Poverty proofing Doncaster health and wellbeing 2026

Poverty proofing delivery partner model

Children North East are working in partnership with Rotherham, Doncaster and South Humber (RDaSH) NHS Trust to fulfil its ambitious promise to “poverty proof” all of its services by December 2025. The trust has committed to piloting a bespoke Delivery Partner Model developed in partnership with Children North East (CNE).

Poverty Proofing is a nationally recognised tool, designed to educate and enable health care professionals to identify, acknowledge, and reduce the impact of poverty, advocating for equality of access to healthcare, services and technologies that contribute to overall health outcomes experienced by those living in poverty.

A locally trained team (LTT) of people have been trained and are being supported by Children North East to carry out this work in line with the ethos and principles of poverty proofing.

• Phase 1: 3 model audits carried out by Children North East
• Phase 2: a further 6 audits carried out by the locally trained team with support from Children North East
• Phase 3: all other trust services will engage in the poverty proofing process during 2025 and 2026. Children North East will deliver training to all staff; the locally trained team will carry out scoping of services and engage patients and staff in consultations; and the trust strategy team members will deliver feedback and write reports for each service. Moving forward, services will become more poverty informed, learning how to work with their patients to identify barriers, so that poverty becomes everyone’s business, and no-one is left out or left behind

This whole system approach is unique and has accountability at every level and a commitment to alleviate barriers that apply across the whole system.

Poverty proofing Doncaster health and wellbeing 2026

The poverty proofing audit for physical health and wellbeing service began in January 2026 to better understand the experiences of families and individuals who are living in poverty.

The work was conducted in partnership with staff, families, and adults who attend the service to build up a rich picture of the barriers and challenges faced by those accessing Doncaster physical health and wellbeing clinic. Due to the nature of clinic-based appointments and staff unable to book extra time out it was believed by the service managers it would be better if staff supported patients and carers to download the quick-response (QR) code and for them to complete the questionnaire or for staff to support patients’ carers to fill in the questions.

The physical health and wellbeing service offers annual health and wellbeing checks for people experiencing a serious mental illness. This is designed to help patients identify health needs early, manage ongoing conditions, and improve overall wellbeing. People with mental health problems are well known to have higher rates than in the general population of obesity, smoking, heart disease, stroke, hypertension, respiratory disease, type 2 diabetes mellitus and breast cancer.

It is this vulnerability of patients with a serious mental illness diagnosis that makes it essential for health care professionals to proactively reach out and offer support to help adopt healthy lifestyles.
In recognition of this, the National Institute for Health, and Care Excellence (NICE) recommended in 2009 that physical health checks should normally be provided within primary care at least once a year.
The Community Wellbeing team will work in partnership with Primary Care Doncaster. The service is delivered by an experienced team of health professionals and offers primary care to patients through annual health and wellbeing checks.

The service is based at Tickhill Road Site, Tickhill Road, Balby, Doncaster, DN4 8QN, and the service is delivered Monday to Friday between the hours 9am to 5pm. However, the service delivers clinics across the four localities within Doncaster. The South locality clinic is based in The Stone Castle Centre, gardens Lane, Conisbrough, DN12 3JW. The North locality clinic is based at the Jade Centre, Askern Road, Bently, DN5 0JR. The Central locality clinics are base at the Burns Practice, Oakwood Practice, The Scott Practice, Sandringham Road Health Centre and The Flying Scotsman all within the centre on Doncaster and the East locality clinic is based at the Vermuyden Centre, Heathfield Health Centre and Field Road Surgery all within the east of Doncaster. Referrals are identified by the general practice severe mental illness (SMI) register to ensure that the annual health and wellbeing checks are completed as part of the shared care agreement.

In Doncaster, 16.6% of the population was income-deprived in 2019. Of the 316 local authorities in England, Doncaster is ranked 48th most income-deprived, with 1 being the most deprived.

Key findings from a Mind report of August 2021 tell us:

“There’s still a lot of shame about money and mental health. Many feel mental health is a while, middle-class conversation into which they can’t tap. Poverty increases the risk of mental health problems and can be both a causal factor and a consequence of mental ill health.”(Poverty and Mental Health, Mental Health Foundation, August 2016).

Poverty proofing ethos

No activity or planned activity should identify, exclude, treat differently or make assumptions about those whose household income or resources are lower than others.

Voice

The voice of those affected by poverty is central to understanding and overcoming the barriers that they face.

Place

We recognise that poverty impacts places differently, and so understanding place is vital in our response. Organisationally we also need to be clear about why and how decisions are made. This understanding of context is essential.

Structural inequalities

The root causes of poverty are structural. What structural changes can we make at an organisational level to eliminate the barriers that those in poverty may face?

Poverty proofing process

Stage 1: training and consultation with staff

Staff were invited to attend, along with other services, the half day poverty training throughout January, February, and March, where they completed a three-hour training session. Three staff members are recorded on electronic staff record (ESR) as receiving training.

Stage 2: scoping

Time was spent gathering information about the setting and how it works. This stage included conversations with staff and management, observing interactions and reviewing key areas such as the website and communications.

Stage 3: patient and community consultations

We spoke to eleven people who use the service and some were supported by family carers. We spoke to nine staff who make up the service. This information was completed via the surveys.

Stage 4: feedback session

The report was shared with the Service Manager, Barbara Taylor to consider the findings. We then produced this final report.

Stage 5: review

Around 12 months after completion, the trust will complete a review, identifying impact, good practice and potential considerations moving forward.

Common themes

The next sections of this report highlight the most common themes to come out of the poverty proofing consultations. For each theme the report covers:

• what works, what you do now that supports those experiencing poverty
• the barriers and challenges faced by those experiencing poverty
• recommendations, each recommendation comes with a set of considerations for “poverty proofing” the service

The themes are presented alphabetically, and this does not imply any hierarchy of importance. The themes for Doncaster health and wellbeing were:

• communication
• health-related costs
• navigating and negotiating appointments
• patient empowerment
• staff awareness and guidance
• travel

Communication

Communication is important to consider in Poverty Proofing both from a health literacy perspective of how information is communicated and understood and in ensuring there are reciprocal lines of communication between services and service users. O’Dowd (2020) reported that availability of care was a particular concern for those on a low income and there were significant inequalities in care availability for the most deprived areas. Communication is a key factor in ensuring availability of care.

What works

The service is welcoming

For those using the Doncaster health and wellbeing service people suggested that they strongly agreed or agreed that the service is a welcoming place. Describing the staff as very friendly, welcoming, helpful and that they are good at their job. Also voiced was that seeing the same member of staff and the option of home visits helped.

“The staff are very friendly and welcoming.”

“You are all good at your job.”

“Staff are friendly, I get to see the same staff member, and they sometimes do home visits.”

“Very friendly and welcoming helped me feel relaxed and very helpful information.”

When staff working in the Doncaster Health and Wellbeing Service were asked what one thing they could change in their practice to make life better for people experiencing poverty they suggested

“Asking the patients direct questions.”

“Finding information to help patients.”

“Being able to access information quickly so not to make life stressful for patient.”

“Asking patients if they require any support and where they can find help.”

Barriers and challenges

A few people using the service suggested that if they could not afford their care they felt they could talk to staff about this challenge, however majority people who responded suggested they were not sure, this appeared to be as the question had not been asked about Poverty, but could be supported by staff asking the question.

“Never had a chat on this.”

When staff working in the service were asked what they believed the poverty-related barriers were for patients accessing the service majority staff suggested:

“Communication (no data or access to credit WiFi).”

“Health literacy (understanding of written materials or verbal communication).”

Improvements

When people who use the service were asked how the service could improve its understanding and support for patients facing financial barriers they suggested:

“Better training for staff.”

“Better communication and outreach.”

People who use the service also suggested it would help if they received more information on community resources or financial help for their healthcare, and when asked what more services could do to support families on low incomes to take up the care on offer, majority of people suggested:

“Give clear communication about available support.”

When staff members were asked what the barriers to communication are, they reported:

“No data, access to credit or WiFi.”

“Health literacy (understanding of written materials or verbal communication).”

Recommendations for communication

Ask direct questions about poverty

• Consider asking the questions about poverty at the initially contact.
• Consider asking the questions about poverty at all physical health check meetings.
• There is some work across the trust to send out text messages to patients to suggest people who are experiencing poverty and may result in not been able to attend appointments can gain support for this, look out for more information on this and ensure this is incorporated into practice.
• Ensure peer support workers are able to ask the question about poverty and support people to access the support.

Health literacy or communication

• This constantly came up in the voice of both patients and staff.
• People mentioned they would benefit from more information around tackling their financial issues.
• Staff suggested it would be helpful to have access to information quickly
• It would be helpful for staff to ensure this information is available in appointments.
• Consider developeing a resource pack that is available.
• Ensure staff are aware if the Citizens Advice resource available across the trust that could support with this focus area.

Offer non-digital options for all key communications to reduce digital exclusion

• Identified as a trust issue, work is starting as a trust to look at this challenge.
• It would be helpful if people are asked about their communication needs and preferences, and this is recorded on SystmOne.
• Refer people to Citizens Advice in Rotherham, Doncaster and North Lincolnshire for digital support programme.

Health related costs

“Money buys goods and services that improve health; the more money families have, the more or better goods they can buy.” (Joseph Rowntree Foundation, How does money influence health? 2014).

The Food Foundation (2023) found that in order for the poorest fifth of the population in the UK to meet the Government recommended healthy diet guidance they would need to spend half of their disposable income, compared to just 11% for the least deprived fifth.

What works

Cost to patients

Of those who access Doncaster health and wellbeing service, majority of people suggested they did not have to pay for any items or services as part of their healthcare, and some agreed that the service was accessible and affordable for everyone, regardless of their financial situation. However, there were people that suggested they sometimes had to pay for items related to healthcare.

Appointments

Half the people who gave their voice denied they have had to delay or miss an appointment due to financial reason (travel, childcare, prescriptions). The service offers care and support in people’s home and communities if needed, reducing the hidden cost of health care.

Barriers and challenges

Cost to patients

Although those who access Doncaster health and wellbeing service, in part suggested they did not have to pay for any items or services as part of their healthcare, there was also people suggesting they sometimes had to pay for item related to healthcare that were not affordable. Limited people also suggested they were aware of any support provided by the service, or that services help you access support if struggling with poverty, those who did suggested they were aware reported they were aware of support for “prescription costs.”

When people who access the service was asked what type of financial support would be most helpful to you, they reported:

“Help with travel expenses.”

“Support with access to digital interventions (device data).”

“Delivery for prescriptions.”

When staff were asked what more the service could do to support families on low incomes to take up the care on offer, staff reported:

“Complete the training and ensure the team are aware.”

Appointments

Although some people who use the service suggested they did not have to delay or miss appointments due to financial reasons it was reported that this challenge affected more than half the people who responded, when people were asked why they had to delay or miss appointments due to finical reasons they reported:

“Cost of travel and taxis.”

“Can’t Drive into the centre and busses trigger angina.”

“Travel cost.”

“Buses and taxis are too expensive.”

Improvements

When staff were asked what they believed were the barriers to patient accessing services, they reported:

“Costs of appointments (time of work, childcare, missed free school meals),”

“Communication (no data or access to credit WiFi).”

When people who use the service were asked how the service could improve its understanding and support for patients facing financial barriers majority of people suggested:

“More financial assistance programs.”

Recommendations for health related costs

Travel Costs

• There is a trust wide process for people experiencing poverty to access travel support (bus passes), please ensure staff are aware of this and use this resource
• It would be helpful if staff are aware of any schemes or benefits that people can access to support with cost of equipment (for example, personal health budgets, Health Care Travel scheme and prescription support)
• To continue to offer flexibility in appointment for example: home visits, in people communities and the use of peer support
• Ensure peer support workers are able to ask the question about poverty and support people to access the support for travel cost and the areas of focus below.
• Encourage routine discussions around health-related costs as part of holistic care.

Support with access to digital interventions (device data)

• Identified as a trust Issue, work is starting as a trust to look at this challenge.
• It would be helpful if people are asked about their communication needs and preferences, and this is recorded on SystmOne.
• Refer people to Citizens Advice in Rotherham Doncaster and North Lincolnshire digital support programme.

More financial programs

• The trust have recently gone into partnership with Citizen’s Advice Bureau in Rotherham, Doncaster, and North Lincolnshire. Ensure staff are aware of this service and how to refer people who may benefit from the service.

Navigating and negotiating appointments

Life can be particularly unpredictable when living on a low income. The challenges, for example around childcare or zero hours’ contracts can make attending appointments very difficult. Pressures on the NHS around waiting times and stretched services can mean there is little scope for flexibility and strict discharge policies are applied for those who miss appointments, effectively severing access for those with changeable circumstances. Furthermore, social problems often accompany poverty, and sometimes life can be chaotic, which makes consistent appointment attendance difficult. Availability and flexibility of care are important for improving access to health care for those on a low income.

The King’s Fund (2021) report states that:

“Services need to be flexible, accessible, responsive and offer continuity of care.”

What works

Appointments

The service offers care and support for people on a clinic a basis that are in people’s communities, majority of the clinics are held in general pactice so people who use the service should be familiar with the environment. The service also offers an outreach service into people homes if there is a need for more flexibility. It needs to be highlighted that the Doncaster health and wellbeing service was one of the first service to adopt peer support workers in partnership with a community organisation, peer support workers can support people to navigate and negotiate appointments. Due to this flexible approach people who use the service should have less challenge with navigating and negotiating appointment which is evident in the feedback.

When staff who work in the service were asked if there anything they feel their service does well for patients and families who need additional support due to their income, majority of staff suggested they believed they did do things well for example:

“Peer support helping to get to appointments.”

“We have peer support workers that will help with patient needs and support them with financial worries and the local community activities.”

“We have peer support workers that will go out to our patients and help with patients needs, for example, taking to appointments, getting support for sorting out their gardens, helping to fill out complex forms.”

Barriers and challenges

A positive note is that both people who use the service and staff who work in the service did not voice many of barriers to navigate and negotiate appointments. People who use the service did not voice any barriers to navigate and negotiate appointments which is testimony to the service flexible approach.

When staff were asked which poverty-related barriers apply to patients accessing your service staff members suggested, Complex Health Systems (difficult to navigate, referrals appointment ) which given the evidence the team have already worked to address.

Improvements

When staff were asked what more could the service do to support families on low incomes to take up the care on offer, people suggested

“Provide more financial help.”

Recommendations for navigating and negotiating appointments

Provide more financial help

• The trust have recently gone into partnership with Citizen’s Advice Bureau in Rotherham, Doncaster, and North Lincolnshire. Ensure staff are aware of this service and how to refer people who may benefit from the service.
• It would be helpful if staff are aware of any schemes or benefits that people can access to support with cost of equipment (for example, personal health budgets, Health Care Travel Scheme and prescription support)
• Use the peer support resource to support people who use the service to feel comfortable to ask for this helps and to support them to access this support

Complex health systems

To continue to offer flexibility in appointment for example: home visits, in people communities and peer support.

Page last reviewed: May 29, 2026
Next review due: May 29, 2027

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