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Category: Scheme best addressing Health Inequalities
Name: Julie Hirst
Job Title: Health Development Manager
Organisation: High Peak & Dales PCT
Email: julie.hirst@highpeakanddalespct.nhs.uk
Telephone: 01629-817931
Key team: Andy Taylor, High Peak Citizens Advice Bureau, Heather Clifton-Smith, Mid-Derbyshire Citizens Advice Bureau, Julie Hirst, All Our GP Practices
Title: Citizens advice in rural general practice
The need for change was identified in a research report 'Hidden Deprivation in the Peak National Park' published by Manchester University in 1991 which described how low population density in the Peak District led to a lack of services, poor access and a significant number of rural people missing out on their welfare benefit entitlements leading to poverty and social exclusion.
In 1993 Paris and Player published their seminal evidence relating to Citizens Advice in general practice in the BMJ. In 1995 we piloted this approach in a rural general practice in the Peak District.
We hoped to achieve an uptake of the weekly CAB service, resulting in amelioration of poverty and other social and economic problems facing disadvantaged groups in the area. We also hoped the results of this pilot would indicate the extent of the 'hiddenness' of local rural deprivation.
We expected a wide range of people to benefit, in general those experiencing rural deprivation; in particular, people living on low incomes, the un- or under-employed, single parents, older people, people with disabilities and other special needs and people without access to private transport.
We did it by working in partnership with our two local CABx and the general practice in Hayfield. The evidence from the BMJ was instrumental in convincing the GP to participate in the pilot and the original funding of £2,000 was provided by the health service.
We placed a CAB advisor in the Hayfield practice for half a day a week for a year. The CAB did a lot of local publicity and the primary health care staff also made referrals to the service.
Following the successful evaluation of the pilot this intervention was rolled out to four other practices funded through the fundholding mechanism available at the time. Results from these practices were equally impressive and other practices started to enquire about providing the service too.
The CABx were very helpful, accommodating of the needs of the primary care setting, and were very professional. The practices were also enthusiastic and supportive. Developmental support and funding solutions were provided by the health development manager.
Results from the pilot and from subsequent evaluations of other practices left no doubt about the success of the intervention. Very significant amounts of money were generated for patients through the identification of previously unclaimed benefits and many other of their problems were solved, for example housing and employment problems, domestic abuse, debt and legal problems.
GPs were very happy with the service, not least because their time was saved by referring appropriate patients to the in-house CAB service.
More recently Liverpool University has published the results of a three-year evaluation of this work (in which we participated) and concluded that significant health gains are achieved, in particular with regard to mental health and vitality (SF36 domains).
The pilot happened in 1995 and it has taken seven years to extend this service to all our 16 GP practices. The two challenges that had to be overcome were
- funding: this was solved for five years by a successful healthy living centre bid commencing July 2001
- some GP resistance to the concept; this was overcome by reference to the increasing evidence base for the intervention, and use of good interpersonal skills over a period of time (not giving up).
The key unexpected outcome was the degree to which the service has been used since its inception; although the CAB has had a weekly presence in Hayfield practice for eight years now, the demand remains constant. This confirms the findings of a rural report on the dynamic nature of poverty in rural areas (JRF 1998) and it seems that the service will always be needed.
The other unexpected outcome is the volume of problems that sub-groups of our rural pop
ulation have; for example, the most recent annual evaluation of this service shows that:
- Clients seen = 2176
- Enquiries presented = 4618
- Confirmed benefit gain for the first 9 months = £520,000.
Although High Peak & Dales PCT did not 'invent' this intervention, we have taken it and applied it to our population with great success. We believe that we are the only PCT that is providing this service to all our practices and patients, which is our response to the disparate nature of deprivation in our population, and it is for this commitment in particular that we seek recognition.
As one of the 'early adopters' of this intervention, we have been invited to speak and share our experiences and success at local, regional and national conferences. An article has also been published in a community health journal.
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