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 high intensity 2026
The Doncaster High Intensity Care team (HICT) is a specialist service within Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) that provides intensive, relationship based support to individuals experiencing complex emotional needs and recurrent mental health distress. The team works closely with Doncaster community mental health teams, offering an additional layer of therapeutic intervention for service users who find it difficult to engage with traditional models of care.
In response to rising mental health–related demand on police services, the National Partnership Agreement Right Care, Right Person was introduced in 2023. The policy aimed to ensure that people presenting in mental health crisis receive appropriate support from health professionals rather than the police. As a consequence of this shift, South Yorkshire Police formally withdrew their integrated role within the High Intensity Care team in June 2024. This change created both a challenge and an opportunity to further develop the High Intensity Care team as a clinically led, trauma informed service embedded within community mental health provision.
The primary purpose of the High Intensity Care team is to work with individuals who often have extensive histories of psychological trauma, adverse childhood experiences, and disrupted relationships with services. Many service users experience deep rooted fears of rejection and abandonment, mistrust professional intentions, and may feel passive or powerless in relation to their care. High Intensity Care team aims to address these challenges by prioritising therapeutic relationships, consistency, and collaboration, enabling service users to regain a sense of control and agency.
The High Intensity Care team model is underpinned by a set of core principles aligned with trauma informed care. These include an asset based approach that focuses on strengths rather than deficits, a flattened expert–patient relationship that emphasises partnership, and a non prescriptive approach to engagement. The team promotes psychological and physical safety, adopts a guiding rather than directive stance, and supports long term engagement where discharge is collaboratively negotiated rather than imposed. Service users are supported to participate actively in their own crisis planning and benefit from consistency and direct access to named practitioners.
Integration with Doncaster community mental health teams is central to the future development of High Intensity Care team. The service operates as an adjunct to, not a replacement for, existing locality teams. Referrals no longer rely on formal documentation; instead, care coordinators can make referrals through direct discussion or email, enabling timely and responsive decision making. Importantly, referral criteria have broadened beyond frequent emergency service use to include individuals with complex emotional needs who may not present in crisis settings.
High intensity care only accepts referrals for individuals already open to Doncaster community mental health services, ensuring continuity of care and avoiding parallel or fragmented support. Ongoing collaboration between High Intensity Care team practitioners and care coordinators is considered essential, supporting shared understanding, influencing practice culture, and improving outcomes for service users. This collaborative approach is further strengthened through monthly High Intensity User Group meetings, enabling multi agency information sharing and joint decision making.
Overall, the Doncaster High Intensity Care team provides a flexible, trauma informed, and relational model of care that enhances existing community services and responds directly to the needs of individuals living with complex emotional distress.
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 the 3-hour training on poverty proofing in March 2026 and 1 staff member attended.
Stage 2: scoping
Time was spent gathering information about the service and how it works and consultation were held with staff.
Stage 3: patient and community consultations
We received feedback from 11 individuals.
Stage 4: feedback session
A feedback session was held with Barbara Taylor, Service Manager and Christian Guest, Clinical Nurse Specialist where findings were discussed, and changes were collaboratively discussed that could be implemented.
Stage 5: review
Around 12 months after completion, the trust will complete a review identifying good practice and potential considerations.
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 high intensity were:
- communication
- health-related costs
- navigating and negotiating appointments
- patient empowerment
- staff awareness and guidance
- travel
- housing
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
Staff communication
Staff communication was consistently described as friendly, helpful and supportive. This relational approach seem to play a key role in engagement from patients, and such communication play a key role in building a foundation of accessibility of the service.
“It’s very helpful due to my physical and mental health, I look forward to seeing X.”
“I can talk to staff about my problems.”
“Yes, I am very well supported.”
“I feel comfortable, easy to talk to.”
“Good service from community team.”
Flexible communication
Flexible communication methods are being used phone, text email and virtual platforms. Having direct access to staff improves on responsiveness and trust, and having same day call back supports continuity.
“Patients.. have direct contact… if a patient calls and I’m engaged… I will ring them back that same day.”
“I cancel my appointments often due to my mental health, but they still support me.”
Barriers and challenges
Interpreter services
While getting an interpreter isn’t difficult, the variability of interpreters affects the quality and consistency of communication through dilution of nuances in mental health conversation.
“The interpreter… doesn’t quite understand the mental health problem… it doesn’t replicate what you’re saying.”
Lack of formal feedback
Formal feedback while available via Care opinion are underused due to QR code and digital barrier
“we’ve received a few thank you cards, not so much on the care opinions… because of the QR code.”
Recommendations for communication
Interpreter services
Improve continuity and offer to create training of interpreters in mental health. This can be through developing guidance for working effectively with interpreters in mental health context via leaflets for improving understanding on different mental health conditions.
Communication
Maintain and protect direct contact arrangement as core poverty proofing measure.
Feedback
Provide non digital feedback options (paper, verbal or text message).
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
Financial conversations
Financial issues are actively identified during assessments. Staff are then able to support patients with benefits, crisis loans, financial navigation and contacting DWP. Having such holistic discussions with patients allows to early on set targets to work together which includes employment and financial wellbeing
“…it’s about life…, the holistic life, not just about one narrow view… are they well enough do voluntary work or employment, or it’ll just be a natural discussion of, right, what’s the next goal.”
“We will see them through the process of the phone call as some of them due to the mental health can get quite frustrated and angry on the phone and, you know, just can’t tolerate the phone call very well with their consent.”
Barriers and challenges
Cost to patients
Hidden costs still exist, which include cost for data and internet access required for virtual or telephone appointments and travel costs. Out of the eleven patients who responded on one informed that they had had to delay or miss and appointment due to financial reason. However, eight chose “help with travel expenses” as they type of financial support that would be helpful to them. With “help with prescription cost” as the other financial support sought. Anxiety and mental distress make financial systems harder to navigate independently.
“Too expensive… depends on what benefits you are able to have.”
Financial resilience
Limited financial resilience among patients and difficulty manging money due to mental health conditions, can cause delays in improvement of mental health. Therefore, it is crucial to support the financial resilience of patients but be able to offer this as support as it can be harder for them to navigate independently
“Some people… aren’t that good with money… money management is not brilliant.”
“Some get crisis loans…. we’ll ring together and get it sorted.”
“Too expensive… depends on what benefits you are able to have.”
Of all the patient who responded over 50% sighted that help with prescription cost and help with travel expenses would be the financial support that would be most helpful to them
Recommendations for health related costs
Health related cost
- Proactively discuss hidden cost of healthcare with patient to find out where these are to be able to support.
- Share information on prescription exception available or option to reduce prescription costs.
- Share where required the trust travel fund support available to patients to attend appointments.
Financial resilience
- Build routine pathways for financial advocacy support, this could be though community banks.
- Referral to Citizens advise for patients Doncaster Citizens Advice.
- Develop financial assistance programmes that patients can access that can help them learn better money management.
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
Appointments within the service are delivered through a highly flexible and person centred system, with all arrangements fully negotiated in line with the individual’s preferences, capacity, and current needs. Contacts can take place in the service user’s home, community settings, hospital environments, or virtually, ensuring accessibility and continuity of engagement. Appointment frequency is tailored to clinical and emotional need rather than operational convenience, allowing support to intensify or reduce appropriately over time. Missed or cancelled appointments are not met with punitive responses; instead, they are viewed within the context of the individual’s circumstances and quickly rescheduled to maintain therapeutic momentum and trust.
“Everything’s on the table… phone appointments, virtual… however it works for the person.”
“100% of patients are offered an appointment venue of their choice either home clinical Base or an alternative of their choosing.”
“I cancel my appointments often due to my mental health, but they still support me.”
“I don’t have to travel for my appointments.”
Barriers and challenges
Although the above, when staff were asked which poverty-related barriers apply to patients accessing services one staff members informed:
“Complex health systems (difficult to navigate, referrals appointments)”
This was voiced to say even though we are supporting our patients with appointment flexibility there is still issue when they are referred on to use other services within RDaSH that relate to lack of flexibility of appointment types as the service tend to be location based reintroducing travel barriers.
“Two buses away… there’s not a chance they’re going to pay… it is a big factor.”
When navigating complex health systems, it’s beneficial to know what support is available. This was another area raised by 50% of the respondents that being given clear communication about available support would support them in their care journey. While this can be affected by limited staffing within the service to improve expansion and outreach consideration can be made via other services
Recommendations for navigating and negotiating appointments
Complex health systems
- Advocate for embedding flexibility as a non-negotiable best practice on referral to partner services on behalf of patient to ensure continuity of care.
- Share where required the trust travel fund support available to patients to attend appointments even when referred further on to other services within the trust.
- Provide support for digital navigation (apps and booking systems).
- “Get another staff member or join forces with South Yorkshire Police again” (patients’ recommendation).
Patient empowerment
Being in poverty can be hugely disempowering and contribute to reduced literacy skills (Literacy Trust, 2012), lower educational attainment, lower levels of confidence and less engagement with health behaviours and healthcare (Sheehy-Skeffington and Rea, 2017). Services can support this by tailoring support to different education and literacy levels, working alongside patients and families to build health literacy and confidence in managing their health as independently as possible and ensuring there are opportunities to share their views and shape services.
What works
Patient led
Care is shaped around a collaborative, recovery focused ethos in which patients lead decisions about their appointments, engagement, and overall direction of support. Emphasis is placed on sustained, long term engagement to build trust, confidence, and shared decision making, with interventions prioritising the development of coping strategies rather than reliance on purely medical models of care. Patients are actively supported to pursue meaningful personal goals, including employment, education, or volunteering, as part of promoting independence and social inclusion. Discharge from the service is deliberate, gradual, and led by the patient, reducing feelings of insecurity or abandonment. With consent, staff also take an active advocacy role, working alongside patients to represent their interests and support navigation of wider systems and services.
“Discharge is negotiated and gradual… led by the patient.”
“Engagement… is negotiated by the person really.”
“Yes, I am very well supported.”
“Good service from community team.”
“I can get referred to other services if I ask.”
Barriers and challenges
Socioeconomic barriers impact
Financial stress can significantly undermine an individual’s confidence, limiting their ability to challenge systems, advocate for themselves, or seek support when it is needed. Many patients report feeling unheard or insufficiently supported during periods of crisis, which can further erode trust and confidence in services. Poverty constrains life choices and opportunities, often compounding emotional distress and restricting access to stabilising resources. Low confidence combined with emotional dysregulation can reduce a person’s sense of autonomy and capacity to make empowered decisions, while limited access to community resources further reinforces isolation and dependency.
“They are not bothered about me no more.”
“Money… limits the choices and lifestyle.”
Information provision and feedback
While information is shred with patients based on their needs and preferences and is made available in print, digital or as part of discussion. There is a greater focus on the more holistic approach rather than solely medical diagnoses.
Feedback tend to be more informal via text messages, cards and informal communication, as Care Opinion is less used.
Recommendations for patient empowerment
Social economic barriers
- Continue advocacy, focused practice as a core function.
- Strengthen trauma, informed approaches to ensure patients feel believed and supported.
- Provide structures goal setting and empowerment programmes which support access to education training or volunteering.
- Explore options for establishing or partnering with community day centres or one-stop shops to provide social and medical support for isolated patients.
Feedback and information provision
- Develop and maintain a bank of information shared with patients taking into consideration the reading age especially for information on holistic care.
- Develop text message feedback that can be collated and stored centrally to evidence and be used for service improvement.
- Encourage the use of care opinion on visits and support patient to use it where needed.
Staff awareness and guidance
This theme is around identifying the social and economic needs of patients and giving holistic care so that they can be fully supported. Research has shown that those living in England’s most deprived areas tend to receive the worst quality healthcare, for example with longer waits and worse experiences accessing appointments (O’Dowd, 2020). Patients will have different needs depending on individual, demographic, systemic and social needs, and countless other factors.
What works
Staff awareness
Poverty is proactively identified as a central factor in care rather than an incidental concern, with staff demonstrating strong awareness of how financial hardship impacts engagement, confidence, and wellbeing. Conversations with patients routinely take a holistic approach, exploring employment, volunteering, and broader life goals alongside mental health needs. Financial hardship is treated as a priority issue within support planning, and staff provide practical, hands on assistance, such as contacting services alongside patients, to reduce barriers, build confidence, and enable access to essential resources.
“Formal financial screening tools that are routinely carried out.”
“Verbal screening, asking those we think need help”
“It’s about holistic life… not just one narrow view.”
“We will see them through the process… as some… can’t tolerate the phone call.”
Barriers and challenges
Barriers to effective poverty proofing within services include a heavy reliance on individual staff judgement to identify financial hardship, resulting in inconsistency in recognition and response. Staff report variable confidence in their knowledge of available support and resources, which can limit the guidance offered to service users. This is compounded by limited staffing capacity within small teams, reducing time and opportunity for proactive intervention. The absence of a formalised poverty proofing framework means practice often depends on individual initiative rather than a consistent, structured approach, creating variability in how poverty is addressed across the service.
“Judgements of staff.”
Recommendations for staff awareness and guidance
Staff awareness
- Encourage uptake of poverty proofing training for members in the service.
- Increase staff capacity to meet complex needs
- Embed poverty awareness into supervisions and service design
- Develop and provide staff with clear up to date poverty support directories of services to refer into.
Travel
Healthwatch UK (2019) showed that travel is a key issue for people, with 9 out of 10 people consulted saying a convenient way of getting to and from health services is important to them. Difficulties with transport were also identified as a common reason that people will miss appointments. There is a phenomenon known as the poverty premium, where those with less money end up having to pay more for essential items, which further perpetuates the cycle of poverty. For some families (who do not have access to a car) public transport and taxis are more expensive than it would be to drive.
What works
Travel barriers are mitigated through flexible appointment locations at home or in the community that are offered. The offers of home visits reduces the need for transport and patient s highly value not having to attend base locations
“I don’t have to travel to my appointments.”
“X comes to see me in hospital or home.”
Barriers and challenges
High travel cost prevent access to extremal services. Patients at times can’t afford bus fares to services they are referred to. Some journeys may require two busses and this in turn can lead to disengagement
“£6 for a day ticket… there’s not a chance they’re going to pay.”
Recommendations for travel
Travel cost
- Support patient with free bus passes in line with the trust travel fund.
- Referral to Citizen Advice to see if there is support that can be provided for travel for the service user to link to their current allowances and situations.
- Proactively raise travel options during appointment booking especially when referring to other services.
Housing
What works
Housing issues are identified early in assessment and referral s are made to appropriate service, for example, housing support, food banks
“Some people are homeless… no money and no food.”
Barriers and challenges
Housing support
There is limited specialist housing options for people with complex emotional needs. Housing instability exacerbates mental distress and disengagement and impact on recovery.
Recommendations for travel
Housing support
- Strengthen links with housing providers and local authorities.
- Prioritise housing stability in care planning.
- Advocate for supported housing options for high intensity patients
- Advocate and help to develop integrated mental health housing pathways.
References
- O’Dowd, A. (2020) Poverty status is linked to worse quality of care.
- Literacy Trust (2012), Adult Literacy
- Sheehy-Skeffington and Rea (2017) How poverty affects people’s decision-making processes.
- Healthwatch UK (2019) There and back, People’s experiences of patient transport.
- NHS England. (2019). NHS Long Term Plan.
- Disability Living Allowance (DLA) for adults
- Help with health cost
Page last reviewed: June 02, 2026
Next review due: June 02, 2027
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