Opportunities for the Advice and Health and Social Care sectors to add value

1. Opportunities for the Advice and Health and Social Care sectors to add value

2. Neil Grahame – • 1985-1995, Manager of a local authority Advice Centre -advice and court/tribunal representation on Housing, Welfare Rights and Debt. • October 2007 -August 2010, Deputy Delivery Manager with the Health Inequalities National Support Team (HINST), Department of Health. HINST main task was undertake visits in order to provide consultancy advice to the (approx) 70 ‘Spearhead’ areas in England –where life expectancy is/was the lowest compared to the national average. Some additional visits were undertaken in the West Midlands. HINST held workshops on the ‘social determinants of health’ -subject areas often relevant to advice services: • Low Income, Debt and Health –Durham (pilot), Telford and Wrekin, Worcestershire, Solihull, • Housing and Health –Shropshire, Tamworth, • Employment, Worklessness and Health –Middlesbrough /Redcar /Cleveland, and Hackney. • Offender Health –yet to be piloted. This presentation will look at the links between both ‘social determinants’ and health, and advice services and health.

3. Why are key areas of advice giving relevant to health and to health inequalities? References within the Marmot Review: Fair Society, Healthy Lives, February 2010 • “Having enough money to lead a healthy life is central to reducing health inequalities. The Commission on Social Determinants of Health (CSDH) showed that poverty and low living standards are powerful determinants of ill health and health inequity… In the UK, as the current benefits system stands, many find their income plus benefits is inadequate to support a healthy life: even maximum entitlements for some benefits fall well short of many individuals and families being able to have a healthy standard of living… This shortfall contributes to social exclusion and associated health risks.” Information produced by the World Health Organisation – ‘The Solid Facts’ Edited by Richard Wilkinson and Michael Marmot • “Absolute poverty – a lack of the basic material necessities of life – continues to exist, even in the richest countries of Europe. The unemployed, many ethnic minority groups, guest workers, disabled people, refugees and homeless people are at particular risk. Those living on the streets suffer the highest rates of premature death.

4. Relative poverty means being much poorer than most people in society and is often defined as living on less than 60% of the national median income. It denies people access to decent housing, education, transport and other factors vital to full participation in life. Being excluded from the life of society and treated as less than equal leads to worse health and greater risks of premature death. The stresses of living in poverty are particularly harmful during pregnancy, to babies, children and old people. In some countries, as much as one quarter of the total population – and a higher proportion of children – live in relative poverty… • The greater the length of time that people live in disadvantaged circumstances, the more likely they are to suffer from a range of health problems, particularly cardiovascular disease… • Poverty and social exclusion increase the risks of divorce and separation, disability, illness, addiction and social isolation and vice versa, forming vicious circles that deepen the predicament people face.

5. What are the links between ‘social determinants’ and health? 1. Where services dealing with the ‘social determinants of health’ have good coverageand are being effective, there are likely to be health benefits -which may be expressed in terms of reduced call on GP services or reductions in hospital admissions 2. Socially excluded communities are likely to have poorer health and lower life expectancy. There is a huge range of socially excluded communities likely to be encountered by advice services (see table below).

8. 3. Where the ‘pathways’ where customer/patients cross between health and other services. • Low income and debt -information supplied by health professionals to support disability benefits claims • Housing – Occupational Therapist assessments in relation to disabled adaptations • Employment - Work Focused Health Related Assessment to decide whether a JCP customer is capable of work; the Pathways to Work Programme giving access to Condition Management support and Occupational Therapy services • Offender Health - Forensic Medical Examiners (FMEs) and Custody Nurses in custody suites, Community Orders with treatment requirements -Alcohol treatment requirements, Drug rehabilitation requirements, Mental health treatment requirements. Health screening and healthcare services in prison, transfers from prison into the healthcare system. 4. Where there are areas of existing or potential joint working. There may be specific interfaces between, for example, • Low income and debt – mental health and debt counselling services • Housing – the Housing Health and Safety Rating System (HHSRS) and health services • Employment – Pathways to Work /Condition Management Programme, Occupational Health services, ‘Fit for Work’ services • Offender Health – health screening at various points in the Criminal Justice system, notably early in the process e.g. at Police custody suites.

9. Opportunities for putting the above links into practice. Strategic level ownership • Involvement of advice services in thematic work led by the Local Strategic Partnerships. Are there LSP-driven local thematic groups/partnerships spearheading Anti-Poverty work, or strategies and action plans for Housing and Health, Affordable Warmth and Winter Mortality, Employability and Health, and Offender Health? • (Examples from the North East and West Midlands – Partnership against Poverty; LSP Poverty Task Group and Financial Inclusion Working Group; LSP Poverty Strategy.) Information –mapping need, cross referencing, sharing • Mapping to show the expected take-up of benefits in terms of population groups /communities of interest. Information sought from the DWP, Inland Revenue, and local authority Housing Benefits and Council Tax Benefits, and from Health services. • (Examples from the West Midlands – JSNA to include low income and debt, housing, carers; ward profiles include benefits take-up, income levels, with information from Credit Referencing Agencies)

10. Cross-referencing information to show the proportion of people with mental health issues needing advice and assistance on debt • The national estimate is that approximately one in four people with a serious mental health problem are in debt. What is the proportion locally? • Information sought from key enforcement agencies – the Courts, Utilities, mortgage lenders; and Credit Referencing agencies (e.g. Experian, Equifax, CallCredit) as well as Health services. • (Example –a Mental Health audit of suicides which didn’t investigate cause e.g. debt) Mechanisms for sharing information -through a data sharing protocol between for example Advice services, Benefits agencies, Enforcement agencies, and Health and Social Care agencies. • (Example from the West Midlands – DWP data sharing protocol with Adult and Community Services and the Benefits and Contributions Team) Sharing information through such as the Common Assessment Framework (CAF), and/or Single Assessment Process (SAP) shared across the stakeholders, and designed to trigger referrals for benefits and/or debt advice. • (Examples from the West Midlands – over 50s project commissioned from Supporting People triggering referrals for Welfare Rights and debt, mortgage providers informing a local authority of repossession proceedings)

11. Enhancing capacity for advice giving Enhancing capacity through commissioning advice services • - will help sustain their provision. In terms of health and social care, there is potential mutual benefit from: • Health and social care agencies commissioning benefits advice for their services users in disadvantaged groups – in low income/workless groups, for children and older age, and for disability/medical condition; • Mental health services commissioning debt advice -1 in 2 adults in debt has a mental health problem, 1 in 4 people with a mental health problem is also on debt. (The Royal College of Psychiatrists, 2009) • (Example –expressed intention of mental health commissioners to commission debt advice following workshop) Enhancing capacity through front line service delivery ‘Front end’ delivery in health settings –Hospital • For benefits which alter after 4/12/52 weeks in hospital –Attendance Allowance, Disability Living Allowance, Child Benefit, Income Support, Job Seekers Allowance, Housing Benefit (temporary absence from home) • Other people not claiming any benefits may leave hospital with a residual disability and newly qualify, for example, for Disability Living Allowance. • Hence, there is a clear need for hospital-based benefits advice tied into hospitalisation beyond 4 weeks, and into discharge arrangements. • Hospital discharge protocol/s for homeless people (Example from the West Midlands)

12. ‘Front end’ delivery through ‘walk-in’ service provision • ‘Late presentation’ is a characteristic experienced not only by health services, but also by the advice sector. • Walk-in centres, frequently located in town centres, can afford immediate access and immediate assistance in cases of urgent need (‘no money’, ‘due in Court in 5 minutes’ etc.) They can combine health and advice services -suggesting an issue for LSPs to consider. ‘Front end’ delivery through neighbourhoods Neighbourhood based service delivery may be through neighbourhood services, neighbourhood facilities, staff groups /domiciliary services, or 3rd Sector outlets. The manner of service delivery may be signposting, advice and assistance (all requiring training), or hosting a service. • Neighbourhood services such as a Children’s Centre or Healthy Living Centre may provide signposting, advice and assistance. • Neighbourhood facilities such as a GP surgery, community centre or Learning and Skills Access Point may host Welfare Benefits and Debt advice services. (Examples from the West Midlands – hosting of advice services in new GP contracts; a PBC Group organising CAB surgeries in GP surgeries -64% of referrals were for debt advice) • Staff groups /domiciliary services such as Health Visitors, District Nurses, Social Workers, and Health Trainers may provide signposting, advice and assistance. • 3rd Sector outlets may provide any of these.

13. ‘Front end’ delivery through Communities of Interest • Equalities related Communities of Interest (i.e. gender, age, disability, ethnicity, faith, sexual orientation) may be represented by: • An LSP theme group of task group e.g. an Older Peoples Partnership or a Disability Group, • A representative voluntary/community/faith sector organisation. • Health Trainers may support specific communities e.g. BME, Gypsies/travellers, refugees/asylum seekers, ex/offenders, alcohol/drug users, or may be based in neighbourhoods. • (Example –West Midlands initiative for Health Trainers in prisons) ‘Front end’ delivery through specific service sectors • E.g. Employment. The ‘Fit for Work’ programme pilot schemes include both health support (possibly through the Condition Management Programme), and ‘In Work’ social support e.g. debt problems, becoming a carer, etc. • (Examples from the North East and West Midlands: long-term sickness -60% with mental health problems -leading to IAPT referral; Condition Management Programme providing the‘Fit for Work’ service)

14. Co-operation from partners • Organisations which have moved towards support work e.g. Fire and Rescue Service: • referrals from home fire safety checks to ‘Advocates’ (for older people, deaf people, BME groups, refugees/asylum seekers, drug/alcohol users, disabled, carers…), Merseyside; • home fire safety checks triggering referrals on health, domestic violence, housing, benefits and debt, West Midlands) • Other support organisations – (Example - ‘Supporting People’ contracting out for help with benefits and fuel poverty, West Midlands) • Codes of practice on dealing with vulnerable people for bailiffs and debt collection agencies. (Example –code of practice for Council Tax bailiffs –debt write-offs for hardship, West Midlands) • What is the health and advice services input into specialist /problem-solving courts to deal with intransigent social and behavioural problems? - • Drug courts • Domestic violence courts • Mental health courts • Community Justice courts • Offender Management and Control courts.