The impact of income maximisation on health: findings from the Do-

Well Study’

Suzanne Moffatt, Newcastle University

Creating Healthy Places in the North East: the Role of Fire and Rescue Services and Fuel Poverty Partnerships

7th March 2017

Background• 16% pensioners live in poverty

• Groups at most risk of low income:• Aged 75+• Single people• Women• Renters

• Targeted welfare/means testing

• Non-uptake of state benefits THE main cause of UK pensioner poverty

• Non claiming state welfare benefits increasing

• Interventions to assist ‘ad hoc’, short-term, affected by ‘austerity’

Welfare rights advice

• Non-statutory service• Provides active assistance

with identifying and claiming welfare entitlements

• Domiciliary• Older people identified via

general practice (age and socio-economic deprivation)

Aim

To evaluate the effects on health and well-being of a domiciliary welfare rights advice service for

independently living, socio-economically disadvantaged older people (aged ≥60 years), recruited from general

(primary care) practices.

Main study elements

• Individual randomised, single blinded, wait-list, controlled trial• Main outcome: quality of life (CASP-19)• 750 participants aged ≥60 to be recruited from GP practices and

randomised to immediate or delayed welfare rights advice intervention

• Domiciliary welfare rights advice service provided by eight local authorities in the North East (including one CAB)

• Quantitative data collected at baseline & 24 months (interview) & 12 months (postal)

• Qualitative interviews with a selection of participants/professionals

Study design

Main trial findings• 755 aged 60+ (381 intervention; 374 control) took part• Mean age 70 years• Only 84 (22%) intervention group awarded additional

benefits• No significant difference in health-related quality of

life between intervention and control at 24 months• Significant difference in hours of care received by

intervention group in comparison to control (increased from 26.3 hours per week to 56.1 hours per week)

Limitations of the quantitative study• Only 22% of participants were awarded extra financial or

non-financial benefits after domiciliary welfare rights advice• Study participants were less socio-economically deprived

than intended, meaning that fewer than a quarter were eligible for new welfare benefits

• There was evidence that those remaining in the study at 24 months were healthier than those who dropped out for any reason, which will also have introduced bias

• Discrepancies found between self reports of benefits received by participants and welfare rights advisors’ reports

Embedded qualitative study: Participant sample characteristics

30 Intervention, 20 Control30 Female, 20 Male Mean age (baseline) 72 yearsAge range 61 - 86 years31 living alone18 rented sector; 30 owner occupiers IMD scores range 7.43 (least deprived) -71.74(most)

Intervention Outcome; Qualitative Participants (N=50)

38 gained financial or non-financial benefits

Average gain: £75 per week (range £3 - £151)

Total amount backdated (Intervention and Control): £22K

Mean tested benefits: PC, HB, CTB

Non-means tested benefits: AA, CA, DLA, Injuries Comp.

Non-financial – Blue badge, aids and adaptations etc.

Direct impact of additional resources

• Travel• Utility bills• Better quality ‘healthier’ food• ‘Home-help’ services (cleaners, shoppers,

household/gardening jobs)• ‘One-off items’ replaced• Preventing debt/maintaining savings• Managing increases in cost of living

Utility bills / cold homes / fuel poverty

Because of my arthritis when it’s cold everything just seizes

up, it’s painful at times. Before I got this [extra benefit

income], I still wouldn’t put the heating on because I’m not

gonna be able to afford it … I just sat here, I had me gloves

on, me hat and me scarf … it was freezing in here at times.

Then when this [extra benefit income] come along, I put the

heating on more. Harry, 71, Control, received £37 pw HB, £440

backdated.

Preventing debt / managing increases in cost of living

[Upon receiving benefits] Absolutely shocked to the core, absolutely shocked to the core, I phoned [the welfare rights advisor] up when the letter came and I just said “it’s wonderful, I can’t believe it, can’t thank you enough … Well I know it’s there if I need it, the extra… Elaine, 77, Intervention, received £139 weekly Attendance Allowance and Pension Credit

Heating or eating?

Well I buy more food than I was able to do before, because sometimes I struggled to get you know like by the time you pay for your heating and everything… you feel more like confident, because you are not thinking oh how am I gonna get this from, will I go and borrow something … some money to put in the gas you know [mm mm] and you feel better for it because you know I’ve got that [benefit entitlement] there.

Beatrice (74) received £139 extra pw (AA (Higher) and Carer’s Allowance) £1,844 backdated.

Welfare Rights Advice

Necessities Transport

Social activities Food, paying bills

Heating, Extra help Preventing debt Adaptations to

home, Blue Badge

Capacity to cope with

crises

Emergencies Savings

Occasional expenses Furniture / household

Day trips / holidays Special equipment for illness disability

Peace of mind Able to participate in society

Maintaining independence

Quality of life

Non-financial benefit

Financial benefit

Public Health ResearchProgramme

Headline findingDomiciliary welfare rights advice for socioeconomically disadvantaged older people did not improve health-related quality of life at 2 years, but other important benefits were detected.

Implications• Welfare rights advice is an important social and economic intervention that should

continue to be delivered• Health care providers should continue to opportunistically identify and refer

patients• Methods need to be developed to identify patients most likely to benefit from

welfare rights advice services, so they can be systematically targeted in primary and secondary care

Barriers to claiming entitlementsLack of knowledge

EntitlementEligibility (means tested vs non means tested)

Process of claimingarduousdemeaninggenerating fear

Attitudes/experiences/cultureShamePrideValuesStigma

Increasing stigma towards benefit recipients [government]“They [government] class every one of them [benefit claimants] as scroungers. They’re not giving any leeway for people who actually need it, “You’re all the same. Oh you’re on benefits,” you’re an outcast to them … They show you the ones they want you to see, yes, but the ones who are entitled to benefits, no, you never see them”.Paul, aged 78, received Attendance Allowance (£81 per week)

Increasing stigma towards benefit

recipients [media] “I think it’s because the papers, they don’t talk about the decent people on benefits. They’ll only talk about the ones that are on benefits, [with] all the children and they’ve got a 52 inch television screen, and they are smoking their head off and having a drink you know. But not all of the benefit people are like that.”Myrtle, aged 71, not eligible

Increasing stigma towards benefit recipients [public]

“I think the general public has got a bad opinion … I think they look down on people with benefits. The opinion coming out in the papers, all benefit claimants are not the same. I think a lot of people who aren’t on benefits think [claimaints] are all scroungers. Well they are not really” Debbie, 62, received Disability Living Allowance Renewal (£78 per week)

Policy & practice implications (1)Continued need for WRA services to overcome barriers to claiming, and maximise incomes

“The staff build up a relationship with the service user and encourage them to claim and not worry about doing it wrong or being accused of fraud because everything will be done with [welfare rights advisor] and explained at every step … often the people in the most need who are reluctant to claim, they need a friendly face to sit down and talk it through with them.”Alice, Welfare Rights Advice Senior Manager

Policy & practice implications (2)

Primary care is a good point of contact for older people“A lot of benefit entitlement is linked to changes that happen to people during their lives, and a lot of those changes will end you up in the GP surgery, so that is the place where you should be trying to identify people and link them into [welfare rights advice] services .”Melissa, Civil Service

“Obviously the health sector is one of the places where people can go and it’s universal. That means it’s an open door and people don’t feel judged … it’s a good opportunity for the advice sector but also it very much speaks to things like the Marmot Report.”Samantha, Welfare Rights Sector

Policy & practice implications (3)Service delivery models?Domiciliary – overcomes physical/psychological/sensory

issues - Enables rapid assessment on circumstancesBUT

Intrusive/ Paternalistic/ Resource implications“It’s good to have a mix of places to see people … some might see home visits as an intrusion … one size doesn’t fit all … some people might actually prefer to be seen in the GP practice if they are living in poverty and those prouder older people may not want to have strangers coming into their home .” Judith, Local Authority Public Health

Social justice and welfare rights

“Increasingly we have engaged in value for money, cost benefit analysis of showing what we do saves other parts of the state money … I can completely understand why funders are asking for that. But I think there is a second probably equally important thing that the advice sector does and that is about social justice. We are there because our society is not working in an equal way and people need to be able to have a mechanism for addressing that. That feels to me nothing to do with outcomes. That is a basic human right that everybody should have.” Samantha, Welfare Rights Sector

Acknowledgements

The work was undertaken by Fuse, a UKCRC Public Health Research: Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research council, Medical Research Council, and the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is greatly acknowledged.

Opinions expressed in this presentation do not necessarily represent those of the funders.

Funder: National Institute for Public Health ResearchDoWell Team: Martin White, Denise Howel, Andy Bryant, Sarah Lawson, Luke Vale, Elaine McColl, Eugene Milne, Terry Asprey, Emma NobleWelfare Rights Advisors: Rosemary Bell, Neill HeauchanAll interviewers, participants and participating welfare rights organisations, general practices, Primary Care Research Network, Clinical Research Network