Welfare Advice in General Practice - The Better Advice, Better Health Project in Wales.

John Borland, Senior Academic Advisor, University of Wales - Bangor
Delyth Owens, Better Advice: Better Health Project Co-ordinator

Summary

Links between poverty and health were established as long ago as the Black Report in the 1980's and advocates of introducing welfare advice into general practice have been active since then. Research on the impact of such schemes have generally established their ability to increase the income of poor patients but they have not established patient endorsement nor practitioner support, two factors that contribute to the success of such interventions. The introduction of advice systems to GP practices in Wales, know as "Better Advice: Better Health" in 2003, was an opportunity to measure the support of both patients and General Practitioners and to review existing research findings. The year long study across Wales confirmed that the programme encouraged more patients to seek advice and those who did were drawn from sections of the population that did not usually seek advice in the conventional settings of the CAB. Patients were agreed that Better Advice: Better Health provided a high level of service and almost 40% of them said that they preferred receiving advice in their doctor's surgery than in any other context.. A 60% random sample of GP's involved in the project showed overwhelming support for the service, they felt that it extended their practice, removed the stigma from patients seeking advice and they welcomed a welfare advisor as a member of their team. On a wider level GP's felt that Better Advice: Better Health enabled more people to access health care, reduced health inequalities and enabled patients to access a service that otherwise would be unavailable.

Introduction

Interest in welfare advice in general practice has a long history. Just over ten years ago, Paris and Player (1993) reported that

"The introduction of citizens' advice into primary care is a worthwhile new intervention."

But the discussion did not end there. Over the next nine years a number of other studies reported on similar interventions. Initially the evaluations of these projects concentrated on the statistical returns of the number of patients using the service, the number of enquiries they made and the income generated as a result of welfare benefit gains. (Paris & Player, 1993; Veitch, 1995 ;Coppel et al, 1999; Middlesbrough Welfare Rights Unit, 1999; Emanuel & Begum 2000; Galvin et al, 2000; Emanuel 2002) Generally these studies reported that most enquires made by patients related to welfare benefits, for example, Galvin et al dissented and pointed out that the "majority of consultations related to financial and social problems, they were not dominated by benefit claims alone". (p.281). These studies and those of Pacitti & Dimmick 1996; Warden 1996; Bird, 1998; NACAB, 1999; Abbott & Hobby 1999; found considerable under claiming particularly by those people suffering from mental health problems and significant increases in benefit claims when patients were given advice in these settings.

One of the main justifications of introducing advice services to General Practice was that it would increase the health and quality of life for patients. (Veitch 1995; Abbott & Hobby, 1999, 2000; Emanuel & Begum, 2000) Here the results of intervention have been less clear. Veitch administering the Nottingham Health Profile to 52 patients found that the sample size was too small to show statistical significance, the instrument was not sufficiently sensitive, the experiment did not control for extraneous factors and the length of the experience may have been insufficient to show any effects. On the other hand Abbott & Hobby did find significant improvements after six months in patients' vitality, role functioning and mental health. However after 12 months these improvements had not been maintained. Generally there has been concerned about the small sample sizes used in these experiments (Emanuel & Begum) and on the difficulty of isolating the effects of CAB intervention from other factors.

Another important concern was the way in which the introduction of such schemes affected the patients' use of health care services. (Abbott & Davidson, 2000; Abbott & Hobby 1999,2000; Emanuel & Begum, 2000) Impact in this regard was less than expected. Generally there were no significant differences reported in the use made of the health service between those receiving advice and those who did not. The one exception was in a study by Abbott and Davidson who reported a significant reduction in the number of GP consultations and new prescriptions for those followed up after 12 months

The reports on patients' experience of the service and the attitude of GPs and practice staff to the service are less substantial and yet these are critical to the establishment of a successful service. Unless patients feel comfortable in seeking advice in these circumstances they will not use the service and unless a GP feels that an advice service will benefit their practice, their patients and that an advice worker will fit within their practice 'team' such a service will not be established.
As with the impact on patients the reports of the attitudes of GPs and primary health care staff is somewhat ambiguous. Early studies suggested that Doctors and practice staff
"Welcomed the presence of the advice worker in their surgeries; access to an advisor trained in a wide range of subjects relevant to the everyday problems of their patients has given rise to a great deal of non-medical referral. This has proved a valuable resource to practices working in areas with high levels of deprivation." (Veitch & Terry. 1993)

This view was confirmed by Porter (1998) who also found that doctors saw the service as an important resource. However, not all studies agreed. Dowrick et al (1996) and Chaggar (1993) reported that the provision of such services may lead to the view that GPs are "responsible for, and indeed expert on, every welfare, social and medical issue that effects their patients" (p.261) In a later study, Abbott & Hobby (1999, 2000) indicated that it was clear that the majority of GPs involved in the project did not approve of the service, in a telephone interview eight out of nine disapproved (p. 33). In their later study they reported that:

"It is not surprising that the prospect of extra and unrewarded work in supporting welfare benefits claims may discourage GPs from welcoming advice services into their practices. More broadly, many GPs do not believe that it is appropriate for patients to discuss social problems with them, even if such problems may influence their patient's health." (p. 324)

Other studies have reported more favourable attitudes by GPs, for example, Coppel et al (1999) found that GP's welcomed the service. However, the validity of this evidence is undermined by the smallness of the sample, four in all. More positively Abbott & Hobby (1999, 2000) and Emanuel & Begum (2000) report that most administrative/reception staff, such as office managers, practice nurses and receptionists, did not feel the advice service had an impact on their workload, and they found it helpful. But again the samples in these cases were small.

In summary the research findings to date show that patients;

" Gain financially from being able to access advice workers in GP practices
" but the evidence is less substantial when other matters are considered, particularly the medium and long term health effects on patients and on the willingness of GPs to welcome the service to their practice.

In recent years these findings have been supported by the growing realisation of the links between poverty and health and the way in which the health of the 'rich' has improved at a much faster rate than the Health of the 'poor' (Gordon, D. et al 2001) and the need to ensure that this connection and the wider social context of patient treatment are included in undergraduate education of the profession.

Financial gains for patients are important and are clearly related to health gains but unless they are willing to use the service and feel comfortable in that context and unless GPs welcome the service to their practice advice services within primary health care will never become established. The establishment of the Better Advice, Better Health programme in Wales is an opportunity to both test the findings of earlier studies; the increase in client referrals and enquires as well as patients' financial gains and to produce more evidence on the attitudes of clients and GP's to the introduction of the service.

Better Advice, Better Health is a national programme of welfare advice giving established by the Welsh Assembly Government in partnership with Citizens Advice Cymru in response to the report "Better Health Better Wales" which claimed that "a person's social and economic circumstances are probably the strongest influence on health, avoidable sickness and premature death."

In 2001 the project was funded for three years. In 2001 - 2002 the project was piloted in seven local authority areas, the following year it was extended to include all 22 Welsh local authorities. Four models of delivery were used, all envisaged that welfare rights advice would be given by paid specialist and volunteer generalist advice workers and that patients would access the service by referral from GP's, health visitors, nurses and practice staff. They differed in that some projects were based in GP surgeries; others in community hospitals, a third group would take referrals from health care workers but advise people in their own homes. In the few areas where it proved impossible to establish a 'presence' in a health care setting and home visiting was impractical the service was delivered in CAB premises. Under this programme 22 projects were established covering all the local authority areas in Wales and by the end of the year, involving 146 different primary health care practices. While the project took into account of the importance of establishing projects in areas of greatest need, many were established in more economically favourable areas and thus Better Advice, Better Health represent a wider cross section of GP practices than was the case with earlier projects were the emphasis was to establish a service in areas of social deprivation.

Specifically the development of the Better Advice, Better Health initiative in Wales allowed the exploration of the themes established in earlier research reports, namely;

1. The number of patients using the service, the number of enquiries generated and the income generated as a result of welfare benefit gains
2. The patients' experience of the service
3. The attitude of GPs and practice staff to the service

Results

1. Meeting the National Assembly Targets.

At the beginning of the project the Welsh Assembly Government set achievement targets for 2002-2003. To be successful the service had to generate 4000 clients, 12,000 new enquiries and raise £4,000,000 in benefit claims.

These figures were collected monthly by the project administrators they were frequently checked for reliability and validity.

Table One. Better Advice, Better Health Monitoring of Clients, Enquiries and Claims, October 2002 - September 2003.

Table one shows the number of clients seen by the advice centres in a year, 6445, the number of enquires made, 4200, and the overall benefit gain, £3,448,672. These figures confirm the results of earlier findings that the number of clients seen, enquiries made and benefits gained in such projects is considerable. However, while the number of clients exceeded the expectations of the Welsh Assembly Government by more than 50% the number of enquiries and the benefit gain fell below targets.

A quarter-by-quarter comparison showed that the level of performance has increased in each quarter over the year and while there is significant variation in the difference in performance between local projects all national targets were met in the final quarter of the year.

2. The Patients' Experience of the Service

The patients' experience of the service was measured by asking them to complete a feedback questionnaire and to return it by post to the central project office to ensure confidentiality. In all 1088 patients responded. There was great variation in the level of returns from different parts of Wales. Three areas; Flintshire, Powys and the Vale of Glamorgan accounted for over 40% of the returns whilst nine areas; Blaenau Gwent, Bridgend, Caerphilly, Cardiff, Conwy, Gwynedd, Merthyr Tydfil, Rhondda Cynon Taff and Swansea accounted for less than 1% .

Throughout the year the survey collected information on

• The quality of service; including the level of satisfaction with the service, the ease of understanding information, the quality of their advisor, and whether they received fair treatment.
• Their self esteem
• Their assessment of the Citizen's Advice Bureau as opposed to the Better Advice, Better Health advice provision
• Their suggestions as to how the service could be improved

2.1 The Quality of Service

To assess the quality of service they had received patients were asked four groups of questions; four about the advisor, did they listen, were they helpful, did they give them a good level of information and did the advisor treat them fairly. Two about the service; were they kept up to date with their case and did they understand what was being done on their behalf. Finally they were asked how they felt after they had experienced seeking advice and to what extent they were satisfied with the service as a whole.

Generally the advisor was rated highly, 96% of patients thought their advisor was very helpful, 95% though they listened very well and gave them a very good level of information and 94% thought they treated them very fairly. Clients were slightly less enthusiastic about the service as such, 86% found information they were given easy to understand and 85% felt that they were kept up to date with the progress of their case. However, when asked to give an overall rating of the service 91% said they were very satisfied with the service they had received. As an overall impression of the success of the service 88% of clients said they felt better after seeing the advice worker.

Table Two. The Quality of Service.

2.2 The relationship of 'High street' Citizen's Advice Bureau and the Better Advice, Better Health advice points.

One of the concerns that had been expressed both by the Assembly and Citizens Advice Cymru when the project was conceived was that the High Street bureau and the Surgery advice centre could undermine each other by dividing the available clientele. The increase in clients generated by Better Advice, Better Health already indicates that such fears were unfounded. However in the patients survey respondents were asked which they preferred to use the High Street or the doctors' surgery. Most patients, 61%, said they would use either but 39% said they would only use the doctors' surgery in these case it was because of:

• Ease of access
• The high quality of the service
• The location or their local Bureau was not know to them
• The doctor or another health worker had suggested they should use the surgery service
  

Table Three. Reasons for using Better Advice, Better Health locations rather than local CAB offices.

3. The impact of the project on the primary health care teams.

The evidence from earlier studies on advice giving in GPs practices was ambiguous, the larger studies indicated that doctors were generally hostile to such developments, later studies suggested the opposite, the difficulty in accepting these studies was that the samples from which the conclusion were drawn were very small. In this study we were able to draw on the experience of 80 GP practices. In doing so it became clear that GPs have a number of concerns that have not been fully explored in earlier studies. Primarily and not surprisingly GPs are concerned about the effect such a development would have on their practice, for example, on the scope of their activity, on their productivity by saving time and on the level of advice giving skill in the practice. Second, they were concerned for their patients, would advice in the surgery remove the stigma felt my many when seeking help? Would it result in patients feeling better, being more able to cope and increasing their quality of life. Third, GPs were concerned about the advice worker. Coming from different professions with different traditions doctors were concerned that they would hold the same ideas about professionalism, that they would be helpful, approachable, productive, informative, flexible and a team player. Finally they wanted whatever was introduced to make a contribution to health in a general sense, to the community as a whole. To evaluate these concerns we decided to take a sample survey of 80 practices involved in the project

To balance the need for precision with the cost of the investigation it was decided to take a 60% simple random sample of the surgeries involved throughout the year. After a significant amount of piloting involving six face to face interviews and ten telephone contacts, 48 surgeries were contacted by post and asked to return a questionnaire to the research team. Surgeries that did not reply to this letter within one week were contacted by telephone. A maximum of two reminders were given to surgeries and at the end of the survey period 72.9% of questionnaires were returned. The response rate on individual questions ranged from 68.2% to 72.9%. The rate of return is sufficiently high to indicate that the sample is likely to represent all the GP practices in Wales involved in the Better Advice, Better health programme.

3.2 The Impact of the Project on the Agency/Surgery.

To begin with respondents were asked thirteen questions about the effect of the project on their practice. In each case they were asked to make one of five responses, whether they;

• strongly disagreed
  
• disagreed
• neither agreed nor disagreed
• agreed
• strongly agreed

Table Four. The Effect on the Practice

The analysis of these returns indicates that there are four areas in which the advice service impacts on practices. The first affect was on quality of the service health professionals were able to give their patients and to the ability of the project housed in the practice, to remove any stigma people might feel about asking for help. The second affect was they way in which the project improved patient access to advice services and also the way in which patients' confidence to seek advice was improved as was the health workers confidence in offering it. The third general area of improvement in the service they offered was related to their belief that the employment of the advice worker had taken a lot of work off the shoulders of health workers and thus released them for other activities. The least effect was on the doctor's direct relationship with the patient. In this respect the role of the advice worker was more limited nevertheless more than 63% of doctors thought that having the advisor in the practice led them to be better informed and therefore not raising unjustified expectations about benefits in the minds of the patients and 66% agreed that the advisor was able to tell them about benefits that may work for patients that they didn't know about.

3.3 The Project and the Patients.

In the second part of the questionnaire doctors were asked how they felt the project had affected their patients. Table Five is a summary of their response.

Table Five. The effect on patients

From the results of the survey GPs felt that the service affects patients in four main ways. First, it increases their access to service, by removing stigma, by giving them 'permission' to take the service and by providing physical access. Second, it improves their self image by showing them that someone cares about them, by reducing feelings of hopelessness and making them feel more positive about themselves. Third, it increases their quality of life and helps them care for others. Finally a significant majority of GPs felt that it led to an improvement in patients' health and help them cope with chronic illness.

3.4 Fitting in with the Team

Being certain that a newcomer will fit in with the existing practice team is an important consideration, for doctors, when expanding the practice service and they will only take this step if they feel that the advice worker will be suitable member. In this section of the questionnaire doctors were asked, on the basis of at least one years experience, about how they felt about the Better Advice, Better Health advisor as a member of their 'health team'.

Table Seven. The Advice Worker as a member of the primary Health Care Team.

Predominately doctors had found the advice workers to be helpful, approachable and professional, all important qualities as far as GPs are concerned. More than two thirds of doctors also say the advice worker as productive and informative. There was less agreement on three further qualities only about 50% felt that advice workers were flexible, active and a team player.

3.5. Meeting the General Objectives of the Assembly.

Better Advice, Better Health is one of many health initiatives funding by the Assembly, all of which are expected to contribute to the Welsh Assembly Government's overall objectives for the improvement of life in Wales. Doctors were asked to estimate the extent to which they felt Better Advice, Better Health had met the general objectives of the Assembly Government in this regard.

Table Six. Meeting the general objectives of the Assembly Government.

Predominately health professions felt that Better Advice, Better Health was good or excellent at enabling people to access health and care services, reducing health inequalities and in strengthening the role of the voluntary sector. They also felt it makes a significant contribution to the enjoyment of life by the most vulnerable sections of society and in spreading prosperity to all parts of Wales. A smaller majority of health professionals felt the project was less good at eliminating discrimination and only a minority felt it was good at helping people to have access to good quality and affordable housing.

3.6 Improving the Service.

The importance that doctors gave to the advice service was seen in the suggestion they made to improve the service.

Table Eight. Suggested improvements in the service.

The core of the improvements suggested by doctors while important in themselves; essentially they wanted the project to receive more funding and wider publicity, are also an indicator for their support for the service itself. The overall support they gave was summed up by one doctor who said to one of the researchers "It's quite remarkable you know, this is the only service we have ever introduced into the practice that we have not had someone complaining about, we even had one complaint when we introduced anti-natal care."

4. Conclusion/summary.

Better Advice, Better Health is probably the most comprehensive introduction of advice services into GP practices that has ever taken place in the UK. It covers the whole of Wales, deprived and affluent areas alike. The service has been seen to be so successful by the Assembly that it has now been incorporated into the core health budget for Wales, thus it will become part of the main stream service.

This research supports earlier findings that advice services in GP practices generate significant increases in clients, new enquiries and benefit gain.

It extends the evidence by reporting on the attitudes of patients and practitioners to the establishment of a service. The effect on patients is considerable, not only do they gain in increased benefits but they are generally impressed with the quality of the service they received and they felt better after they had received advice. Because of ease of access, the quality of the service and the support they received from their doctor, a significant minority of patients would not go elsewhere for advice

If anything the reaction of GPs was more impressive. To begin with more than 70% of them returned the questionnaire, a high response rate for any investigation of this type. This coupled with their agreement that the service should receive more publicity and spread to more locations shows a very high level of commitment. More specifically GPs felt that the service impacted on their practices in four ways; first and most importantly if removed the stigma of seeking help from the state, it extended the service they were able to give to patients and gave them access to a service that otherwise would be unavailable and had taken a lot of work off the shoulders of practice staff, themselves included.

For patients, doctors agreed that the effects could be profound: first, psychologically, doctors were of the opinion that because of the service, patients felt that someone cared and the service reduced their feelings of hopelessness, doctors felt that patients, who had benefited from the service, were personally more effective and were exhibiting higher levels of self esteem. Second, the increase in benefits increased their quality of life and their ability to care for others. For many doctors, about 60%, these benefits were supported by an improvement in the general health of patients and helped them deal with chronic illness.

As far as bringing advice workers into their practice, that was seen in very positive terms, they were seen, almost universally, as helpful, approachable and professional, and a significant majority of doctors saw them as productive, informative, and flexible. They were less sure about them being active and a 'team player'

On a wider level, Doctors also felt that the advice service made a contribution to wider issues, particularly the Welsh Assembly Government's overall health objectives for Wales. In relation to those objectives Better Advice, Better Health was seen to contribute significantly to enabling people to access health and care services, reducing health inequalities and in strengthening the role of the voluntary sector. They also felt that the service made a significant contribution to the enjoyment of life by the most vulnerable sections of society and in spreading prosperity to all parts of Wales. They were less certain about the ability of the project to eliminate discrimination and they were much more sceptical about whether the project was good at helping people to have access to good quality and affordable housing.

References.

Abbott, S. & Davidson, L. (2000) Easing the burden on primary care in deprived urban areas: a service model. Primary Health Care Research and Development, 1:201-206.
Abbott, S. & Hobby, L (1999) An evaluation of the health and advice project: Its impact on health of those using the service. Health and Community Care Research Unit. University of Liverpool. Thomas Yates Building. P.O. Box 147, Liverpool L69 3BX
Abbott, S. & Hobby, L.(2000) Welfare benefits in primary care: evidence of improvements in health. Public Health, 11495) 324-327.
Bird, L.(1998) Advice: independent advice services for people with mental health problems: needs and provision. Mental health Care, 2(4): 135-9
Chaggar, J.S. (1993) Citizens' advice in general practice: a burden GPs could do without BMJ, 307(6898), 261.
Coppel, D.H.,Packham, C.J. & Varman, M.A.(1999) Providing welfare rights advice in primary care. Public Health, 113, 131-135
Dowrick, C., May, C., Richardson, M. & Bundred, P. (1996) The biopsychosocial model of general practice: rhetoric or reality? British Journal of General Practice, 46, 105-7
Emanuel, J. (2002) Citizens Advice Bureaux in primary care: a tool to address social and economic inequalities. In L. Adams, M. Amos & J. Munro, promoting Health Policy and Practice, London: Sage Publications.
Emanuel, J. & Begum, S. (2000) What do you advise Doc? A Citizens' Advice Bureau in primary care in the west midlands. Manchester Monographs 40. Centre for Higher and Adult Education, Faculty of Education, University of Manchester.
Galvin, K., Sharples, A & Jackson, D. (2000) Citizens Advice Bureaux in general practice: an illuminative evaluation. Health and Social Care in the Community. 8(4) 277-282.
Gordon, D. et al (2001) Wales NHS Resource Allocation Review, Independent Report of the Research Team, Cardiff, Wales NHS.
Middlesbrough Welfare Rights Unit, (1999) Project report: welfare rights advice in general practice. Middlesbrough Welfare Rights Unit & Tees Health Authority
NACAB, (1999) Prescribing advice, National Associations of Citizens Advice Bureau: London.
Pacitti. R. & Dimmick,, J. (1996) Poverty and mental health: under-claiming of welfare benefits. Journal of Community & Applied Social Psychology, 6(5), 395-402.
Paris, J.A.G. & Player, D. (1993) Citizen's advice in general practice, BMJ, 306(6891): 1518-20, 5th June
Veitch, D. (1995) Prescribing Citizens Advice: an evaluation of the work of the Citizens' Advice Bureau with Health and Social Services in Birmingham. Birmingham District Citizens Advice Bureau.
Veitch, D. & Terry. A. (1993) Citizens' Advice in general practice: patients benefit from advice. BMJ, 307(6898), 261-2.
Warden, J. (1996) Benefits inflexible for mentally ill. BMJ, 313 p. 709.
Better Health Better Wales" (REF)

First Published June 10th 2004

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