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Strengthening the links with the Citizens Advice Bureau

Stephen M Coopey
RGN DNCert CPT BA(Hons)
Lecturer Practitioner
North Hampshire Primary Care Trust
Basingstoke
Hampshire

The introduction to the recent consultation paper Tackling Health Inequalities stated that "a healthy lifestyle is still linked to social circumstances and childhood poverty".(1) The report sought views from a wide range of agencies on how to build on previous work by setting priorities for action and building on good practice. Income, along with a range of health determinants (education, employment and housing), continues to be a significant factor in determining health inequalities(2)
While the government is seeking to tackle these issues at all levels - for example, low income through the working families tax credit, sure-start maternity grant, national minimum wage and children's tax credit - there remains the need to ensure that benefit advice and information is accessible. Even if financial support is possible, without raising awareness and enabling people to claim, inequalities in healthcare and poverty will continue.
This article is the result of the Public Health Development Course in Hampshire and the Isle of Wight, a project to develop local capacity and capability. The aim of this project was to improve benefits advice to the elderly in our practice area, and as the project developed it encompassed work by other health professionals, including health visitors, who were providing advice to families with young children, and practice nurses. The role of the Public Health Development Project was central to the sharing of information and enabling networking. The benefits advice project continues to be a work in progress, and its success is as much about the process as the final outcome achieved.

Networking
The Public Health Development Course was set up to enable health professionals to carry out projects that had been identified as part of work linked to practice development plans and local health improvement initiatives. It comprised ten members from different professional backgrounds providing a wealth of experience that could be shared. The course consisted of four half-day workshop sessions and was attended by three practice nurses, two health visitors, one district nurse, two midwives and two school nurses. The course ran over a six-month period and was facilitative in approach, allowing the presentation and sharing of progress within the group, which acted as a brainstorming and problem-solving team. 
One of the key benefits of the project was the opportunity for networking and the recognition that other professionals were working on similar schemes, allowing resources and information to be shared. Consequently the benefits advice project brought together the work of health visitors, practice nurses, GPs and district nurses for one local community. Although benefits advice and support is offered by health visitors through a "community mother scheme", advice to the elderly had not been discussed, and links with the Citizens Advice Bureau (CAB) as a key voluntary agency had yet to be made.

Using the CAB
The aim of the benefits advice project was to increase the uptake of benefits by the local practice population. Initially this was to be achieved by providing nurse-led benefits advice drop-in clinics in the surgery, but following discussions with the CAB it was recognised that we had not considered the opportunities to use their expertise and resources. 
A research approach was adopted, and the first step was to systematically identify what was happening locally and to review the literature on the subject of benefits advice. Local networks revealed a range of activity that other professionals might be unaware of: for example, the CAB provide an outreach worker to the local hospital every Wednesday afternoon, and will do home visits to clients who are elderly or housebound. Other organisations provide support, and the local social services have volunteers who will help clients fill in forms. 
Two local community projects were identified. One was a multi-agency group - health, police, housing and voluntary agency representatives looking at the needs of the area. The other was a regeneration project led by the housing association. As a result of exploring what is happening locally, we have been invited to participate as health representatives in a monthly "community surgery" where a range of professionals will be available to provide advice and support to the local population.
Work within the local community and the practice population revealed that access to services was often described as difficult. Although anecdotal, the evidence from colleagues and experiences of patients and clients revealed that transport, and therefore access, was often a key issue. This gave us encouragement and confirmation that providing more local services for clients and patients is a valid exercise, along with supporting lobbying for an improved transport system. Many offices for both voluntary and statutory agencies are within the town centre, some miles from the majority of the practice population.

Literature review
A literature search revealed that schemes set up to provide benefits advice at health centres have tackled poverty.(3-5) In addition, work has been done with specific client groups, such as those with diabetes.(6) This study interviewed 48 patients with diabetic complications and revealed that 39 of the 48 were claiming less than their entitlement or no benefits at all. 
The Sandwell Project provided a welfare rights adviser from the housing department and in a six-month period secured lump- sum payments of £10,393 for 18 clients and projected recurring benefits of £14,358 for 1992-3.(4) Likewise, Moore identified 70% of the clients referred to the adviser were claiming less than their entitlement.(3) 
The Child Poverty Action Group has identified that 37% of single and 25% of pensioner couples are in poverty.(7)
Therefore we should ensure that our clients and patients are claiming what they are entitled to. Research by the CAB reveals that of the six million problems presented to the service in 1998-9, the highest percentage was for social security problems - 1.8 million (30%).(8) The evidence from these reports demonstrates that while poverty and inequalities are continuing to exist, there is often a failure to access economic help even when it is available. Consequently, any actions to improve access for patients and clients through information or referral may lead to an improvement towards a healthier lifestyle.(9)
One key study that has been widely reported is the result of a Health and Advice Project, a CAB initiative that was evaluated by the Health and Community Care Research Unit at Liverpool University. This project was part of a citywide initiative to ensure that individuals and families received the benefits they are entitled to as part of a strategy to improve health. The Health and Advice Project offered advice to patients referred from the primary care team and directly from the client. Advice was given either at the surgery or at home. The conclusions from the project reveal that, despite high levels of chronic morbidity in the research population (68 research subjects), the 48 who received increased benefits reported improvements in their quality of life and showed statistically significant improvements in three areas of health. 
Despite the study's limitations, this goes some way to establishing a link between health gain and welfare benefits and indicates the importance to all health professionals of giving or referring clients for benefit advice. The literature search also provided evidence to support the view that benefit advice in the primary care setting is better accessed by older people than in the high street.(9)

Educating staff
A meeting with all interested professionals was arranged, and the manager of the local CAB was invited to attend. This was a useful opportunity to develop a greater understanding of each other's roles. As a result it was agreed that before setting up a nurse-led benefits advice clinic we would wait for developments in the CAB service, as they were undertaking a mapping exercise of all voluntary services. In addition, we would support their application to provide a new peripatetic welfare benefits officer that we might be able to access locally. 
As a first step in raising awareness among community nurses, and while these changes were taking place, the CAB manager agreed to put on a training session for 12-15 local community staff. This was very successful and would be of practical benefit to staff in other areas, as even if they are not giving detailed advice themselves staff need to know how patients can access advice and support. The session also helped build relationships with members of the primary  healthcare team and demonstrated that a shared commitment to tackling local health needs through joint learning helps foster teamwork. The local CAB information presented for 2000-01 revealed that benefits advice is a very common issue. It was second only to consumer debt as an issue for those seeking advice. This sort of information gives a wider view of population needs beyond the narrow focus on health needs and medical treatment.

The future
Since the final meeting of the Public Health Development Course this project continues to support local initiatives. In the last month a new "Community Surgery" has commenced, which is run from a local community centre and meets on the first of every month for two hours. Health, police, housing and counsellors are present to give advice and support. Future plans include running a series of specific benefits presentations when we move into our new surgery and continuing to access educational support from the CAB for community staff. It is hoped that in the future we will have access to a local peripatetic benefits adviser.

An integrated approach
This article has illustrated some of the evidence that is available concerning benefits advice and health gain. While conclusive proof establishing the links between deprivation, poverty and its effects on health is hard to find, it is becoming clearer. It is important that we do not neglect our responsibility as healthcare professionals in being able to give benefits advice or know when and where to refer patients. There is substantial evidence that patients are often not claiming entitlements, and this may be more significant in the older population. 
A first step must be to identify and recognise what the needs of the practice population are and then to identify what services are available locally. Once this is done, gaps in provision can be identified and solutions explored. This can be achieved only through inter- professional and interagency working, as the problems are often complex. Furthermore, an integrated approach reduces duplication of effort and uses the skills of the most appropriate person for a particular problem. Benefits advice will remain an integral part of the work of the primary healthcare team as long as financial hardship determines the health of our patients.

References

  1. Department of Health. Tackling health inequalities. London: Department of Health; 2001.
  2. Department of Health. Independent inquiry into inequalities in health (Acheson Report). London: HMSO; 1998.
  3. Moore A. Benefits check-up. Nursing Standard 1999;13(41):17-18.
  4. Ennals S. Providing citizens' advice in general practice. BMJ 1993;306:1494.
  5. Coppel DH, Packenham CJ, Varnam MA. Providing welfare rights advice in primary care. Pub Health 1999;113(3):131-5.
  6. Simpson AJ, Hall A, Gray RS. Do UK patients with complications of diabetes mellitus receive the financial state benefits to which they are entitled? Pract Diabetes Int 1998;15(1):12-4.
  7. Child Poverty Action Group. http://www.cpag.org.uk
  8. Rowlingson K, Black P, Harrington A, Merrin W. A balancing act: surviving the risk society. Derby: University of Derby; 1999.
  9. Abbott S, Hobby L. An evaluation of the health and advice project: its impact on the health of those using the service. The Health and Community Care Research Unit Report. No 99/63. Liverpool: University of Liverpool; 1999.

Resources
Online Advice Guide
W:www.adviceguide.org.uk
Age Concern
W:www.ageconcern.org.uk
Child Poverty Action Group
W:www.cpag.org.uk
Department of Social Security (for general advice and guidance)
W:www.dss.gov.uk
Rights Net
W:www.rightsnet.org.uk