Poverty proofing Doncaster physical health specialists services 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 physical health specialists

The Poverty Proofing audit for Long COVID moving forward, cardiac rehabilitation, heart failure nursing, and viral hepatitis services began in April 2026 to better understand the experiences of families and individuals who are living in poverty.

The work was carried out in partnership with staff, families and adults to build up a rich picture of the barriers and challenges faced by those accessing  Doncaster long covid-moving forward, cardiac rehabilitation, heart failure nursing, and viral hepatitis services.

Long COVID: moving forward

The long COVID service is a team of specialists who provide people with education, advice, support, and treatment to help them understand their condition and manage their symptoms. The Service offers one to one and group therapy in a range of settings to suit a person’s needs.

The Doncaster long COVID service accepts referrals for people who are experiencing ongoing symptoms for 4 weeks or more since testing positive for COVID-19 infection or having a suspected infection with COVID-19.

Referrals are made by GP’s, advanced care practitioners, consultants, or allied health professionals, for example:

• physiotherapist
• occupational therapist
• counsellor
• community nurse
• pharmacist

People must have a Doncaster GP and be over the age of 18 to access the service.

Certain interventions occur through individual clinic sessions, while others are provided in a group setting. These interventions include:

• education on managing breathlessness and cough.
• advice for fatigue and sleep issues.
• gentle exercise to aid in returning to activity.
• mindfulness and relaxation techniques.

The service works in the community and is based at St Johns Information and Support Centre, Tickhill Road Hospital.

Cardiac rehabilitation

The cardiac rehabilitation service is a service that creates a plan for people after a heart event, surgery, or diagnosis. The team helps people return to an active life and feel confident about managing their heart condition in the future.

After a person’s heart event, a cardiac nurse will offer the person an appointment at clinic or at home if needed.

The service offers a wide range of physiotherapy options, including:

• group exercise and education sessions
• one-to-one sessions
• home visits
• walking programmes
• adapted Tai Chi and relaxation sessions
• home exercise plans
• self-help and instructional videos
• phone support or remote monitoring

The team of specialist nurses and physiotherapists work closely with someone’s GP and cardiologists to create a personalised plan.

Most referrals come from hospitals after an emergency admission, but a person can also be referred by their GP or cardiologist. The service also accepts referrals for physiotherapy through the heart failure and arrhythmia service if cardiac rehabilitation would help their recovery.

The service works in the community and is based at Cantley Health Centre in Doncaster.

Heart failure nursing

The heart failure and arrhythmia service is run by specialist nurses. The service supports patients who have irregular heart rhythms (arrhythmias) and those whose heart scans (echocardiograms) show their heart’s left side is not pumping well, a condition called left ventricular systolic dysfunction (LVSD).

The service use 24-hour heart monitors to check for irregular heartbeats if patients have symptoms such as a fast or fluttering heart.

People can also get help with:

• putting on 24-hour heart monitors
• doing heart tests called electrocardiograms (ECGs)
• checking blood pressure.
• taking blood samples.
• general health checks

If a person has heart failure, the GP or cardiologist can refer the person to the service, especially if a recent heart scan shows a problem or their symptoms are getting worse. If someone has used the service before and their symptoms have worsened, they can also contact the service directly to self-refer or using the online system.

The service works in the community and is based at Cantley Health Centre in Doncaster.

Viral Hepatitis

The viral hepatitis service has a specialised nursing team is highly trained in hepatitis C care and supports patients throughout their treatment journey across primary and secondary care settings, including local prisons.

The nurses provide:

• consultant-led hepatitis C clinics
• clinics at Doncaster Royal Infirmary and prisons
• combined support with drug and alcohol services in the community
• community clinics
• phone support services

Any adult diagnosed with hepatitis C, whether through a healthcare professional or via self-referral, can be referred to the service.

The service works across the community and various setting, and is based at Cantley Health Centre in Doncaster.

According to the Indices of Multiple Deprivation 2019, Doncaster is ranked 48th most income-deprived out of 316 local authorities. Of the 194 neighbourhoods in Doncaster, 68 were among the 20% most income-deprived in England.

In research by the Joseph Rowntree Foundation and King’s Fund:

“The authors describe how patients may struggle to access NHS diagnosis and treatment due to issues such as the cost of travelling, difficulties accessing online services, and paying for NHS charges. They also note that the stigma of poverty can lead to a reluctance to come forward for treatment, or to seek help more broadly, for example by accessing financial advice. Additionally, administrative processes, such as claiming back travel expenses, can be complex.”

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

​​11 ​staff completed a ​three-hour​ training session.

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

​​37 ​people who use the service completed a survey. We spoke to 16 staff who work in the services, and received 12 surveys from staff.

Stage 4: feedback session

A draft of the findings was shared with ​Samantha Edwards​ prior to publication. We will discuss our findings and collaboratively consider various changes that could be implemented at the poverty proofing community of practice group.

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 physical health specialists 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 friendly and welcoming

Every person told us that they felt that the service is welcoming and friendly. This is also supported by the positive feedback ​these services​ get on Care Opinion.

“The nurse I see is very friendly and welcoming and easy to speak to. Very professional.”

“Highly informative made to feel at ease especially re sensitive diagnosis.”

“Lovely team.”

“I’m greeted with a smile whether it’s in my home or at clinic and everything is explained to me why I’m on the treatment I need and if I don’t understand I get it explained in a simple way that I understand which then puts me at ease.”

“I’ve been attending the service for 12 weeks and really enjoyed it the people are great and I’ve really appreciated the help and advice given.”

Providing information in different languages

We were told by services that they will provide information in Easy Read, for example in cardiac services, and for people whose first language isn’t English provide materials that have been created by other organisations. For example, the viral hepatitis service use information created by the Liver Trust and Hepatitis C Trust that gives information about a person’s condition and treatment in different community languages. The viral hepatitis service will also use Google Translate and have an interpreter available via digital means, for example when supporting someone in prison or at testing events if needed.

“We use resources from the British Heart Foundation.”

Barriers and challenges

The language we use may mean some people don’t understand what is being asked of them, or is available

Whilst there are good examples, a number of staff said that the way we communicate with people might be a barrier to them understanding what is on offer to mitigate poverty. It is important to understand a person’s communication needs and ability, so they know what is available and the treatment they will receive.

Some challenges regarding interpreters

We were told that some challenges regarding interpreters exist. In Cardiac Services, staff told us that sometimes it would seem that interpreters who were being contacted remotely had a lot of background noise, which made the communication difficult. The Viral Hepatitis Service told us that getting a face to face interpreters who can speak Romanian and Vietnamese respectively had been a challenge.

“Phone interpreters can be unreliable, poor signal, background noise.”

“Face-to-face is preferred but often unavailable.”

“Patients may leave without full understanding.”

“Booking is really, easy. The only problem we’ve got, if you can call it a problem, is you’ve got no chance. There’s no point even trying to book somebody in person most of the time. It’s going to be over teams.”

“We have had problems with interpreters who was late to every single appointment.”

Recommendations for communication

Communicating with people based upon their needs and ability

Make sure people are asked about their communication needs and preferences, and this is recorded on SystmOne.

Make sure communication needs and preferences are recorded in SystmOne

Check with people that they understand what is being communicated to them. Get them to explain what is being said.

Interpreters

Ensure that any issues (for example, availability, performance) regarding interpreters is recorded on Radar as an incident.

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

People have not missed appointments because of costs

We asked people if they had ever missed an appointment because of costs: nobody said this was the case.

Barriers and challenges

Hidden costs of care

We were told by staff that the service asked them to pay for items they do not necessarily provide like weighing scales, blood pressure monitors, exercise classes, hand weights and foot pedals to support cardiac recovery. Also, suggesting more healthy diets, which often cost more. What isn’t clear is if the person has been asked if they have the money to pay for such items. This may mean people either don’t buy them or go without something else. Some staff told us providing (in some cases, loaning) equipment would be a good thing to introduce.

“Some pharmacies now charge for medication packs.”

“Patients may need to buy weighing scales.”

“We suggest using GP surgeries or pharmacies for free checks.”

“Some pharmacies provide free blood pressure services.”

“We do recommend a lot of dietary recommendations so, we’re almost prescribing this diet that’s unaffordable for a lot of our patients and always has been unaffordable for them.”

Staff might not feel confident in talking to people about money

When staff were asked if their service have a way to identify people who may be experiencing poverty they answered yes and suggested they did this through their judgement or verbal screening, though the process for this wasn’t something all staff thought the service has a way to identify people who may be experiencing poverty. It’s not clear how staff identify those they think need help, and those that don’t.

Cost of prescriptions

There are some instances where people will be entitled to free prescriptions. It may be that these people are entitled to Universal Credit or another benefit and should be referred to Citizens Advice for a money check. Some people told us that help with the cost of prescriptions would be a good thing to introduce.

“It would help if prescriptions were free for heart issues.”

Recommendations for health related costs

See if people are entitled to help with prescription costs

• Advise patients about the HC2 form and how to fill it in effectively.
• Advise that patients who are paying for prescriptions whilst their HC2 form is being processed, should keep their receipts to be reimbursed.
• See if people are entitled to financial support to help with health treatment costs (for example specialist diets).
• Make all staff aware that of the trust’s travel fund.
• Refer people to Citizens Advice Doncaster to see if they are entitled to support with transport or other costs and other benefits (link at the end of this report).

Other costs

• Consider purchase of regularly required equipment for loan.
• Look at potential other funding (for example, sponsorship) to source equipment for people on low incomes.
• Work with leisure and other providers to have free or subsidised exercise classes to help with people’s rehabilitation.

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

Giving people clear information

We were told by someone about their experience that really helped with their appointment.

“The staff member I met with was approachable and happy to answer my questions, and before the appointment took place it was very useful to have detailed instructions re: directions and what to bring to the appointment in advance by text message. The fact that the different segments of this message were labelled, so that any missing segments could be identified, was very helpful too. The clinician was knowledgeable and professional, yet able to communicate that knowledge in an accessible and relatable manner, which was most welcome.”

Flexibility where some services are provided

We were told by staff that they would look to arrange appointments close to where people live. For example, the Cardiac Service will work from a local GP surgery close to where a person lives. Staff also told us if someone has told the service that affordability is an issue to attend appointments, they will try and arrange a home visit.

“We will see people at home if transport is an issue.”

“We work in leisure centres and clinics closer to patients homes.”

“We do try to allocate appointments in the area patients live already and provide home visits options if transport was unavailable or lack of funding. we have flexibility to provide the care we deliver to our patients.”

“Yes, clinic, home visits, phone, and virtual options depending on the patient.”

“We assess what works best for each individual.”

Service will be flexible to meet people’s needs

Staff also told us that depending upon a person’s circumstances, they would try to offer appointments in different ways and different times to meet needs better. Clear examples of this were in the viral hepatitis service, where there can be a stigma of people who have this condition. The service will look to see the person in community and more discreet settings. An example was also given of working with Eastern European Communities, where testing events were held using music to encourage people to attend.

“Hepatitis C peers will bring patients to appointments. We will go to the patient, that is take our clinic van to patient on street or outside their home. Will arrange to see patient outside of work hours so they do not miss work.”

Appointment reminders and follow-up if people do not attend (DNA)

Staff also told that people get reminders about appointments as well as initial confirmation when they take place. All staff told us there would be follow-up with people if they did not attend. For example, Viral Hepatitis Service told us that unlike many services, patients are not routinely discharged after missed appointments. The team recognises that engagement can be inconsistent, particularly among vulnerable populations. Staff continue trying to locate and engage patients, sometimes over several years.

“They like the reminders, they like the confirmations, they love all that. They like the fact that if they need to reschedule and appointment, I can send them option via text.” (long COVID)

“Because someone did not attend, we don’t discharge them. We never have.” (viral hepatitis)

Barriers and challenges

Opportunities for home appointments

Whilst we found that many services go to where the patient is / lived, we were told by some people that it would be good to offer appointments at home which would mean that costs of travel are avoided.

Appointment times

We were told by staff that the service could be more flexible in the times of appointment (for example, evenings and weekends). This would help people, for example, who had working or childcare commitments.

“Some patients struggle to attend due to work.”

Clarity on what to do about did not attend (DNA)

We were told by staff there could be contradiction between looking at poverty and out did not attend (DNA) policy. Staff felt more clarity was needed in what to do.

“We make contact or the first did not attend; we do give them seven days to rebook. if they haven’t been in touch, they get another one to say you need to contact us within seven days or you’ll be discharged.”

“The policy does state if you’re a second time did not attend, you’re supposed to go straight to discharge, but we’ve got patients that did not attend a lot more than that.”

Stronger community partnerships

Viral hepatitis staff told us that working with community leaders, peer networks and organisations such as parish nurses can open access to groups that traditional healthcare struggles to reach.

More community clinical spaces

Viral Hepatitis Staff said the service identified a lack of accessible local venues where staff can safely meet patients, undertake assessments and take blood samples.

“There aren’t enough clinical spaces around Doncaster where you can just pop in and use a room.”

Greater flexibility across healthcare

Viral hepatitis staff highlighted that many patients struggle because other services require them to fit traditional appointment systems.

“We work in a completely different way.”

Recommendations for navigating and negotiating appointments

Home visits

• Consider offering home appointments to people identified as being on low-income or with increased health risk, where this isn’t currently offered.
• Consider offering home appointments where possible, especially during the initial period of accessing the service. This could allow people to feel more comfortable and open up more than in a clinical setting.

Appointment times

• Consider if appointment times are meeting the needs of the whole family and if there are any caring responsibilities that create a barrier to accessing appointments.
• Identify which appointment times are suitable with patients during assessments or treatment sessions.
• Explore the possibility of providing more out of hours appointments so that those with zero hours contracts or the self-employed have more choice when booking appointments reducing the potential loss of earnings.

Did not attends

• Confirm the arrangements for managing did not attend (DNA) patients across each of the services.
• Contribute to any changes to did not attend policy, based upon the needs of people the respective services support.

Community spaces

• Look to use community spaces for clinics, in neighbourhoods where space is short.
• Some spaces that are available, including free ones, are on the Intranet and a link is at the end of this report.

Navigating health systems

• Identify key mainstream health services that should work with people with viral hepatitis.
• Hold an initial workshop (similar to what was done for homeless people) to see how people can be supported by the whole health system better.

Working with communities to support people

• Identify what peer and community support is available for people who use the respective services.
• Look to see who this can be strengthened.

Page last updated: November 09, 2026

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