This welfare rights advice programme had been running for 2 decades Hackney. It was set up in recognition of the many social determinants of health, not least poverty, poor and/or insecure housing, unstable low-paid work, ill health and disability and the barriers in accessing services and rights (eg OHID, 2014; Marmot Review, Marmot et al 2010). Hackney is one of the most deprived boroughs in London and has pockets of multiple, severe and long-standing deprivation and intersectional issues. These interplay to undermine people’s abilities to access their rights. Nearly there in ten ( 28%) of Hackney residents live on less than 60% of median income, one accepted tally of poverty; and 43% of Hackney’s children live in poverty, the highest are in London (Trust for London, 2024)
When this project was originally set up in 2002, 10 experienced advice organisations worked in almost 30 health settings, spread cross the borough. Over the subsequent 22 years the programme changed in size, governance and distribution. At the time of this evaluation (Autumn 2023- Spring 2024) its funding had been reduced significantly, following austerity cuts. In 2023-24 five of these organisations delivered advice and advocacy services covering housing, welfare benefits, debt, immigration and other issues in eight Hackney GP practices and a local hospital.
This evaluation used a mixed methodology, including a rapid literature review, secondary analysis of existing data and in-depth qualitative interviews and focus groups with key stakeholders (n=32). The latter included advice organisations, health professionals and social prescribing agencies and key local authority personnel .
The main advice model was for a qualified and experienced welfare right adviser from a well-establish Hackney advice service to attend the GP surgery one day a week and see patients, mainly by appointment. People with urgent deadlines were also fitted in.
These advice services were found to be totally integrated and well respected in these surgeries. Appointments were booked by GPs, receptionists and other staff and by patients directly through the surgery’s normal appointment system and ran smoothly. One organisation also provided back-up expert advice to social prescribing staff.
Over a 12 month period in 2022-23, 727 people received advice and advocacy on 1724 discrete legal matters in these health settings. Topics included welfare benefits, housing, debt, immigration and at different levels of advice and complexity, from initial claims to appealing erroneous decisions.
Available data shows those advised reflected Hackney’s richly diverse demographic and most had a disability and/ or a long-term health condition (48% to 98% of people seen per setting). Many of the patients interviewed in this evaluation said they would not have been able to access mainstream advice centres because of their health condition or disability.
Financially, the programme resulted in an estimated income increase of £1,356,456 across those assisted for a 12-month period over 2022-23. In addition, many people received one-off lump sum payments, mainly in respect of benefit arrears and a reduced or cancelled debt. This totalled £246,937 for the same period. This evaluation did not have time to conduct a cost-benefit or value for money analysis, but the returns are impressive in respect of the £120,000 total annual grant from CH Public Health. Such a positive financial outcome chimes with the literature on the return on investment : including a Citizens Advice report and analysis by NHS Scotland (2019). However a rapid review by Granger et al (2022) argues that much more data and analysis is needed on this angle.
As well as securing their entitlement, reducing debt and attaining their legal rights, patients reported reduced anxiety and stress. Most had not known what to do, or how to cope, before being referred for advice.
“It made all the difference. I slept for the first time in a week … I was able to sleep again. It was that worrying … the best appointment I ever had” [Individual advised 1]
The findings indicate that the co-location at a health setting and/or being referred by a health professional boosted access to advice. Patients reported finding it easier and more acceptable and more confidential to visit an adviser based at their GP practice. Moreover there was an element of trust extended to the adviser from being co-located in, and trusted by the health staff . Plus over time patients had come to directly trust the advisers too. The majority had been unaware of their potential rights or remedies and had not sought advice on their problems before.
GPs, practice managers and receptionists reported that the service reduced the pressures on them (e.g. in trying to find suitable organisations to refer patients to, or find answers to their problems) . They particularly valued being able to refer patients for help with housing, benefits and legal matters they recognised as important, but were otherwise at a loss to deal with. This reduced their workload and enabled them to focus on the patient’s health matters. Moreover they were able to track their patients’ progress on their system, eg to see if appointments were followed up and what remedies were secured. They and their patients noted improvements in mental and physical health from getting advice, which chimes with the literature.
“Several times every week I will be asked about [advice topics]. Get questions from people with food insecurity, with housing, problems, with damp housing, people threatened with eviction. People who just haven’t got enough funds to feed their family and pay the rent, … immigration, of course as well, because a lot of people have no recourse to public funds. … Destitution … the need for advice is greater than it’s ever been” [GP]
The main challenges found were the threat to the continuity and funding of this small but highly valued project. This was aggravated by its low profile and successive cuts over previous years, and the limited awareness of welfare rights services and needs across the borough.
Link to final report and summary report