Poverty proofing report NHS Talking Therapies 2024

Contents

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 NHS Talking Therapies

The Poverty Proofing audit for NHS Talking Therapies (to include Doncaster, Rotherham and North Lincolnshire place) began in January 2025 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 NHS Talking Therapies services.

NHS Talking Therapies provide treatment to adults who are struggling with symptoms of common mental health problems such as depression, anxiety and stress.

Talking Therapies can offer a range of different treatments which can take place on a one-to-one basis or in a group setting, the service also offers support to adults living with long-term health conditions and who are experiencing symptoms of depression, anxiety and, or stress.

The service can help with a range of therapies for example: cognitive behavioural therapy (CBT), counselling for depression, couples therapy for depression, eye movement desensitisation and reprocessing (EMDR), interpersonal therapy and guided self-help.

The service is provided in person in the community at various clinic bases that cover Doncaster, Rotherham and North Lincolnshire, or via telephone, video call or text messages.

Referrals into this service are mainly from GP surgeries and other healthcare professionals, however people can also self-refer into the service,

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

Key findings from a Mind report of August 2021 tell us, “There’s still a lot of shame about money and mental health. Many feel mental health is a while, middle-class conversation into which they can’t tap. Poverty increases the risk of mental health problems and can be both a causal factor and a consequence of mental ill health.” (Poverty and Mental Health, Mental Health Foundation, August 2016).

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 NHS Talking Therapies 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 NHS Talking Therapies services said their communication and their contact with staff had been positive, describing staff as approachable, always felt welcomed, not judged, and thankful the service existed.

• “The staff are lovely, and I feel that I can ask for help they’d be able to help me.”
• “Calls are answered very quickly.”
• “Very calm, don’t feel judged.”
• “Staff are very pleasant, caring and professional.”

People that used the service also suggested that the access to a variety of methods to complete their appointment, and the text messaging service was helpful to enable them to attend their appointments.

• “I had an instance when I couldn’t make face-to-face, and they offered me telephone or video.”
• “I always get a text reminder the day before.”

5.1.2 Barriers and challenges

5.1.2.1  Interpreters

In some cases, people using the service require the use of interpreting service to be able to discuss their needs and treatment. However, it has been noted that the current service is often inaccessible in terms of response or turning up for appointments.

• “At times interpreters will not turn up.”

5.1.2.2 Digital

Staff identified at times that by making the service more flexible and accessible there is a risk of excluding some people.

• “As a service, and across the trust we can digitally exclude people, we can assume people can access text messages and have smartphones. Need to be mindful some patients can’t complete pre-assessment questionnaires.”

Patients did suggest that more support around digital access would be helpful.

• “I am given homework, which is sometimes emailed through, and husband helps with this for technology as he has the contract which has more data provision.”
• “Support with digital is always helpful.”

5.1.2.3 Information

Those using NHS talking Therapies said that access to resources regarding financial support is varied, at times information is there in the form of leaflets, but the usefulness of the information is questioned, some people also suggested they had not been asked the question about their financial situation.

• “More points of information within the clinic. There are no materials offering information on the help.”
• “I’ve never been asked the question, incorporating asking questions about financial barriers at the start would be helpful.”

5.1.3 Recommendations for communication

5.1.3.1 Interpreting 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 Digital (ensure communication with people is based on their needs)

• Ensure people are asked about their communication needs and preferences, and this is recorded on SystmOne.
• Refer people to Citizens Advice Doncaster’s digital support programme.

5.1.3.3 Information

People mentioned they would benefit from more information around tackling their financial issues. It would be helpful for staff to ensure this information is available in appointments.

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

Those who access Talking Therapies services, in part suggested they did not have to pay for any items or services as part of their healthcare and agreed that the service was accessible and affordable for everyone, regardless of their financial situation.

• “It’s free at the point of access.”

Staff also reported that if people are facing challenges they will connect with local organisations.

• “We do link in with Crossby Community association, age UK, the pantry and clothing banks.”

It was reported that the service was flexible of how they offer appointments, which supported any hidden healthcare cost of childcare and taking time off work.

• “Patients can attend virtually or face-to-face to keep costs down.”

5.2.2 Barriers and challenges

5.2.2.1 Cost to family

Although some patients discussed that the service was flexible and offered alternative appointments and worked with their preferences, some people preferred to meet face to face. Of these people some suggested that family members supported them to attend appointments and those that caught the bus discussed issues with some bus services.

• “Making sure there is support for transport when people can’t afford it.”
• “Escorted by daughter who had taken time off work to attend, could mean loss of earnings for daughter.”

5.2.2.2 Resources

Both patients and staff recognise the possible challenge of the recommendation to use diaries for homework which are at cost to patient

• “I’ve had to purchase a diary to write some of my reflections.”
• “I am not very technology minded so I have purchased diary to keep track of my homework.”

It was also identified that at times apps maybe recommended to support self -help and interventions, however not everyone may have access to a mobile phone.

• “Apps are recommended, but not everyone has a phone.”

5.2.3 Recommendations for health related costs

5.2.3.1 Cost to families

• To continue to offer flexibility in appointment for example video or telephone if appropriate.
• To continue to offer appointments that are flexible around work arrangements, to ensure no extra cost is incurred.

5.2.3.2 Resource

• Provide information or training to staff about having conversations with people about poverty.
• Make sure staff know what is available for people, in terms of entitlement, where there is a cost to accessing care (for example, personal health budgets)
• Provide information to people on correspondence (for example, letters, texts) about contacting the service if they have problems with affordability.
• Ensure staff discuss the option of printing resources for people if they are unable to afford apps and dairies.

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 Appointments

People that access the service suggested they have not missed appointments due to financial reasons and that the flexibility they have been offered or granted when requested had been helpful. This has included flexibility in the method, day, and time of the appointment.

• “The service is great we get appointments that are offered either by phone or virtual.”
• “Flexible so the relatives do not have to take time off work, 6 weeks holidays more difficult.”
• “I’m able to work my appointments around my work schedule.”

It was also suggested that when appointments must be cancelled or re-arranged the service will contact people back to arrange an alternative.

• “Call back to re-arrange when cancel.”

5.3.2 Barriers and challenges

5.3.2.1 Childcare

Some patients reported they had to pay for childcare to be able to attend their appointment, staff reported that if in intensive therapy this could increase.

• “I would hope that we were able to bring back the day centres, physical recovery centres or even a crèche of sorts to allow for parent who require high intensity session to be able to attend without having to worry about childcare.”
• “Childcare for patients who need high intensity therapy, may struggle to come appointments.”

It has been reported that some people are unable to accept appointments as they are unable to take time off work for financial reasons.

• “I have had lots of patients say it’s not possible with work and finance, and don’t want to sacrifice their 30-minute lunch break or prefer face-to-face.”

5.3.3 Recommendations for navigating and negotiating appointments

5.3.3.1 Child care

• To continue to offer flexibility in appointment for example video or telephone if appropriate.
• To continue to offer appointments that are flexible around work arrangements, to ensure no extra cost is incurred.

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 Comfortable in asking for help

People who access the service reported that they felt the service would support them if they were unable to afford their care.

• “I’m confident to raise any concern with the practitioner and know they will try and help.”
• “Very approachable.”

When staff recognise that patients may be having issues with poverty, they have acted on this and supported patient to gain support.

• “Sometimes when staff are having video consultation with patients, it’s the norm to see patient wearing coats and hats telling them that their house is cold and can’t afford to put heating on.”
• “Sometimes we find ourselves supporting patients to fill in forms for personal independence payment (PIP) or giving them access to be able to make a phone call to have appointment set for their benefits.”
• “Staff members help patients to access the food banks and to obtain food vouchers.”

5.4.2 Barriers and challenges

5.4.2.1 Financial support

When patients were asked how the service could improve its understanding and support for patients facing financial barriers, they suggested more financial assistance programmes and points of information.

• “Provide more financial help.”
• “More points of information within the clinic. There are no materials offering information on the help.”

5.4.3 Recommendations for patient empowerment

5.4.3.1 Financial support

The trust has recently gone into partnership with Citizen’s Advice Bureau, ensure staff are aware of this service and refer people who may benefit from the service.

5.5 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.

5.5.1 What works

5.5.1.1 Additional provisions

The service is particularly good at identifying where patients need extra support in relation to poverty, supporting them to gain the extra support needed either by using sessions to empower patients to act or to refer people to food banks, voluntary organisations, or charities.

• “We signpost to a lot to other services and do ask and share information amongst each other, we try to check in and make sure we are empowering patients.”

When staff were asked “how well you feel your service supports patients and families in poverty” majority of the staff that responded suggested “well”.

5.5.2 Barriers and challenges

Staff awareness

Although staff were good at identifying people’s need in relation to poverty, they also suggested it would be beneficial to have more knowledge and support around what support is available, suggesting this would give staff confidence.

• “It would be beneficial to have knowledge of what support is available to patients or where we can signpost them to, so that they get the help they need.”
• “Empowering staff to have the confidence to know what’s on offer.””
• “It would be interesting to know how many of staff have read our financial wellbeing section under talking therapies.”

When staff were asked “what one thing could you change in your practice to make life better for people experiencing poverty” staff suggested:

• “A way of identifying this need, which is private and sensitive for the person.”
• “Further questioning around current difficulties or impact on quality of life.”
• “Ask questions everyone questions around finances and if they are problematic for them.”

5.5.3 Recommendations for staff awareness and guidance

5.5.3.1 Additional provision

Having info as standard to give to all patients about poverty and support available.

5.5.3.2 Staff awareness

• Staff expressed an interest in knowing more about how to support patients. It is recommended that staff attend the Poverty Proofing training delivered within the trust, with a view to more bespoke training delivered by Citizens Advice.
• Ensure all staff are aware of the financial wellbeing guidance available to Talking Therapies.

5.5.3.3 Having conversations with people about affordability

• Provide information or training to staff about having conversations with people about poverty.
• Make sure staff know what is available for people, in terms of entitlement, where there is a cost to accessing care (for example, personal health budgets).
• Provide information to people on correspondence (for example, letters, texts) about contacting the service if they have problems with affordability.

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

The service is delivered over three places been Rotherham, Doncaster, and North Lincolnshire, in a variety community settings.

• “The service is conveniently located as it doesn’t take long to get her from the bus station as I only get one bus from where I live.”
• “Parking with where the service is located is great. I have a 45-minute appointment today and the parking just nearby is free for 1 hour.”
• “Some practitioners work from GP surgeries which help to increase the spread of the areas we cover. This does have benefits due to the rurality of some of the areas and how infrequent bus services run in those areas.”

5.6.2 Barriers and challenges

5.6.2.1 Help with travel costs

When were staff asked, “what poverty-related barriers apply to patients accessing your service?” all reported travel and transport costs. People who use the service and prefer face to face appointments do have to attend clinics and travel to their appointments which as times can be difficult and have a cost impact.

• “Patients struggling to afford the cost of travel.”
• “A patient called to say that they weren’t able to make it for their appointment due to not having enough bus fare.”

People who use the service and prefer face to face appointments do have to attend clinics and travel to their appointments which as times can be difficult and have a cost impact.

• “Public transport isn’t great around here.”
• “I get dropped off by my husband as there is limited parking and whenever we have been there is never a free space to park.”

About a quarter of the people who use Talking Therapies and responded said they would like more financial support with travel costs. The lack of support is putting pressure on them in other ways (that is, affording other basic necessities).

5.6.3 Recommendations for travel

5.6.3.1 Travel cost

• This is a trust wide area of focus; work will be developed in May for people to access travel cost to attend healthcare appointments if appropriate. This may involve pre-loaded travel cards or similar for people who do not have the money up front.
• Communicate with staff the nationally publicised help that is available for people which is published on the trust website:
  • help with transport costs
  • NHS Low Income Scheme
  • help with health costs for people on Universal Credit
  • help when you need to pay for NHS care (prescriptions, dental care, eye care wigs and fabric supports)
  • personal health budget
• The trust has recently gone into partnership with Citizen’s Advice Bureau, ensure staff are aware of this service and refer people who may benefit from the service.

6 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.
• Disability Living Allowance (DLA) for adults

Page last reviewed: May 29, 2025
Next review due: May 29, 2026

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