unless providers are

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committed to the concept of welfare provision and seethe primary care surgery as a venue for such provisionand as an appropriate referral point, the links and solu-tions to welfare provision and health may not occur.The data represents a challenge for purchasers to raiseawareness of the need for specialist welfare rights pro-vision in primary care. Nonetheless, further provision isrequired by most practices, regardless of whether theyhave current provision or not.

The nearest alternative provider was identified asa bus ride away by 45% of surgeries and as a mean of10 minutes’ walk away by 27% of surgeries. Therefore,access to specialist advice for those who may be ingreatest need such as elderly people or those with dis-abilities is reduced. One obvious obstacle to provisionof advice is that 29% of surgeries did not know the locationof their nearest welfare facility. This information isimportant for both those who do offer in-house provi-sion (since they have limited hours of service) and thosewho do not.

The provision of printed information (regardingeligibility, payment rates and contact details) should beencouraged in waiting areas of surgeries, and is a low-cost and easily delivered format that can direct patientsto specialist advice. However, only 67% currently hadsuch information available in their surgeries, and only33% of all surgeries had such information available inlanguages other than English. Only 22% of all surgeries(49% of those surgeries with specialist provision) hadan advice service that offered interpreters. The avail-ability of interpreters must be increased in order toensure equity of provision and to address the specificneeds of ethnic minorities.

The provision of specialist welfare benefits advicesignificantly improves the service available to patients.Generally, those surgeries with welfare provision findaccess and provision to be easier, as well as moreadequate and efficient. The lack of association betweenwhether they have current provision and the variablesof availability of printed information, knowing thedistance to the nearest provider or the availability oftraining for staff demonstrates that there is no differencein willingness to offer means of conveying informationbetween those who currently do and do not havecurrent provision. However, it may be that those whodo not currently have specialist provision have a greaterneed to know the location of welfare rights providers.Even those without specialist provision who had somereservations were, nevertheless, strongly in favour ofspecialist welfare rights services within surgeries.

Home visits for welfare rights advice were offeredby only half of those with a welfare service (25% of allrespondents). The intervention aims to address welfarerights in a health context, and therefore, practical access

issues are crucial (particularly among older people andthose with disabilities), especially for those who maynot be detected by, or be able to attend, other services.

The amount of ongoing training and informationprovided to surgery staff is very low, being availableonly to 8% of surgeries. However, welfare rights adviceis a specialist service covering an area of knowledge thatis constantly changing. It is unreasonable to expectclinicians to provide this given their other priorities,although it is feasible for such needs to be identifiedwithin a consultation and the patient directed to welfarerights personnel. Streamlined approaches should allowfor sufficiently basic knowledge in order to direct andmotivate patients appropriately. The care pathwaywould not differ from other types of referrals forspecialist care made from general practice. Those whoprovided printed information within the surgery weremore likely to feel that they had an adequate serviceand that access is better compared to those without.Therefore, practices should endeavour to provide basicinformation to raise awareness of the basic range ofbenefits, either as a signposting intervention to in-houseprovision or to inform patients of other providers.

The present authors have noted that there is no asso-ciation between having in-house provision and know-ing the location of the nearest provider. Those whoknew such locations found that obtaining advice ransmoothly, was more adequate, and that patients couldaccess services without difficulty. Therefore, practicestaff should have the location and contact details forspecialist providers available to them.

These reports show that the delivery of welfarerights advice in general practice appear to be bothfeasible to the participating surgeries and acceptable topatients, with a positive impact on the quality of, andaccess to welfare rights advice for patients. The benefitsto patients may be feasibly expanded to the majority ofgeneral practices and health inequalities reduced, sincethis study demonstrates that general practices wish toincrease specialist welfare advice if adequate economicresources can be identified.

Acknowledgements

We would like to thank the Lambeth, Southwark andLewisham Health Action Zone for funding this study,the local PCGs who assisted in its implementation, andall the practices who participated.

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