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Poverty proofing report hospice 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 hospice

The Poverty Proofing audit for hospice services (to include hospice inpatient, cancer information centre, St John’s counselling, community palliative service and day therapy) began in November 2024 in order 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 trust hospice services.

2.1 Hospice inpatient

St John’s Hospice inpatient unit is a service in Doncaster providing specialist palliative end of life care to adult patients and their families.
The service provides help with symptom management and end of life care, supporting with complex, uncontrolled or difficult-to-manage symptoms.

2.2 Cancer information centre

The St John’s Cancer Information service is delivered by an experienced team of health professionals and offers a range of information and support including:

  • booklets and leaflets
  • emotional support
  • referrals to local and national services
  • information about living with cancer
  • cancer screening information
  • recognising early signs and symptoms
  • healthy lifestyle advice
  • links to clinical teams

2.3 St John’s counselling

The counselling service supports individuals with a life-limiting illness and their families, offering high-quality, personalised care that addresses emotional, physical, psychological, social, and spiritual needs. It aims to empower individuals and carers by providing tailored support.

2.4 Community palliative service

The Doncaster community specialist palliative care service supports patients and families living with life-limiting illnesses by providing expert care, symptom management, and home support. We collaborate closely with your GP, district nurse, and other healthcare professionals.

2.5 Day therapy

The St John’s day therapy unit, located at St John’s hospice, supports patients with life-limiting conditions by improving quality of life and managing symptoms. Through guided activities and connections with others, the service helps patients achieve personal goals and enhance wellbeing.

Sessions are typically in group settings, though one-to-one sessions may be arranged when needed. They can be full or half-day sessions or in a clinic-style format.

Patients have access to:

  • peer support and socialising
  • a range of activities supported by our activity coordinator
  • self-management education sessions
  • exercise classes
  • one-to-one assessments and support
  • complementary therapies or hairdressing
  • offer of complementary therapies or hairdressing
  • referrals to other services
  • a variety of information resources
  • lunch and refreshments

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.

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 hospice services 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 The service is welcoming

Those using the hospice services said that their communications have always been positive. The staff are always kind and helpful, and they really value the service that they receive.

  • “I can talk to them about anything.”
5.1.1.2 Communication is generally easy and speedy

Communication is typically good across all hospice services. For all outpatient services, the majority of important information is relayed during appointments, so there is little need for contact in between, which is ideal for most patients. Patients feel it is easy to get in touch and they know to use the triage line to cancel or rebook appointments.

Upon referral, the service provides a holistic based assessment which includes a brief discussion about the patients’ finances but this only for cancer patients as it is carried out by Macmillan.

There is good evidence of collaborative working with the Macmillan team which allows for better patient support, and patients find they do not have to keep repeating their issues.

  • “When you call the service there is the option to leave a message and getting a call back which is great, I used it a couple of weeks ago and got a call back same day.”
  • “Support from the service has never resulted with the need of using my mobile phone, most of the information spoken about we usually are provided with information to take away.”
5.1.1.3 Patient confidentiality is important

Patients and their carers felt reassured that confidentiality was particularly important in the service, and they really appreciate the password system which is in place for inpatients. This means that when carers or family members calls the hospice for an update on a patient’s condition, they must provide a password which has been previously agreed before any information is shared.

  • “The password system is good.”

5.1.2 Barriers and challenges

5.1.2.1 Translation services are problematic

All Hospice services use translation services for both face-to-face and telephone appointments, where necessary. However, it has been widely noted that the interpreter service which currently holds the contract is particularly unreliable with last-minute cancellations and faulty connections being a regular occurrence.

  • “Interpreter services are not great as it is a dial in-service over the phone which when you get cut off during a consultation and you call back you get a new person you speak to which result in the conversation having to start all over. This was mainly for the inpatient service.”
  • “We use interpreters for more face to face appointment but, at times we get the interpreter cancelling last minute.”
5.1.2.2 Leaflets for information

In the community service, patients have commented that they would like to see more leaflets which can direct them to any financial help they may be entitled to.

  • “It would be great to have some leaflets on the back of the sessions offered to refer to if I need the help again or to reflect but have never had this.”

5.1.3 Recommendations for communication

5.1.3.1 Translation services

This is a consistent theme across the Poverty Proofing audit, and the trust should consider procuring a more reliable approach which is more appropriate for patients and staff.

5.1.3.2 Leaflets

Several community patients mentioned they would benefit from more leaflets around tackling their financial issues. It would be good to staff to take some out with them so they can be offered, and for any gaps in information to be identified.

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). 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.

5.2.1 What works

5.2.1.1 Support with some health-related costs

For the vast majority of patients within the hospice services, they are really pleased with the support available with their health-related costs. In the hospice itself, patients receive a comfort pack which includes face wipes etc and most qualify for free prescriptions due to their long-term conditions. Patients also acknowledge and appreciate the free parking which is available to all.

  • “My prescriptions are free, I don’t have to pay towards them.”

5.2.2 Barriers and challenges

5.2.2.1 Discrepancies around incontinence pads

Some patients expressed issues around having to pay for incontinence pads for use at home and they can be very costly. One patient told us that they spend £30 per week on incontinence pads. Staff within the service offered some clarification around this; patients are referred to the incontinence service if needed. The incontinence team will assess the patient and, if they meet a certain threshold, they will receive their pads on prescription. If they do not meet the threshold, then the patient must fund this themselves.

In addition to this, patients also have preferences around the types of incontinence pads. If they wish to have pull-up style protection, then this is not available on the NHS. Only the standard pads (of varying sizes) are available on prescription.

  • “Pull-ups are not available on the NHS.”
5.2.2.2 Paying for funerals

Within inpatient services, there has been a rise in the use of GoFundMe and other similar online fundraising efforts in services like the hospice, particularly to pay for upcoming funerals. Patients and their carers spoke about their nervousness around affording a funeral and what their funeral might look like with very little funds, this adds further distress to an already upsetting time. Macmillan nurses are able to direct relatives of those with cancer to bereavement grants but availability of funding for non-cancer patients is unclear.

  • “There has been conversation with families who have mentioned that they have had to set up ‘GoFundMe’ to be able to cover funeral cost.”
5.2.2.3 Parking

For counselling services, several patients commented on the lack of parking although they are very appreciative that is it free. Visitors are able to park anywhere for free on the trust site, not just the Hospice area, but not all patients and carers are aware of this.

  • “It’s great that there is free parking on site, but there are times when there are no spaces, and you must spend some time driving round to find a spot.”
  • “Parking is not easy, I have to drive around a bit until I find a parking space.”
  • “Parking was a bit tricky today as none of the disabled bays where available. The car parked next to me on disabled bay did not have a badge displayed.”
5.2.2.4 Café

At the St John’s building, there is a café which is fantastic for visitors who are spending extended periods of time there in with loved ones. However, the café is often closed due to staffing issues and has developed a reputation for being unreliable. Most visitors will bring their own food now, as they cannot risk the café not being open. There have been multiple comments about how they wished the café could be open to make things easier for them.

  • “Issues with the café let down what is an excellent service.”

5.2.3 Recommendations for barriers and challenges

5.2.3.1 Discrepancies around incontinence pads

Information around incontinence pads to be made clear, including why pull-ups are not advised. Patients to continue to have their incontinence needs routinely reviewed, including for those who have not been deemed incontinent in the recent past.

5.2.3.2 Parking

To make patients and carers aware that they can park for free anywhere on the trust site and there is plenty of availability. However, it might be a slightly longer walk for some, which might not be feasible. Where possible, staff should avoid using areas in high demand.

5.2.3.3 Café

Facilities team to urgently review staffing in the café to ensure it is more widely available for visitors of the inpatient ward. Many depend on quick meals and the café currently cannot offer this consistently.

5.2.3.4 Signposting

A review of what funding or grants are available to bereaved families (not just those who are poorly with cancer).

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

In appointment-based services, most people have not missed appointments due to financial reasons; however, this is not to say that some do not struggle to make them due to tight funds.

5.3.1.1 Flexibility of appointments

Flexibility is a positive feature of the appointment system. In outpatient services, the next appointment is usually made whilst the patient is attending their appointment, which means they can choose a future time and date which is most convenient for them. Blocks of appointments are sometimes made, so the patient knows exactly when they need to come over the next several weeks.

5.3.1.2 Rescheduling appointments

Patients feel it is easy to get in touch with the service and they know to use the triage line to cancel or rebook appointments. The service does what it can to accommodate the individual needs of its patients.

  • “Counselling appointments are very flexible around those who work. At one time I had to request to shorten my appointment due to having another appointment which was better that not having to cancel.”
  • “Appointment offered are flexible. I have been offered virtual or telephone appointment, but I prefer face to face.”

5.5 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.

5.5.1 What works

5.5.1.1 Comfortable in asking for help

The vast majority of patients feel as though they could ask for help if they needed it.

  • “We would be comfortable in speaking to the staff here about any concerns they are great I guess even if it was about finances they would be able to signpost in the right direction I think they are good like that.”

5.5.2 Barriers and challenges

5.5.2.1 Staff awareness

Patients are keen for the services to engage with additional learning about how they might better be able to support those in their care. This is something which would evidently be mutually beneficial for all.
When asked about what the service does to support those facing financial hardship, some staff said they felt unsure about what the service does, and some staff said they would benefit from some kind of training. Better staff awareness would empower patients to better support themselves.

  • “I have never needed to talk about my financial situation, but equally have not been asked.”
  • “Better training for staff.”

5.5.3 Recommendations for patient empowerment

5.5.3.1 Providing information to patients which they might not otherwise have access to

Patients would like to know what is available to them as they are not always able to find out themselves. This could include charities, food banks and benefits.

5.5.3.2 Staff awareness

Staff expressed an interest in knowing more about how to support patients. It is recommended that more staff attend the Poverty Proofing training delivered within the trust, with a view to more bespoke training delivered by Citizens Advice.

5.4 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.

5.4.1 What works

5.4.1.1 Visual assessments

In community services, staff already do visual assessments of a person’s financial circumstances and are able to make judgements about any potential financial hardship as they visit houses and can see surroundings or environment. Some staff will have conversations with patients who they feel are struggling financially.

5.4.2 Barriers and challenges

5.4.2.1 Staff awareness

Supplementary to the section above were patients expressed a desire for staff to be able to supply information, the staff themselves were also keen to engage with additional learning about how they might better be able to support those in their care. This is something which would evidently be mutually beneficial for all.

  • “Some patients do disclose issue with money worries or help with things around the house. Is not always easy to know who to refer them to.”

5.4.3 Recommendations for staff awareness and guidance

5.4.3.1 Visual assessments
  • Where staff rely solely on visual assessments, it would be good practice to make conversations around poverty more routine to ensure nobody slips through the net.
  • It would be ideal to initiate conversations around financial difficulty with those living in our Core20Plus5 areas. This information can be found on our SHAPE app, or on RePortal.
5.4.3.2 Staff awareness

As recommended above, staff expressed an interest in knowing more about how to support patients. It is recommended that more staff attend the Poverty Proofing training delivered within the trust, with a view to more bespoke training delivered by Citizens Advice.

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 Barriers and challenges

5.6.1.1 Travel to appointments

During patient consultations, some patients expressed a dissatisfaction with the cost of transport to enable them to get to appointments which relate to their condition. Many patients are unable to use public transport due to low immunity or poor mobility and rely on private methods of transport instead. Volunteer services are used as much as possible, but there is a shortage of drivers and, therefore, the demand is often not met. Alternatives such as taxis are particularly expensive, and the costs can be inconsistent which makes it difficult to budget.

  • “Taxi fares vary: Dependent on the taxi company you get the fare is always different 2 weeks ago got a taxi that cost £7 and today it was £4.90.”

Staff were also able to provide additional context:

  • “Patients who use our service rely more on the volunteer drivers to get them in and these are in short supply at the moment.”
  • “For services like day therapy, it would be great if we were able to provide the service at home as well especially for those who are unable to leave home and allow for more 1-to-1 provision. This has been stopped due to staffing levels.”
5.6.1.2 Staff travel

During staff consultations, staff expressed some frustration with the process for claiming mileage. Due to the nature of the community role, full-time staff may have to input lots of miles worth of claims per week which can be very time-consuming for them. The process is not automated.

5.6.2 Recommendations for travel

5.6.2.1 Transport options

The trust, as a whole organisation, needs to consider a wider approach to transport as this is evidently a critical issue. Volunteer transport needs to be expanded, and private transport needs to remain available for those who cannot use public transport.

5.6.2.2 Co-wheels
  • All staff to register with co-wheels.
  • The trust to look more widely at how co-wheels are used. Those without cars (due to unforeseen circumstances) should be allocated a car, even at short notice.
5.6.2.3 Automated mileage system

The trust to consider an automated mileage system which also builds a colleagues working day, choosing sensible routes with the fewest miles.

6 References

Page last reviewed: June 19, 2025
Next review due: June 19, 2026

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