Poverty proofing report early intervention in psychosis 2024

1 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 CNE 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: Locally trained team roll out half day workshops to the remainder of the services. Through this approach, services will learn how to work with their patients to identify barriers and to apply the learning and approach to their own services and settings 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.

2 Poverty proofing Rotherham early intervention in psychosis

Children North East engaged with Rotherham Early Intervention in Psychosis during September, October and November 2024, in order to better understand the experience of families and individuals who are living in poverty. It was the third of the trust services to undergo the Poverty Proofing process.

The work was carried out in partnership with staff and patients to build up a rich picture of the barriers and challenges faced by those accessing or attempting to access the early intervention service. Due to the nature of psychosis, senior staff felt that telephone consultations would be the most appropriate way of gathering voice from patients. This required the service to approach patients first in order to find out who was willing to share their experiences and they then passed on patient details to Children North East. On contacting patients, Children North East were faced with a high drop out rate.

Rotherham early intervention in psychosis (EIT) service is based at Swallownest Court, Aughton Road, S26 4TH. As stated on the website, “the service uses diverse approaches to assist individuals” who have experienced a first psychotic episode. This includes aiding in understanding their situation, medication, individual or family therapy, supporting education, employment, finances, and engaging in physical or group activities.

Early intervention in psychosis is such a specialist, bespoke service, tailored very much to the individual needs of each patient. Such close working could create natural opportunities for co-designing and collaboration with patients around any developments to the service. Exploring opportunities to develop partnerships within the community could also prove to be beneficial to this service, amongst others.

In Rotherham, 16.8% of the population was income-deprived in 2019. Of the 316 local authorities in England, Rotherham is ranked 45th most income-deprived, where 1 is the most income-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 white, middle-class conversation they can’t tap into.” In addition, “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).

3 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.

3.1 Voice

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

3.2 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.

3.3 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?

4 Poverty proofing process

4.1 Stage 1: Training and consultation with staff

18 staff completed a three-hour training session.

4.2 Stage 2: Scoping

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

4.3 Stage 3: Patient and community consultations

We spoke to 89 people in total who attended the service. This included adults, parents and carers and young people.

4.4 Stage 4: Feedback session

A feedback session was held with a senior member of the podiatry staff and a senior strategic development manager from the trust, where we discussed our findings and collaboratively considered various changes that could be implemented. We then produced this final report.

4.5 Stage 5: Review

Around 12 months after completion, Children North East will return and complete a review, identifying impact, good practice and potential considerations moving forward.

5 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 Rotherham early intervention in psychosis were:

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

5.1 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.

5.1.1 What works

5.1.1.1 Easy to contact the service

Patients were confident that they could easily get in touch with the service, especially their care co-ordinator (CC), whose personal phone number they had. Email was another option of communication, preferred by others. There is no heavy reliance on digital means to access support from the service, which is good from the perspective of those patients with the least resource.

“Usually care co-ordinator email, which is my preference. Therapist is the same and text. The only letters are to do with the hospital, like neurology, explain what we talked about in the appointment.”
“Ever since, any time I need them, I just have to message or phone. I never feel lost, there’s always a phone number.”

5.1.2 Barriers and challenges

5.1.2.1 Patients without phones

Staff explained that the nature of psychosis means that patients are at higher risk of losing or breaking phones and they are too expensive to keep replacing. They are sometimes faced with competing challenges of paying for a phone or paying for food. Not having a phone will affect the ability of the patient to contact the service and vice versa. It ends up that they try to access the service through a relative’s phone.
Staff:

“People making decisions, trying to make the least worst decision, not making the appointment.”

5.1.2.2 Use of interpreters

On most occasions, a telephone interpreter will be used. At the press of a button, interpreters of virtually any language can be found, although staff did explain that there is a distinct lack of interpreters for Roma, Slovak and Hungarian languages. Staff said that face-to-face interpreters tend to be saved for events such as a medical review.

While interpreters are largely readily available on the phone through DA Languages, barriers exist because of poor connection, unclear sound and other technical difficulties; alongside the occasional cancellation at the last minute or failure to turn up.

Another barrier is about language itself, for example, not having a specific word to match the English word. It can be difficult for the staff to fully know how the patient is feeling and how much they are understanding the conversation. So much of what gets discussed in appointments is very personal and of a delicate and sensitive nature. Staff said that when using an interpreter, they have to be very structured in a way that they usually would not be. They described it being difficult to put a patient at ease, because of going through a third party. Patients need to feel as comfortable as possible during appointments, so will often ask for the same interpreter to be used each time, although this rarely appears to happen.

Staff: “I don’t think the service we use is the best; just this morning one (interpreter) didn’t turn up. We can cancel and rebook, but this delays treatment and it’s cruel to make them (patient) wait. We only have one Roma Slovak interpreter.”

People not proficient in the English language are unlikely to be getting an equitable service as the interpreter service is not able to deliver the same as for a person who does not need to use them. As we were not able to speak to any patients who made use of the interpreter service, it cannot be said for certain whether poverty is exacerbating this barrier or if it is just a language issue. However, research would suggest that there is likely to be a correlation. “Most Black and minority ethnic groups are disproportionately affected by socio-economic deprivation, a key determinant of health status.” (Ethnic health inequalities and the NHS, NHS Race and Health Observatory, 2021)

This is an area to be further explored. Are patients ever asked for feedback on their experiences of using interpreters? What else is going on in communities? Are there other networks of support available? Can the language barrier be approached in a different way?

5.1.3 Recommendations for communication

5.1.3.1 Patients without phones

Contact Good Things Foundation or other charities or organisations about providing phones for those patients without. They may give free sims and data too. Also worth contacting the local council, for example, Oldham council has a scheme for providing digital devices to patients in need of one.

5.1.3.2 Use of interpreters

Explore possibilities for increasing availability of interpreters for Roma, Slovak and Hungarian languages.
Review the current system for interpreters. Consult with staff and patients on this to uncover what is and is not working about it. What needs to change to make it work for even the poorest patients?
Investigate community alternatives to the current interpreter system.

5.2 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).

5.2.1 What works

5.2.1.1 Staff awareness of costs

Staff show knowledge and awareness of the prohibitive costs of buying extra items, so will be cautious around any suggestions they make to the patient. They may promote the benefits of healthy eating and exercise, and follow this up with signposting to local food banks. They will always look for cheaper alternatives to help the patient.

5.2.2 Barriers and challenges

5.2.2.1 Staff reclaiming costs

Various staff have spoken about spending their own money out of a need to help a desperate patient, only to then struggle to reclaim these expenses. This includes money spent on providing food for a patient with nothing, because food banks were closed and unavailable. On another occasion, a patient had chest pains so staff dropped him off at hospital and they gave him £20 for a taxi home. A senior staff member described having to really “fight” to get that money back for her staff.

If £10 or less is spent by staff, this is not really questioned and can be claimed back. However, even in these cases, due to a convoluted process, staff have said they often don’t bother “because it’s more hassle than it’s worth.” These small costs, unclaimed over any period of time, will mount up to significant money that not all staff can afford. For any claiming back of amounts above £10, justification to the senior leadership team (SLT) is required. When staff approach managers to claim, the manager feels pressured to interrogate their staff about the circumstances for them spending the money. This whole process puts staff in a very difficult predicament when faced with a patient in immediate need of support.

“I feel like I’m having to challenge people so much, but that’s not coming from me, it’s coming from above. It feels like you’re saving money, but where’s the patient in that? It’s frustrating, feels like nobody else is supporting you.”

5.2.3 Recommendations for health related costs

5.2.3.1 Staff reclaiming costs

For costs of £10 or less, make the process simpler for staff to use.
Consider introducing a petty cash fund that can be accessed by staff to avoid the need to “claim”.
As a trust, explore other possible processes to avoid putting unnecessary financial burden on staff, while providing necessary support for patients.

5.3 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.”

5.3.1 What works

5.3.1.1 Flexibility of appointments

The frequency of appointments tends to follow a pattern. New patients or patients in crisis can expect weekly appointments for at least the first month, then go down to fortnightly appointments. This will generally reduce to monthly appointments for up to three years, but may be for a shorter time if the patient no longer needs support. In terms of appointment locations, they can be offered at the patient’s home, in clinic, or somewhere else agreed upon; and one member of staff said they could be offered at the patient’s local GP practice, although none of the patients spoken to said they had done this.

The service works really hard to offer great flexibility in appointments, in order to accommodate the needs of its patients. Appointments with care co-ordinators are flexible and are arranged together with the patient, which gives an element of choice in time and location whenever possible. This helps to eliminate many hidden costs often incurred in attending appointments, such as unpaid time away from work, the cost of travel and the difficulty of arranging childcare. Text reminders are also sent, which is very helpful, especially for people living very chaotic and stressful lives, as is often the case for those in poverty.

“I can work around childcare, they are flexible.”

Appointments can be face-to-face or on Teams if preferred. This has been beneficial to students, who have been able to squeeze Teams appointments in during timetable gaps, whereas they would have had to miss lessons if only able to attend face-to-face.

“For care co-ordinators appointments either home or virtual. Works well for me, but now I’m back at school so virtual works well. Equally helpful, we do Teams so we can see each other.”

Care co-ordinators will always give the option of going out to see patients at home. This removes the potentially enormous barrier that travel can create, both financially and from a practical perspective. Many patients are unable to drive, due to the anti-psychotic medications they are on, meaning they would otherwise be forced to use public transport, which may be very difficult for a person with psychosis, or use a taxi at great cost.

“Appointments are at my house; they have done that from day one. It’s always what they have done.”
“Sometimes at the clinic, sometimes at my house. They ask me where I want it and I decide.”

5.3.1.2 Easy to rearrange

Patients spoke of the ease with which they can change or rearrange appointments, just with a phone call, text or email. Through a poverty lens this is useful because being able to contact the service easily and receive tailored advice and support when they need it, reduces patient stress, did not attends (DNAs) and the need to access 111 or Accident and Emergency (Mallorie, 2024).

“Depends on how I’m feeling. If I need to I can bring my appointment forward.”
“I don’t miss school at the moment. Recently I had exams, not many frees, so I emailed the therapist and she cancelled it and made a new date.”
“It was flexible, it was easy enough to cancel or rearrange and yeah was always flexible.”

5.3.1.3 Various means of referral

A referral comes through as a task on the IT system. It will then be discussed in the morning meeting and be allocated to one of the clinicians, according to availability. The clinician will be responsible for contacting the patient.

Patients entered the Early Intervention service through different means. It may have been a visit to their GP, who then referred them on; or a visit to the hospital, which resulted in admission. For others it was a case of friends, family or colleagues observing changes in their behaviour and prompting them to seek help, either through the GP, hospital or the Early Intervention service itself.

“My daughter gave me their number and told me to ring them, she googled it.”
“Through the hospital, they sectioned me.”

If there is any hint of psychosis, there is a 2-week time period, which staff said they were quite good at meeting.

5.3.2 Barriers and challenges

5.3.2.1 Physical health check clinic

The appointments that create the highest number of did not attends (DNAs) are the Friday physical health check. This is a necessary and important part of the process, to keep a check on any impact caused by psychotic medication taken, which can for example cause weight gain and other serious side effects. These appointments take place at the start of the early intervention in psychosis journey, then again at one, three, nine and twelve months, then annually after that. While patients are encouraged to attend clinic for these appointments, staff said that they do offer mobile health checks at home, which would remove the need for the patient to travel. So, the question then is why are there still so many DNAs for these physical health checks?

One patient said:

“The only thing is health checks, it would be good if the care co-ordinator had equipment to do the checks when they come for my appointment.”

According to staff, this is possible; in which case, is the barrier created because not all patients are aware of this flexibility around health check appointments, and incorrectly believe that they must be done at a clinic?

5.3.2.2 Unable to record reason for did not attends

It is also worth noting that when a did not attend (DNA) occurs, staff said it gets put down in the system but not the reason why; it just says they did not attend “just ticking a box.” Poverty may be a factor underlying this perceived lack of engagement with the service, yet will remain hidden unless there is opportunity to record this on the system. Consequently, patients in poverty may be inadvertently discriminated against.

5.3.2.3 Home visits may not be appropriate for all patients

While home appointments can help avoid travel costs for patients, they are not always the venue of choice. Staff have spoken of occasions when a patient, especially someone living in deprivation, may feel embarrassed or ashamed of their home environment, and the thought of having someone visit may cause them added stress. An alternative location has included meeting in a park, but this was not really a suitable place for having a confidential conversation. Even the offer of a taxi to clinic may not be appropriate for some patients, whose traumatic experiences will prevent them from even being able to get in the taxi.

We were unable to dig deeper into the potential barrier of home appointments for those in poverty, but staff comments suggest this is definitely something to investigate further. This is something to explore in partnership with patients directly affected.

5.3.3 Recommendations for navigating and negotiating appointments

5.3.3.1 Physical health check

Ensure all patients are aware of the flexibilities around the health check appointment.

5.3.3.2 Unable to record reason for did not attends

Review the current system of recording did not attends (DNAs) and explore ways of adding the reason, in order to build an accurate picture for each patient.

5.3.3.3 Home visits not appropriate for all patient

For those patients most financially vulnerable, create a care package with them, where they get a say in where appointments might take place, etcetera.

5.4 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.

5.4.1 What works

5.4.1.1 Patients are aware of their long term plan

Patients are generally made aware of their long term plan, once joining the service. This is good Poverty Proofing practice, because it means information is forthcoming and it takes any pressure away from the patient having to ask. Self-advocacy can be difficult to muster for those overwhelmed by poverty. People know they are in the hands of the service for up to around 3 years.

“I do have a long term plan, for about 3 years at the start, clear.”
“They were quick, straight on the ball from the word go. Up to 3 years with them. Take a step at a time.”
“I’ve got another 25 sessions of cognitive behaviour therapy, which I get every week.”

5.4.1.2 Strong relationships

Without exception, patients spoke of the strong, trusting relationships they have been able to build with their care co-ordinator and other members of the team.

“The consistency; you build up a bond, a good friendship.”
“Fantastic relationship with them.”
“I can’t recommend them at Swallownest highly enough. They’re even great with the little one!”

5.4.1.3 Holistic approach

The early intervention in psychosis service is quite unique in terms of the level of support it provides to its patients. The one-to-one personalised approach of the care co-ordinators, working alongside wider members of the team, creates that delicate balance of support and empowerment. Patients have described feeling listened to. If there is anything they do not understand, they feel empowered to be able to ask. Even in terms of collecting prescriptions from the pharmacy, the staff have taken care of this, rather than see the patient struggle.

“She took me swimming. I moved home and she supported me to sign for the property.”
“If I don’t understand something, I can just ask, they’ll put it into simple speak.”
“They put me in touch with the counselling team, I am having that once a week which is really helping.”
“From the word go, they’ve been straight there, dealing with my meds, even when I was really poorly… they brought meds out to me, always saying any problems give me a ring.”

5.4.1.4 Family support

Patients have spoken so positively about the impact of family group sessions. While we were not able to speak to anyone who actually said they were lonely or isolated, evidence suggests that poverty creates social exclusion and isolation. Therefore, while having this strong family support network is invaluable to all patients, it can be particularly significant for those with the least resource.

“She explains things to the wider family, it’s insanely useful. I’m not very good with words, especially if I’m having a bad day, not very good socially. It’s so beneficial to have someone else explain things. My mam, grandad, other half, daughter, sometimes my brother, it’s the best social thing that’s helped other people understand what I’m going through.”
“Yeah, well we had training, the whole family had training, it really helped us all understand each other better. We listen to each other now. It’s a lot nicer.”

5.4.2 Barriers and challenges

5.4.2.1 Availability of support groups and activities

Patients have spoken very positively about groups they have attended, often accompanied by a support worker, including craft/art classes and a walking group. However, the barrier arises in the difficulty getting there. Groups are only on in certain areas, meaning many patients have a significant journey to make, which can be costly and logistically challenging. This is prohibitive and prevents everyone from being able to engage equitably with these opportunities. And as explained in the previous section, being able to engage with groups may be even more valuable for those who are financially vulnerable, socially isolated and don’t have a strong family network.

“There’s a walking group, art class, the support worker went with me, just in the short term. If they had more groups on with people who’d experienced the same thing, that’d be good.”
“They recommended a couple of different things, a crafts group, but that’s quite far for me to go, miles away. A lot of the crafts and stuff are far away from me. Getting there, it’s quite a long way. They have provided a taxi for me once. If there were closer ones, I’d go.”
Staff member: “Groups and classes are impacted by poverty, if people don’t have money for travel; fitness group, do they have money for clothes?”
Staff: “Funding, for us and community groups. There are a lot of things in one area but not in others, out of our control. We try and find alternatives and put things on shared drives.”

In feedback, it was explained that this is something already being looked into by the service; that it’s already a work in progress.

“We put groups on, but people don’t turn up so it’s a waste of resource. We’re not putting on as many groups now. Craft groups are external, we don’t pay for them. I will authorise taxis for people to get here. They (patients) get a lot out of it. We now have a combined peer support walking group, alternate where that is from week to week. A rota, patients sent out a leaflet so they know where they’re on. We’ve got 150 patients, never going to get everyone there.”

5.4.3 Recommendations for patient empowerment

5.4.3.1 Availability of support groups and activities

Service to continue ongoing work in this area.
Trust, examine the spread and availability of support groups across the area and explore options around making opportunities more equitable.
Ensure everyone who is eligible has been given a disability bus pass for free travel.

5.5 Staff awareness and guidance

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. Quality of care was worse in the most deprived areas for all of the 23 indicators analysed and in 11 out of 23 indicators, the inequality gap was widening (O’Dowd, 2020). Patients will have different needs depending on individual, demographic, systemic and social needs and countless other factors. This theme is around identifying the social and economic needs of patients and giving holistic care so that they can be fully supported.

5.5.1 What works

5.5.1.1 Support with employment and benefits

Many patients experiencing psychosis have had to give up their jobs, which had serious repercussions on their financial wellbeing. The personalised, individual care provided by the service generally ensures that patients get what they need, when they need it, as far as possible. Care co-ordinators have supported patients to apply for Universal Credit (UC) and Personal Independence Payment (PIP). They have arranged for food parcels to be given to patients who were struggling to afford food and have contacted charities to source other necessities. Patients identified just how difficult it was to fill out benefit application forms and were thankful to have had the support of the care co-ordinators.

“I used to work. Not now, had a total breakdown. The care co-ordinators have found me food parcels before, (name) got me lots of stuff from charity. Supported me to get Universal Credit. Sorted out Personal Independence Payment, just waiting for them to make a decision.”
“The paperwork was the hardest part; instead of doing the usual sessions we used them to go through the paperwork. Halfway through, then it seems to be asking the same things over again. A bit of a nightmare to leave work.”
“They looked for people who I needed to get in touch with for finances, benefits etc. They gave me the numbers, that kind of thing. I can’t remember where they put me in touch, but yeah was good.”

Another invaluable role within the service, from a poverty perspective, is that of the vocational occupational therapy, whose role is to help those patients who want to work, to access work. They will also look at what is available out and about in the community. They explained that their role is not just a one-off contact with the patient, but that they will remain in contact for the duration of their involvement with the service. They will support them according to need.

5.5.2 Barriers and challenges

Staff explained how a person’s physical health and social crisis affects their ability to engage with interventions. They need to address the practical support required, such as benefits and housing, before addressing their mental health. When a patient is in crisis and has no food, this must be dealt with first.

5.5.2.1 Availability of food banks

Food banks provide a vital source of food in desperate situations, but staff expressed concern that they are only available in certain locations and on certain days of the week. Consequently, sometimes staff have clubbed together in order to put together a food and clothing package for patients; or they have driven across town to pick up a food parcel, which costs them petrol money they can’t claim back in full.

One suggestion was to start a food bank within the trust for people who are desperate, that staff can have access to at any time. This would ensure that the patients’ needs could be met without delay and it would prevent staff covering the cost themselves and impacting their own financial stability.

“A lot of food banks are the other side of the city or days away.”
“We thought about making an emergency food box in the office.”

5.5.2.2 Supporting asylum seekers and refugees

Particular concern and frustration was expressed by staff about the challenges faced by asylum seekers and refugees, who they said are not entitled to anything. Staff spend time trying to find loopholes, in a bid to provide much needed help and support. This will also be compounded by the language barriers discussed earlier.

“Asylum seekers, 50 quid to live on, no remit for any other financial support or massively struggling, no money for travel, trying to get him a bus pass. Just to meet basic needs, bought bedsheets etc out of my own pocket that isn’t being re-imbursed.”
“We try to work as joined up as possible, third sector groups or charity groups for patients.”

In feedback, it was explained that staff sometimes get access to free training opportunities, but there is nothing specific relating to asylum seekers and refugees. This could definitely be an area of development for staff, to help empower them in providing support to these patients. Also suggested were a 7 days-a-week food bank that staff could access at any time; and a petty cash fund that staff can use to claim back personal expenses used to support patients in emergencies.

5.5.3 Recommendations for staff awareness and guidance

5.5.3.1 Availability of food banks

Consider how and where food banks can be made available 24 hours a day, 7 days a week for professionals to access in the case of patient emergencies

5.5.3.2 Supporting asylum seekers and refugees

Provide staff with training on benefits, especially relating to the entitlements of asylum seekers and refugees. This will empower staff to know everything they can do to support, within current regulations. As a trust, think outside the box for ways to support those patients with the very least.

5.6 Travel

Healthwatch UK (2019) showed that travel is a key issue for patients, 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 patients 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.

5.6.1 What works

Staff travelling to patient houses for appointments cuts down massively the burden on patients, both financially and logistically.

Many patients are eligible to get a disability bus pass which gives them free travel. This is something the care co-ordinator would help the patient to apply for. It can take months to actually receive the bus pass; and occasionally they will be declined, meaning the care co-ordinator will support the patient to go through an appeals process. It was also explained that staff can do some training with patients to support and empower them to be able to use public transport.

5.6.2 Barriers and challenges

The biggest travel challenges for patients are in attending their physical health check appointment at Ferham and being able to get to various support groups. Many people with psychosis rely on friends or family members to drive them, because they are not allowed to drive while on anti-psychotic medication. Add into this the potential difficulty for people with psychosis to travel on public transport and it becomes challenging. Some patients are so unhappy to travel on the bus, that they will get a taxi despite the higher cost.

“It depends on what kind of day I’m having, sometimes the voices are so loud I start answering them back, so then I get off the bus and walk.”

At feedback, it was explained that previously taxis would regularly be used by the service to transport patients, but that they are now told not to do that. The same is true of staff being able to transport patients in their car. Maybe there is a better way to integrate health into the community, to use community support in creative ways? This links with both the Child and adolescent mental health service (CAMHS) and podiatry services in their need to transport patients.

5.6.3 Recommendations for travel

5.6.3.1 Patient travel

Ensure all eligible patients have a free disability travel pass.
Ensure all patients are aware of the flexibilities that exist around attending their physical health check appointments.
Trust, investigate ways of integrating health and community support.

6 References

O’Dowd, A. (2020) Poverty status is linked to worse quality of care.
Fenney, D. and Buck, D. (2021), The King’s Fund, The NHS’s role in tackling poverty: Awareness, action and advocacy.
Literacy Trust (2012), Adult Literacy (opens in new window)
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.

Page last reviewed: May 13, 2025
Next review due: May 13, 2026

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