A roundtable discussion on the embedding of welfare advisers in health and social care services, as an effective response to the impact of welfare reform.
The discussion involved Kate Burton, Public Health Practitioner at Scottish Public Health Network; Roddy Samson, Welfare Advice Service Facilitator at the Improvement Service; and Karen Carrick, Project Manager at the Improvement Service.
They discuss what a welfare adviser is, and detail the embedded model - its effectiveness, challenges and plans for it going forward.
WA roundtable discussion on the embedding of welfare advisers in health and social care services, as an effective response to the impact of welfare reform. The discussion involved Kate Burton, Public Health Practitioner at Scottish Public Health Network; Roddy Samson, Welfare Advice Service Facilitator at the Improvement Service; and Karen Carrick, Project Manager at the Improvement Service. They discuss what a welfare adviser is, and detail the embedded model - its effectiveness, challenges and plans for it going forward.
You're listening to Iriss.fm Scotland's Social Services podcast.
On the 11th of July 2018, Iriss hosted a discussion on the topic of embedding welfare advisers in health and social care services. It explores what a welfare adviser is and details the embedded model, it's effectiveness, challenges and it's future. The discussion involved Kate Burton, Public Health Practitioner at Scottish Public Health Network, Roddy Samson, Welfare Advice Service Facilitator at the Improvement Service and Karen Carrick, Project Manager at the Improvement Service.
KB Right so, I'm Kate Burton, I'm the Public Health Practitioner with the Scottish Public Health Network which is part of the NHS Scotland and I've been involved in integrating welfare advisers in general practice for about the last 20 years.
RD Hi, my name's Roddy Samson, I'm the Welfare Advice Facilitator with the Improvement Service. My background is in advice services as an Advice Service Manager and Adviser and I've been involved in delivering and developing advice services in primary care for again the last 20 years, like Kate.
KC I'm Karen Carrick, I'm a Project Manager with Improvement Service. Our role is to work with local authorities and their partners to drive improvements, we're particularly interested in how local authorities fund and deliver advice services. I've not been involved in this capacity for as long as my colleagues, but I worked with them to do a social value exercise on the benefits of embedding advisers in practices.
Int. So, to get started then, what is the role of a welfare adviser?
RD So, welfare advisers or advice workers, welfare rights officers, there's various names that they go by but they're the individuals who provide advice, advocacy and representation to members of the public who may have questions or difficulties around benefits, tax credits, money advice or housing issues. So, what a welfare adviser would do is generally to interview the client concerning the problems they have, take the information, they would then go (... unclear) with any third parties, you know advice, be the intermediary between the client and the third parties and if necessary represent them in courts or representation where you know the dispute can't be resolved. So, very generally that's what advice work is.
Int. Okay, brilliant. So, you're talking about this embedding of these advisers in services, what is this embedded model, can you describe or explain what it is for me?
RD Yeah well, I mean, I suppose, going back to saying what advice services do or welfare rights do, I suppose most people would traditionally know the model of them as being maybe a citizens advice bureau or the advice services within a local authority and traditionally people go there and access them. You know, they may be on a high street somewhere, you know somewhere in a city centre often located in large peripheral housing estates but what these advice services generally do is they will sit in there, the advice agency and wait for people to come to them, now occasionally they go and they do outreach and things like that where it's just sitting in other organisations and you know seeing people in different venues which may be more accessible such as libraries, etc, etc. within the clients community. But where the embedded model came from was when I was working at Granton Information Centre which is an independent advice agency based in North Edinburgh, we had funding to start doing advice in primary health care in two G.P. practices which are in areas of multiple deprivation in North Edinburgh. The two practices were Muirhouse Medical Group and Crewe Medical Group, so, we started working in these practices but over the years we developed a very close working relationship with the practice staff to the extent you know, we had very good working relationships and we were allowed access to medical records and you know we were able to talk to the G.P.'s directly about independent clients. So, really became part of that team, so, that's what the embedded model is, it's like full integration that you're not working for two different organisations. You're both working for the patient or for the client and you're pulling resources together as a member of one team to actually support these individuals. So, I suppose that's what the embedded model is, it differs because the access point is through a trusted intermediary in the case of general practice and from there it's seamlessly, the client or the patient will seamlessly go through the processes within the practice. So, they will be sent to see an adviser if that's appropriate in exactly the same way as they would be seeing the practice nurse or chiropody or anything like that. So, it's just from the client's point of view it's just part of the service they would expect to get in primary health care. I think I've got that right, I think I've been talking a bit too much, so I don't know, Kate ...
KB I think from an NHS perspective, we know that income inequalities, poverty, money worries, deprivation has a negative impact on people's health, people die prematurely, people are more likely to experience comorbitity which means they're more likely to have a lot of long term health conditions. If they're experiencing the poverty deprivation worries about housing and debt and things like that so, we were very keen to work with the advice sector to provide advice workers in particularly primary care settings so in general practice because we felt then our G.P.'s could offer a more person centred approach to health care, to health and social care within primary care and I think we're also very aware by the model that Roddy's just described it's about destigmatising advice services because providing them in the G.P. practice means that none of the peoples neighbours or other members of the their community know that actually that person has got a money worry or is worried about housing because they're being seen within the practice and it's not sort of publicly obvious that they're going to see an adviser. So, we felt that was quite important so, the fact the advice services are provided in a setting which is destigmatising, it's accessible, and it's familiar and the way it's delivered is the same way as Roddy has just explained, that people would make an appointment to see an adviser in the same way they would make an appointment to see a practice nurse or somebody else within the practice to get their bloods taken or whatever.
Int. How effective has this model been then?
KC Well we did a social value analysis, so, we went out and we talked to everybody directly who might experience benefits as a result of the model. We talked to the patients and service users, we talked to doctors, G.P. practices, funders, and workers and they all give us examples of the benefits that they had experienced. For the people who were using the service, as Kate has said, it was less stigmatised, they felt more comfortable accessing the service (... unclear) through a trusted intermediary, they also had the health and well being benefits of getting access to advise but something that we hadn't quite anticipated but people did feed back to us was that it made them more likely to use other services at an earlier stage and that's really important in terms of achieving earlier intervention with individuals before their problems get out of control. When we talked to the G.P. practices, they were very clear that allowed them to focus on the patient's health needs and not on other needs as well. Now, obviously that benefits the professionals who are giving a service, the people who are getting the service but also has cost benefits as well in that it's much cheaper to access an advice worker than it is to access your local G.P. In terms of funders, the funders said that for them it meant that they could target resources at people who they identified were most in need, the most vulnerable groups, people with mental health issues perhaps single parent families, so it enabled them to target resources and also at an earlier stage as well as I've already mentioned people were coming forward sooner so in the long term that obviously saves money and improves people's outcomes. For the advisers themselves, they felt that they got more job satisfaction out of this that they were able to, by being part of a team with access to medical records, they were able to give a better service to the clients. They were also able to avoid putting their clients through the stress of perhaps having going to an appeal, decisions were getting made at an earlier stage because the quality of the applications that were put forward for things like PIP were better because they had access to the medical records, so, that cut down all the appeals process that in many cases followed but I'm sure that Roddy has some examples of stats related to Granton Information about how much quicker the process was dealt with.
RD Yeah, well what we found was that just sort of picking up on what you were saying there Karen, one of the practices we worked in we started to look about. We had a feeling that the cases were being resolved at an earlier stage than what was coming through our mainstream service and we had decided to look at employment support allowance to see if we were resolving the cases within general practice quicker than we were within the advice service. So, we looked at employment support allowance, so, we looked mandatory reconsiderations which is the stage before you appeal, so, a mandatory reconsideration would happen if you'd applied for employment support allowance and you'd been turned down for that benefit, you would then have to request the mandatory reconsideration which is basically asking the Department of Work and Pensions to look at your claim for benefit again. Now, what we found within the advice agency was that most of these mandatory reconsiderations were refused so we then had to go to an independent tribunal to argue the case and what we were finding there was, I think, about 70% of the cases were being found in the claimants favour, so, what we were finding in general practice though was that the mandatory reconsideration stage was far more successful and we thought that had something to do with access to medical records. So, we looked basically at the national stats for employment support allowance, mandatory reconsiderations in the first quarter of 2015 and a huge percentage of them were refused, something like 75% of mandatory reconsiderations were refused. But we looked in one practice where we were doing mandatory reconsiderations over the same period and we had a 95% success rate at mandatory reconsideration stage so these are the type of things that we began looking at and saying well this must be more effective and the real reason that we found for that was because we were putting in benefit claims which really were as a result of somebody's illness or disability and when you can have the persons medical records, appropriate parts of their medical records, sent along with the claim as well as the support of the G.P.'s who we were working closely with or other practice staff who may be supporting that patient that once you have that body of evidence, it's very hard for somebody who doesn't actually know the individual to turn them down for a benefit on the basis of their illness or disability. So, clearly what we would call it or what we called it in advice services is front ending the case, so, rather than getting all your evidence before you go to court, put all your evidence in before the claim has reached that kind of later stage in it so, that's one of the real benefits that we found of doing it but similarly we did another short little piece of research in G.P. practices and what we did was we plotted the amount of times that patients were going in to see their G.P.'s over a period of time before they were referred to an advice worker and then we plotted how many times they saw their G.P. after and in every single case there was a drop off of the times that people were actually attending G.P.s and the reason behind that was that people are attending G.P.s for non clinical issues, they're basically attending for social welfare issues which the G.P. has no training in doing so, once we showed that piece of information around in that obviously interested the G.P.s and medical staff because they really want to focus on clinical issues rather than dealing in social issues so, if they have somebody in their team that can deal with the social welfare issues then that small piece of research definitely shows that there's a benefit to the medical practice as well as the patients of where we were getting earlier results within cases by front loading them.
KB We found that there was, what was describing Roddy, that piece of work looking at consultation rates, was also investigated in England at some practices in England and they discovered there was a significant reduction in number of consultations between the patients who had received the welfare rights advice and those patients who hadn't. So, again that adds to the evidence base and what they also discovered was there was a significant reduction in some medication for mental health so from an NHS perspective you're talking at hundreds and thousands of pounds being saved if we're able to actually reduce the number of prescriptions we're giving to patients for some mental health medication which is really powerful and that's because welfare rights advisers have been put into those practices which has really benefitted the patients but importantly has benefitted the practices as well.
Int. Is there any actual case examples of how an individual has been impacted by this, obviously not naming or identifying the person but is there any stories around that?
KB We use a quote quite a lot when we're talking about this area of work, from a G.P., who says "I can't address the medical issues of my patient because I've got to address their other concerns first which is getting food to feed their family and money to heat their home." And I think that sums up what this is about really because G.P.s can't deal with those social welfare issues. They're very good at the clinical work but they cannot deal with the social welfare issues which is why having the adviser in the practices and the advisers having access to medical records has really saved G.P.s an awful lot of time and as Karen said, and other members of the primary care team as well, it's really been incredibly effective.
RD Yeah, I remember one G.P. from the Lothian Deprived Interest Group actually saying though that the impact on general practices has been huge and some of our group have felt it to be crippling with increased workload diverting us from the social clinical care and he's talking specifically in the situation about welfare reform, about the benefits system being changed and so many people having to access general practice in order to try and get support when they were taken off the much needed benefits and entitlements. So, there the G.P. is basically saying that and he went on to say that increasing numbers of consultations are being taken up either focussing on the practical support of patients through the appeals procedure or more disturbingly trying to help patients cope with the mental ill health effects of the process so, not only was welfare reform in austerity, taking up G.P time when they were trying to support people through doing things it was also exasperating mental health conditions at the same time. I can give you a case study which did come out of one of the practices and it was a patient who was from the forces, so the client was ex forces, he was discharged from the army suffering from mental health problems and he became homeless and he was sleeping rough. At that point he accessed the Edinburgh Access Practice, so, unfortunately at that point the client wasn't fully engaging with health services, he was more preoccupied with getting his benefits and housing problems resolved. So, the G.P. although he was seeing this person on a regular basis really wasn't able to get the treatment of the clinical care that this person needs so, he referred to the welfare rights adviser. The welfare rights adviser managed to get personal independence payment benefit in place and also employment support allowance benefit in place. The welfare rights adviser also secured accommodation for the person previously sleeping rough and they were able to get the property furnished with payments from charitable grants and referred to ongoing support. So, from sleeping rough with a mental health problem caused directly by his time in the services the client is now fully engaged with health service and other support services, he has the correct amount of money coming in, he has a flat where he's now settled and he's addressing his mental health issues and he's also attending a course to try and increase his employability. So, that's the kind of impact that we have people who are in chaos, are unable to engage with services but providing the correct service is provided at the right time then that is what we are talking about, embedded models where you can get that person once they've engaged but get them to the right services which is placed in the place where they have engaged and then all the other services that are embedded within there can work with the individual, so, it's a wrap round service but it's getting the person to the correct service at the right time within that.
KB There was also the case study where the patient had been going to their G.P. more and more frequently, their mental health was getting worse and worse and worse and at the last appointment with the G.P. the G.P. realises patient was at high risk of suicide, was incredibly anxious so, the G.P. had to increase the medication the patient was getting for their anxiety and also before the patient left the consultation the G.P. also gave him the phone numbers for The Samaritans because he thought this patient was at such high risk of suicide but the G.P. also helped the patient make an appointment to see the welfare adviser who was based at the practice. The G.P. then realised on reflection that he then didn't see this patient for the following 3 or 4 weeks and when he next saw the patient, he asked him how he was and it turned out that this patient's anxiety and his suicidal thoughts had all come about because he's been turned out for employment support allowance so, the patient had got no income coming in and it was also affecting his housing benefit obviously but because the patient had been referred to the welfare rights adviser, she was able to appeal the decision in terms of welfare rights advice and was able to in a way take some responsibility for supporting the patient to now put everything in place that he needed to in order to get his benefits reinstated so, it was a fabulous outcome so, it meant that this patient could then focus on his clinical issues as his physical issues as opposed to his mental health because the welfare adviser had now dealt with those problems that were causing his sort of deteriorating mental health concerns.
Int. Are there any challenges then to this model?
RD One thing that we probably should have mentioned about the embedded model is that it requires very experienced advisers to actually work in it because you're asking somebody to go out with your organisation, to work in another organisation and to work really, quite on an automatous level. So, what you want firstly is somebody who has the skills to do that, preferably somebody who's also been involved at some level in a project development, all be it a small project, but you know somebody who you can trust to come back and tell you about any problems that's happening because it's important that when you're trying to embed a service that all problems and difficulties are ironed out before they become running, festering sores between the two organisations which can't be resolved. So, you're looking at pretty experienced advisers that you require there that they can do the job without any training obviously, have an understanding of all the advice issues, who will be able to appear in the appropriate courts, etc. and also have an understanding about how to go about developing a service when they're working alongside other professionals. So, in actual fact trying to find these individuals is very, very hard and in actual fact there's not a lot of trained welfare rights advisers out there to actually bring in. So, most of the time when you're trying to follow that model what you're doing is you're taking an experienced adviser working from a project that's already established and having to back fill their post with somebody new and that's it. The other challenges are around funding issues in that most projects are actually very short term funded, so, you're talking about a year or two. Now, to really establish a new service is to go out there and you need time to do it so, to get something really working properly you're looking at well over 6 months, probably a year in order to say, okay that's it done, it's working perfectly, it's snagged. We have an understanding within this practice about where the welfare rights adviser's going to fit in here, we've worked out all our referral protocols, we've worked out about working together and we're getting the right patients through now and we're seeing sort of really good numbers and we're now seeing them by. So, there is that kind of get it up and running timeframe, there's a lot of work to be done there so, that's one of the challenges so, once you've done that you're basically coming to the end of the funding stream so, it's a bit of a leap of faith to actually go out and do this unless you have some sort of secure funding base. So, if you get about sort of 3 years to do something it's easy to do, if you get 12 months to do something, it's very, very hard, especially if you're trying to bring in somebody new to the organisation. You don't have an experienced adviser you can put on to it, you've actually got to bring somebody in, train them how to do some of the more technical aspects of the job and then put them out into service. That actually puts quite a strain on the service because at that time everybody within the organisation is going to be having to pick up slack from elsewhere and there's very little slack, in fact there's no slack within advice agencies at all, they all work extremely hard, so, that's a challenge of just having that breathing space to actually get it up and running. We know it works and we know it has massive impacts but that's the challenge, it's time and experienced staff is the real, real challenges that we've got in there.
KB We were discussing this earlier, the challenge isn't just about money, it's ab out supporting welfare advice agencies whether they're local authority agencies or services or third sector to redesign their services because actually if they redesigned their services they wouldn't require additional funding but they could redesign their services in order to meet this very vulnerable group of people who actually would require a service at a crisis point but by putting the advice workers into general practice in many situations you're actually avoiding the crisis because people are getting to see the adviser sooner but it does take a very confident, a very skilled advice service to take that risk as Roddy has just outlined of moving somebody from maybe a centralised service into a G.P. practice where they've never had a service like this before to then to start to see patients because obviously the service is going to have to start reducing the number of people it sees at it's office space but they will find, Karen will outline an example from Dundee, but we have got examples where people have shifted their services, or redesigned their services to be delivered in an outreach basis and it has been much more effective.
KC Often advice services are quite traditional and there's perceived to be a way that you deliver advice services that people come to a hub or an office as Kate has said but Dundee City Council took a very different approach, they looked at how can we best provide services that will be accessible to people particularly people who don't normally use our services, so, rather than having people coming into a central office they decided to devolve them out into the community. And, they've based now the whole way that they deliver services on that model, they've done so in partnership too with the third sector so that the third sector is working with the council to have an integrated approach to delivering advice services in a variety of locations throughout the city and they've embedded this model now in different medical practices and health settings. And, it's very much focused on what can the person access best and what will provide the best service for the person because all too often when there's any kind of consultation or discussion about advice services, the service providers are involved in that discussion, but the service users are sometimes missed out and in Dundee City Council they've very much engaged with service users to develop a model that meets their needs.
RD I think the interesting thing having spoken to Dundee over a number of years now is that they're finding exactly same things as we found in Edinburgh, it's an early intervention model so, the experience that they're having is the same. They're actually seeing cases where they can resolve at an earlier stage and easier because there is a thing about advice services is that people only go there when they're desperate generally whereas if the problem is picked up early then you can get the advice and support necessary to actually stop that becoming a crisis and that's where this model works and I think there was another interesting stat that came out of work done here in Glasgow, around Parkhead area when they were looking at embedding advice services in general practice that they found, I think, it was 85% of people who accessed the service in general practice would never have accessed the advice service on the high street and indeed some of them were walking right passed the service on the high street to get to the general practice in order to see the adviser who came from that advice agency. So, that's one of these things that really shows or examples that really show that the model does work by the de-stigmatisation in catching cases at an earlier stage or problems at an early stage so that we can resolve them.
KB Health staff are very much seen as a trusted intermediary, aren't they? So, if your G.P. or your practice nurse says "Yes, I think you would benefit by seeing an advice worker." People are much more likely to attend because there's a much more sort of clear referral process rather than saying to somebody "Oh yes, I think you need to see an advice worker. So, if you just go down the road ..." and then people have got to try and pluck up the courage to go down the road to the advice centre in the high street or whatever. So, I think recognising the role of the trusted intermediary, i.e. the G.P. or the practice nurse is really vital in all of this as well.
Int. So, I suppose then finally what's next, what are the plans for these advice services?
KB I suppose the Scottish government have recognised the value of this approach so they have drawn up a primary care workforce plan for Scotland that was released in April 2018, so April of this year and within that primary care workforce plan, they've identified that we need a sort of multi-disciplinary team in primary care to support patients and to take some of the pressures off general practice and one of the professions that they've recognised should be part of that multi-disciplinary team are link workers, and the link workers can include welfare rights advisers as well so there's a desire from Scottish government to see this approach sort of embedded across Scotland.
KC Scottish government is carrying out a review of the way that they fund advice services and a lot of local authorities are looking at how they fund advice services too and how they should be delivered and that's not just about the location, what we're looking at is the different locations in a community setting through which people can access advice services, this is one we're also looking at recovery hubs, at schools, at libraries for instance in Glasgow, so, there's that community access to services, there's people who don't normally access services being able to do them, those people that we really want to reach that we really want to get at an earlier stage but also we're looking at the channel and the way that people access services because there will always be a need for face to face services but there are other opportunities through which people can access services, through the phone, through the web as well so it's a case of looking a bit more creatively and imaginatively about how you can design advice services who's primary purpose is to meet the service user's needs.
RD And of course Kate and Karen and myself are here to assist any organisations that are looking to develop these models so, you know I would say, have a look at the evidence and get in contact with us and we can talk it through from anybody who's interested in pursuing this.
Int. Okay so we'll leave it there, thank you for speaking to me.
RD Thank you very much.
KB Thank you.