welfare advice in General Practice on mental health and service use - PowerPoint PPT Presentation

The impact of co-locating welfare advice in General Practice on mental health and service use Dr Charlotte Woodhead Hillliary Collins Robin Lomas Dr Mizan Khondoker Prof Rosalind Raine

Target group/rationale

Overview The services • What we did • • Why what we did was ok, and how it could have been better

Co-located welfare advice services Haringey Camden 5 practices/health centres 12 practices Weekly/bi-weekly sessions, 6 clients / Weekly sessions, 6 clients / session session 30 minutes/client 30 minutes/client Wide range of issues including welfare Specialist welfare benefits and debt benefits, debt, employment and housing Mainly self-referral Mainly GP-referral Walk-in, first-come-first served Timed appointments booked at practice All residents regardless if / where Only patients registered at host practice registered with GP

Study design Quantitative Qualitative Exploring role of co- Impact on mental health, located services in well-being, service use supporting practice work and help-seeking – How? Why? In what behaviours circumstances?

Study design - quantitative Receives co-located welfare Advice AFTER BEFORE benefits/debt advice group 3 months Propensity Score variables: age group, gender, • GHQ-12 • GHQ-12 ethnic group, marital status, employment status, WEMWBS • • WEMWBS educational attainment, household composition, Financial strain • Financial strain • housing tenure, monthly household income, long- 3 month consultation • 3 month consultation frequency • term health conditions status and financial frequency Help-seeking behaviours • capability • Help-seeking behaviours • Self-report impact of advice Accessing services • • Advice outcomes 3 months No welfare benefits/debt advice Comparison BEFORE AFTER group 6

Quantitative data collection Advice group Comparison group 5973 comparison recruitment packs 295 contacts distributed 6 received with advice (5419 GP, 554 community) advice recipients between baseline and 17 633 baseline follow up declined questionnaires 4 outside returned range of common support 623 comparison 278 advice group group

Study design - qualitative n % Sample characteristics Sex Female 10 42 Male 14 58 Role General Practitioner (GP) 9 38 Reception staff 4 17 Practice manager 3 13 Advice staff 6 25 Funder 2 8 Area Locality 1 11 46 Realist approach to analysis: Locality 2 13 54 Group CM + PM + A = O Advice 13 54 (Pawson & Tilley, 1997; Porter 2015a,b) Comparison 3 13 n/a 6 25

Sample size/ Involvement of power stakeholders Why what we did Theoretical basis Quasi- was OK for outcome experimental selection design Steps taken to Exploring mechanisms minimise selection linking service to bias practice outcomes

Longitudinal data/ More sites in other objective health & areas advice measures How it could have Exploring System-focussed vs been better mechanisms linked intervention- to patient (or different) focussed experience Does it make sense to choose a primary outcome?

For more information: Brief summaries of methods, key findings and implications: c.woodhead@ucl.ac.uk http://clahrc-norththames.nihr.ac.uk/wp- content/uploads/2018/06/CLAHRC_NT_BITE_C o-located-Welfare-Hubs-quant-paper- Acknowledgements: _FINAL.pdf Haringey & Camden Citizens Advice http://clahrc-norththames.nihr.ac.uk/wp- Dr Tamara Djuretic content/uploads/2018/06/CLAHRCNT_BITE_Co -located-Welfare-Hubs-quali-paper-_FINAL- 1.pdf Ipsos Mori Social Research Institute

Appendix

Main findings • 64% self-reported improvements in circumstances as a result of receiving advice, particularly in stress, income, housing circumstances and confidence • Improvement in mental health over time in both groups, but greater among those receiving advice: - 43% greater reduction in GHQ-caseness overall (ns, p=0.078) - 55% greater reduction among those experiencing a positive outcome of advice (ns, p=0.055) - 63% greater reduction among females (p=0.002) - 91% greater reduction among Black/Black British participants (<0.001)

Main findings • Positive impact of advice on well-being if experienced a positive outcome from advice: - increase over time in well-being scores on average 1.29 points greater among advice group relative to comparison group (p=0.015) • Reduction in the proportion reporting financial situation as ‘difficult/very difficult’ over time among advice group but not comparison group: - 58% greater reduction overall (p=0.005) • No impact of advice on three-month consultation frequency. • Advice group members received £15 per £1 invested by funders. This excludes non-directly financial gains.

Accessing services How did you hear about the service? If the service was not here, where would you go? 15% 10% 30% 41% 33% 55% 16% My GP/the GP practice GP/practice staff Word of mouth Other information & advice service Would not have sought advice/don't know CAB/Other information & advice service Other

Accessing services 93% would rather see an adviser at a GP practice; 7% somewhere else. Why? Would prefer to keep separate 4.7 Trust GP, GP understands my… 5.1 Will have access to health records 5.5 Adviser/advice is better 5.9 More chance of being seen 6.4 Familiar/safer environment 17.8 More accessible/more convenient 54.7 0.0 10.0 20.0 30.0 40.0 50.0 60.0

“People come to us with an agenda Qualitative findings – social regarding social issues; for example, if they issues and general practice want rehousing ( … ) or if they want to appeal benefits decisions, they have been told doctors' letters would help them. And then “You often feel quite there are also the social issues where dissatisfied in what we can do people are suffering from stress from work socially because actually that or housing. ” (GP) is ( … ) basically the crux of a lot of patients, the reason why “When we finish work [we] they come in. So we can talk to then have to sit until 8 o'clock, them about medication or 9 o'clock to do letters for counselling but no amount of housing and councils and x, y, sorting that kind of stuff out is z , so if (...) we had a CAB going to really help address it. ” advisor, instead of seeing a (GP) GP [they could] just go to this adviser.” (GP) “It ends up in quite a high wastage “They think the GP has of appointments, when we would more power to help them. ” rather be seeing patients for (GP) strictly medical issues. ” (PM)

How can co-located services support practice work? Contextual Mechanisms + Programme Mechanisms + Agency = Outcome

Service awareness “I have no clue that exists and I don't know how, what exactly they do .” (GP)

BARRIERS ENABLERS   Lack of service reminders and feedback Proactive engagement by all stakeholders   High staff turnover Regular feedback on activity   Large practice/numbers of staff Regular service reminders   Physical separation of co-located services Staff awareness of support offered by advisers  Frequent turnover of services Advertising service within & outside GP  Time constraints practices   Coordination and collaboration do not Viewing social issues as outside of medical Duration of co-location  role happen on their own… co -location is not just ‘Socially aware GPs’ about the bricks and mortar. It is also about   Complex & interlinked social/health issues Advise on broader/locally relevant welfare strategies to bring people together in a  Policies preventing appointment issues  meaningful way.” (Lawn et al., 2014 p.8). gatekeeping Appointment gatekeeping   GP referral only or walk-in service open to Appointment booking  anyone Offer self-referral/referral by other practice  Perceptions of the GP as ‘go -to-location ’ staff   Structural reliance on GP for medical Patient understanding of GP role in social evidence issues  Facilitation of welfare system navigation

Conclusions Co-located welfare advice can Co-located welfare advice has reach people who would not the potential to support GP otherwise have sought advice or practices with demand from who may otherwise turn to their ‘non - clinical’ work; and, to GP for support with welfare issues. support and advocate for patients on their behalf. Advice recipients may experience improvements to short term mental health, reduced financial However, working together strain and receive considerable needs more than physical co- financial returns. location.