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 sessions, 6 clients / session Weekly/bi-weekly sessions, 6 clients / session 30 minutes/client 30 minutes/client Specialist welfare benefits and debt Wide range of issues including welfare 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 registered with GP Only patients registered at host practice

Study design

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

Study design - quantitative

Receives co-located welfare benefits/debt advice

BEFORE AFTER

6

• GHQ-12
• WEMWBS
• Financial strain
• 3 month consultation

frequency

• Help-seeking behaviours
• Accessing services

No welfare benefits/debt advice

BEFORE AFTER

• GHQ-12
• WEMWBS
• Financial strain
• 3 month consultation frequency
• Help-seeking behaviours
• Self-report impact of advice
• Advice outcomes

Propensity Score variables: age group, gender, ethnic group, marital status, employment status, educational attainment, household composition, housing tenure, monthly household income, long- term health conditions status and financial capability

3 months 3 months

Advice group Comparison group

Quantitative data collection

5973 comparison recruitment packs distributed (5419 GP, 554 community) 633 baseline questionnaires returned 623 comparison group 6 received advice between baseline and follow up 4 outside range of common support

Comparison group

295 contacts with advice recipients 278 advice group

Advice group

17 declined

Study design - qualitative

Sample characteristics n % 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 Locality 2 13 54 Group Advice 13 54 Comparison 3 13 n/a 6 25

Realist approach to analysis: CM + PM + A = O (Pawson & Tilley, 1997; Porter 2015a,b)

Why what we did was OK

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

How it could have been better (or different)

Longitudinal data/

• bjective health &

advice measures Exploring mechanisms linked to patient experience System-focussed vs intervention- focussed More sites in other areas Does it make sense to choose a primary

• utcome?

For more information: c.woodhead@ucl.ac.uk

Acknowledgements: Haringey & Camden Citizens Advice Dr Tamara Djuretic Ipsos Mori Social Research Institute

Brief summaries of methods, key findings and implications:

http://clahrc-norththames.nihr.ac.uk/wp- content/uploads/2018/06/CLAHRC_NT_BITE_C

• -located-Welfare-Hubs-quant-paper-

_FINAL.pdf http://clahrc-norththames.nihr.ac.uk/wp- content/uploads/2018/06/CLAHRCNT_BITE_Co

• located-Welfare-Hubs-quali-paper-_FINAL-

1.pdf

Appendix

• 64% self-reported improvements in circumstances as a result of receiving advice,

particularly in stress, income, housing circumstances and confidence

Main findings

• 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

41% 16% 33% 10%

My GP/the GP practice Word of mouth CAB/Other information & advice service Other

15% 55% 30%

GP/practice staff Other information & advice service Would not have sought advice/don't know How did you hear about the service? If the service was not here, where would you go?

54.7 17.8 6.4 5.9 5.5 5.1 4.7

0.0 10.0 20.0 30.0 40.0 50.0 60.0

More accessible/more convenient Familiar/safer environment More chance of being seen Adviser/advice is better Will have access to health records Trust GP, GP understands my… Would prefer to keep separate

93% would rather see an adviser at a GP practice; 7% somewhere else. Why?

Accessing services

“You

• ften

feel quite dissatisfied in what we can do socially because actually that is (…) basically the crux of a lot

• f

patients, the reason why they come in. So we can talk to them about medication

• r

counselling but no amount of sorting that kind of stuff out is going to really help address it.” (GP) “People come to us with an agenda regarding social issues; for example, if they want rehousing (…) or if they want to appeal benefits decisions, they have been told doctors' letters would help them. And then there are also the social issues where people are suffering from stress from work

• r housing.” (GP)

“When we finish work [we] then have to sit until 8 o'clock, 9 o'clock to do letters for housing and councils and x, y, z , so if (...) we had a CAB advisor, instead of seeing a GP [they could] just go to this adviser.” (GP) “They think the GP has more power to help them.” (GP) “It ends up in quite a high wastage

• f appointments, when we would

rather be seeing patients for strictly medical issues.” (PM)

Qualitative findings – social issues and general practice

How can co-located services support practice work?

Contextual Mechanisms + Programme Mechanisms + Agency = Outcome

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

Service awareness

BARRIERS ENABLERS

 Lack of service reminders and feedback  High staff turnover  Large practice/numbers of staff  Physical separation of co-located services Frequent turnover of services  Time constraints  Viewing social issues as outside of medical role  Proactive engagement by all stakeholders  Regular feedback on activity  Regular service reminders  Staff awareness of support offered by advisers  Advertising service within & outside GP practices  Duration of co-location  ‘Socially aware GPs’  Complex & interlinked social/health issues  Policies preventing appointment gatekeeping  GP referral only or walk-in service open to anyone  Perceptions of the GP as ‘go-to-location’  Structural reliance on GP for medical evidence  Advise on broader/locally relevant welfare issues  Appointment gatekeeping  Appointment booking  Offer self-referral/referral by other practice staff  Patient understanding of GP role in social issues  Facilitation of welfare system navigation

Coordination and collaboration do not happen on their own… co-location is not just about the bricks and mortar. It is also about strategies to bring people together in a meaningful way.” (Lawn et al., 2014 p.8).

Co-located welfare advice can reach people who would not

• therwise have sought advice or

who may otherwise turn to their GP for support with welfare issues. Advice recipients may experience improvements to short term mental health, reduced financial strain and receive considerable financial returns.

Conclusions

Co-located welfare advice has the potential to support GP practices with demand from ‘non-clinical’ work; and, to support and advocate for patients on their behalf. However, working together needs more than physical co- location.