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Poverty proofing report North Lincolnshire child and adolescent mental health 2024

Contents

  1. Poverty proofing delivery partner model
  2. Poverty proofing child and adolescent mental health services
  3. Poverty proofing ethos
  4. Poverty proofing process
  5. Common themes
  6. References

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 child and adolescent mental health services

Children North East engaged with North Lincolnshire child and adolescent mental health services during October and November 2024, in order to better understand the experience of families and individuals who are living in poverty. It was the second of the trust services to undergo the Poverty Proofing process.

The work was carried out in partnership with staff, families and young people to build up a rich picture of the barriers and challenges faced by those accessing or attempting to access the child and adolescent mental health services.

North Lincolnshire child and adolescent mental health services is based at St Nicholas House, Scunthorpe, DN15 6NU. As stated on the website, the child and adolescent mental health services team is a multi-disciplinary team of professionals, who provide “mental health assessments, therapy and interventions for children and young people up to the age of 18 years. Also to their families or identified carers when children and young people are experiencing emotional or mental health difficulties”.

According to the Indices of Multiple Deprivation 2019, of the 316 local authorities in England, North Lincolnshire is ranked 106th most income-deprived, where 1 is the most deprived. 13.3% of the population of North Lincolnshire was income-deprived in 2019. Of the 101 neighbourhoods in the area, 20 were among the 20% most income deprived in England, while 9 were in the 20% least 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). The Children’s Society states that, “Children living around debt are five times more likely to be unhappy than children who are not living around debt”.

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 North Lincolnshire child and adolescent mental health 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 Open phone lines

Clinicians are responsible for managing their own diaries, which means the phone line is not clogged with people trying to ring up to make appointments. As a result, communication channels with the service are generally open and available, with a member of staff always around to take calls. People will often only need to ring if they are maybe running late for an appointment and want to let them know that they are on their way; or if they need to speak to their clinician, in which case the person who answers will pass on the message and the clinician will usually ring back the same day if it is important.

  • “If you ring them, she will always ring me back. Ring reception, is it possible to speak to (clinician’s name), if she’s not available, they ask if I want to give her a message to ring me back. If I say it’s really important, she’ll ring back the same day.”
  • “I can email in but normally I call them, generally she replies, the clinician that overviews my son.”

Through a poverty lens this is useful because families can contact services easily and receive tailored advice and support when they need it, reducing stress, was not brought and the need to access 111 or Accident and Emergency (Mallorie, 2024).

5.1.2 Barriers and challenges

5.1.2.1 Relations with schools

Staff, rather than patients, have described there being a barrier in relationships with some schools. This is particularly relating to With Me In Mind, a low-level intervention service which does predominantly school-based work. The referral has to come through school, so if a parent does not have a good relationship with the school, staff said the school may be biased against the child and they felt that this would be a barrier to them accessing child and adolescent mental health services.

Child and adolescent mental health services staff have also said it can be hard to get responses from some teachers, as schools are very busy, and the staff are stretched.

Further barriers with schools will be described in later sections.

5.1.2.3 Communication with the crisis team

This barrier came to light through discussions with staff. If a patient in crisis rings reception, the admin staff have no means of directly putting them straight through to the crisis team. Instead, they end that call and have to pass a message on to the crisis team, who will then attempt to call the patient back. They described this as admin, “Holding the risk until it’s passed on to the next person.” It was said that only two attempts to contact the patient might be made that day. There was a common theme amongst participants and staff that unknown numbers were generally not answered by people. This risk may be increased for those in poverty because of factors such as low literacy, language, confidence and self-advocacy skills. If admin staff were able to put the patient’s initial call straight through to the crisis team, it would cut out the need for a call back. Uncertainty and not knowing when help will come is likely to be distressing for most people experiencing a crisis of any kind. The current call back policy, according to the views of staff, is furthering that distress for both staff and patients. This may be further compounded for those with an experience of poverty, where stigma, shame and scarcity are strongly correlated as are lower levels of tolerance for stress, lower resilience, coping strategies and mechanisms for support.

  • “These girls are taking these calls for a penny more than minimum wage, and the responsibility is on them, we should be able to re-direct those calls… We do feed it back on the system and do feed it back to SLT but nothing gets done. The admin team are going to be the last person to have spoken to someone if something did happen. There will be a child death at some point and until then someone won’t look at it.”

This is a heavy responsibility for low-paid admin staff not clinically trained. Whilst there may be nothing more they can do other than pass the message on, the worry of what may or may not happen sits with them.

5.1.2.4 Communication with triage

A barrier exists because of the need to call back the patient. A patient might receive a message from triage asking them to ring the service. When they do ring, admin cannot put the patient straight through to triage, and must instead take a message and let the patient know that triage will call them back. It is relying on the patient receiving a call back and being able to answer their phone.

  • “It’s frustrating because triage need the time, but patients get frustrated because it asks them to ring and then we tell them to wait for us again. The best we can do is ask for the best time a call back would be to make sure they speak to someone.”
  • “With triage, if they aren’t a child in care but they can’t phone back, so they don’t call back because they don’t have credit, or access to a laptop. What happens to those patients? Contact discharge.”

In feedback, it was explained that there are around 20 people triaged every day and that if the patient misses their call back, then they (triage) have already moved onto the next person. The service is currently, “Scoping out single point of access. Looking at overhaul of triage completely, if we get good quality referral, we wouldn’t need the same level of triage, could come straight to assessment.”

Bringing in single point of access might create positive change. Whatever is decided, consider co-designing it with the families themselves and build a new process around them and their needs.

5.1.3 Recommendations for communication

5.1.3.1 Relations with schools
  • Reflect on and seek to improve current engagement strategy with schools.
  • Identify which schools are not engaging appropriately and target these for specific intervention.
  • Ensure all school staff have a basic knowledge of child and adolescent mental health services, what it does and understand the importance of it. Advertising campaign, short video emailed out?
5.1.3.2 Communication with Crisis team
  • Investigate ways of removing the need for a call back.
  • Explore the possibility of making missed calls show up as “RDaSH” numbers, rather than an unknown number, so people are more likely to respond.
5.1.3.3 Communication with triage
  • Investigate ways of removing the need for a call back.
  • Complete the scoping out of single point of access and decide if this is the best way forward, looking through the lens of the patient with the least resource.
  • Consider in relation to other trust child and adolescent mental health services. Is this a shared barrier that requires wider input?

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

Generally, patients spoke of no extra costs involved in accessing care and support from child and adolescent mental health services, with the exception of one person who had been recommended by a clinician to buy some anxiety books. Staff showed an awareness of people’s inability to afford extra resources, so went out of their way to try to avoid creating extra costs for people.

  • “We try not to incur costs. I would always print out for them, they can email me a letter and I can print out. A thorough assessment is 90 minutes. I would not let them run over the 2 hours cos free parking runs out then. One person comes on the bus. I don’t know of a way to give her the cost of the ticket. I would offer to go to her instead, go to Costa. I would pay and claim back the cost of the coffee.”

5.2.2 Barriers and challenges

5.2.2.1 Unclear policy on providing resources for young people

There is a lack of clarity and understanding amongst staff, relating to the acquisition of resources to be used by the young people in their care. Certain items are beneficial for young people to have (for example, ice packs for self-harm work, and fidgets). Some staff expressed an awareness that not all young people and their families can afford these extras, meaning that sometimes staff end up buying items with their own money. There are many relatively new staff in the service, yet even those who have been here for longer, are unclear about whether they can claim back this money from petty cash or by other means.

  • “I buy stuff out of my pocket cos I don’t want certain kids to miss out. There is petty cash but I don’t know who can use it and for what.”
  • “Items that would support with mental health, we suggest things that they purchase, alternative resources, I am mindful of who I suggest purchasing things for.”

During feedback, it was explained that the service actually has a huge budget for these kinds of items and resources for its young people. There is a cupboard full of resources, which can be accessed by staff. For other items, not readily available, “We can absolutely buy anything if I have a rationale that it’s beneficial: fidget spinners, distraction toys.”

5.2.2.2 Patient perceptions of financial support available

A small theme to emerge was around some families being reluctant to accept any financial support, believing that others needed it more. The suggestion is that they see it as a pot of money, meaning if they claim, there is less for others. It also raises the question of pride, of not wanting to be seen to need support.

  • “There was support available towards buying meals, but I didn’t want to put that on the service, I could buy it myself.”

In feedback, it was explained that the service is able to generate food vouchers through Trussell Trust.

5.2.3 Recommendations for health related costs

5.2.3.1 Policy for providing resources for young people
  • Ensure all staff are aware of the resources cupboard, what is in it, who can access it, what the rules are.
  • Create clear instructions for occasions when specific resources need to be ordered.
  • Consider the best way to make this information known to all staff.
5.2.3.2 Patient perceptions of financial support available
  • If a family is entitled to support, don’t ask if they want it, just give it (this may help reduce the negative impact of stigma).
  • Empower staff by providing information about benefits and support potentially available to their young people and families.
  • Make families aware of how support is funded, that is by accepting support, they are not denying someone else.

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 Reduced waiting times

Referrals are triaged through Getting Help. There has been a very significant reduction in waiting times, which is around eight weeks currently, with the aim to reduce this further to four weeks, followed by another four weeks for patient entry into the pathway for which they have been selected.

Staff have spoken of a “Transformation” which “felt quite disruptive, but it’s been the catalyst to getting times down”.

  • “Staffing levels ensured the wait times have come down dramatically. Getting a new team with a very varied background and gelling together.”
5.3.1.2 Some flexibility with appointment location and time

The majority of appointments are at St Nicholas House, Scunthorpe, but both staff and patient families have spoken of appointments being offered at home, at school, or in a café or family hub, in a bid to make travel easier and less time consuming.

  • “We will go to school if they want us to, to help lessen the missing time.”
  • “We are responsible for our own appointments. We try to be flexible. We can even meet the young person at school.”
  • “We have the flexibility to go to them if they need it. Meet them for a coffee or go to their homes.” Staff would pay and claim expenses back.”
  • “They are flexible around shifts and school or college.”

There is also an option for families who attend two services, to book those appointments back to back and save on travel, rather than attending two separate appointments every week.

  • “We go to the Eating Disorder clinic too and we will be able to book appointments back to back so we don’t have to come twice in every week.”

5.3.2 Barriers and challenges

5.3.2.1 Restricted hours

Despite the flexibility described in the above section, for many families this does not go far enough. In order for young people to attend appointments during the hours of 9am to 5pm, they are missing time away from school and parents and carers are at times missing time from work, which may be unpaid. Despite there being an option to offer some appointments from 8am until 6pm, as some staff work condensed hours, senior staff have still described the biggest barrier as being time:

  • “Some work 8am to 6pm but it means then we lose a day from a staff member. 9am to 5pm has its limitations. If we were 24 hours, 7 days a week we would blur the lines with the crisis team.”
  • “If I worked full time and not part time I would really struggle to get him here and also would lose out on money, and my boss is not happy with people taking time out. Weekend or evening appointments, not missing school.”
  • “I just get time off work and deal with it.”
  • Loss of earnings: “For me yeah and the wife takes time off work too, but it’s more me who loses out as my wife’s work is better.”
5.3.2.2 Appointments in school time

Clinicians offer young people the option of choosing different appointment times to ensure they do not always miss the same lesson at school each week. However, the nature of many young people attending child and adolescent mental health services is that they like routine, so do not want to vary their times.

  • “I am mindful of young people not missing the same lesson each week, but many do prefer to have the same time, cos they like routine.”

A theme emerged around some school attitudes towards students missing lessons to attend child and adolescent mental health services appointments. There have been instances where families were told they would be fined by school, in order to deter them from having appointments in school times.

  • “Some parents worry about getting fined by the school, due to their child’s reduced attendance because of child and adolescent mental health services appointments. This is only the case with some schools, who don’t have much understanding about the need to attend child and adolescent mental health services. These schools push parents to go to child and adolescent mental health services appointments after school hours. However, they can’t fit everyone in during that after-school slot. somebody has to go through the day.”
  • “School was a bit mardy. They could be really rude when she needed to come to appointments. She had to be off for a while. Once we explained, they sorted it with the attendance. She missed lots of school in year 10.”

In feedback, it was explained that in Rotherham and Doncaster, schools have to bid to have With Me in Mind (WMIM), and that this means around 75% to 90% of schools are invested in the offer. In North Lincolnshire it is different, in that 100% of schools are given With Me in Mind. However, because they have not needed to bid for this, some schools feel it has been done to them, rather than it being a choice. In that respect, they are not invested in the service, and this may help to explain negative attitudes towards it.

5.3.2.3 Location of appointments

In the above section, it was described how the child and adolescent mental health services offers various locations for appointments, yet these alternatives are not necessarily what people want. School appointments often appear to be an unpopular choice, while arranging appointments at family hubs can be quite difficult for the clinician to organise:

  • “She was asked if she wanted the appointments in school, but she didn’t, which is understandable because she doesn’t want people seeing her have her appointments.”
  • “Really flexible, we can have it at the school if we want but he doesn’t want it there.”
  • “We can do visits, often what we talk about makes them feel vulnerable, and the home may not be the right place for that.”
  • “Family hubs can be difficult to get booked in.”

Family hubs would appear to be an appropriate location for appointments, offering a confidential space, which is closer and more convenient for the young person to get to. There needs to be an efficient and easy process in place for staff to be able to book them.

5.3.2.4 Contact discharge

Poverty-related concerns were raised by staff over the discharge policy and how it may be inadvertently discriminating against those without the resources to engage with the service. The policy, as it stands, is two contact attempts by phone, then a letter and if there is no response the young person is discharged.

The unwritten assumption being made here is that if there is no response it is on the family and that they either no longer want or need the service.

As the poverty awareness of the Child and Adolescent Mental Health Services team increased, they began to question how poverty may actually be a factor underlying this perceived lack of engagement with the service and however well-intentioned the four-week target is, this may play into unintended consequences of penalising those in poverty and be at odds with the Poverty Proofing ethos.

Resource factors such as being able to make or receive calls, understand or comprehend letters and language and cultural skills, candidacy, advocacy and confidence were all factors discussed in interviews, training and feedback:

  • “What if they have no credit, the last of their money for the month was to get to the GP, or they have no access to a laptop to make the online referral?” (senior staff member)
  • “Contact discharge, we see the backlash of that. A lot of people don’t answer for private numbers. If they haven’t turned up or have been triaged and then get called twice. They might not have credit to call back, they might be too anxious to call us back. It’s very abrupt. It’s the private number, it won’t help with the nervousness.” (admin staff)
  • “They can’t just pop in. Where is the flex for these people who are hard to reach? We are under pressure to complete an assessment in four weeks after referral. How can we meet the target but have some flex for people? We’re going to be running drop-in clinics by February, rotational locations and times, that will potentially help.”
5.3.2.5 Referral process

People can self-refer online or they need to be referred through school or their GP. Staff explained that sometimes GPs will not refer people, and are instead telling them to directly self-refer by calling the service. However, according to staff, they cannot do this over the phone because it is too time-consuming. This creates a barrier for people without internet access, who are unable to complete the self-referral online, yet who are then sent back to the service by their GP. It has the potential to take them round in circles. There is a miscommunication between GPs and the service.

  • “We can’t take self-referrals over the phone, and that’s where people drop off and maybe feel they have been passed around.”
  • “People do often say they are being sent ‘around the houses’.”

Staff did say that providing paper copies of the referral form would be a positive option, as they still need to input the data into their system, whether this data has been provided through the online form or a paper form. It is the phone calls that are problematic.

5.3.3 Recommendations for navigating and negotiating appointments

5.3.3.1 Restricted hours
  • Explore options for extending service hours beyond Monday to Friday, 9am to 5pm.
  • Offer more opportunity for online appointments, especially where travel is a barrier.
5.3.3.2 Appointments in school time
  • Explore options for extending service hours beyond Monday to Friday, 9am to 5pm.
  • Reflect on and seek to improve current engagement strategy with schools. They need to better understand what child and adolescent mental health services is, what it does, how it helps young people and therefore how important it is for them to attend appointments.
  • Liaise with public health to highlight work with schools and education as a public health issue.
5.3.3.3 Location of appointments
  • Investigate making greater use of community venues.
  • Seek to make the booking process easier for staff to use family hubs for appointments.
5.3.3.4 Contact discharge
  • Explore alternatives, through the lens of the person with the least resource.
  • When we have patients on the phone, we need to keep them while we have them, not break that connection by telling them we’ll ring them back. Investigate ways of achieving this, as a service or across the trust?
  • Explore a community messaging system, use existing community networks that people are more familiar with and can access more easily outside of working hours, in order to get messages into child and adolescent mental health services, for example, Asda pharmacies, supermarkets; similar to how post offices went into corner shops.
5.3.3.5 Referral process
  • Provide pre-paid envelopes and printed forms for self-referral, which people can either hand in at the desk or post, enables those without digital access.
  • Create a leaflet which is basic and explains the services at child and adolescent mental health services: crisis, getting advice, getting help, psychological therapies, neuro team, community eating disorder and psychiatric review, to give to families and partner professionals so they understand the referral process in child and adolescent mental health services.

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 Lots of opportunity for patients to give feedback

Scoping of the waiting area at St Nicholas House revealed lots of opportunities for young people and their families to engage with and feed back to the service. This included three different types of feedback asked for: the child and adolescent mental health services itself (child friendly illustrations), then trust (QR code and paper copies) and patient advice and liaison service posters. Also on display was a “Your views, you said, we did” poster, which highlighted examples of practical ways the service had made improvements. There was another poster about an upcoming child and adolescent mental health services steering group, these groups are already up and running in Rotherham and Doncaster and one is about to start in North Lincs.

While only commented on by one family, it is important to hear their disappointment that the LGBTQ+ display in the waiting room had been taken down. The parent explained how much her son had liked seeing it, and she felt it was important to be seen displayed, for people to see themselves reflected.

5.4.1.2 Peer support worker role

This role was positively spoken about, in terms of supporting young people ready to be discharged or needing to go to college, and assisting them to gain independence in going to college and attending Skills Centre Plus. It was described how responsive the support worker is to the needs of the young person, whether they are needed for a full day or just an hour.

5.4.1.3 Strong relationships

It was clear that strong relationships are established between service staff and the young people and families they support.

  • “Stigma around mental health, for our young people, their whole experience, most of them have experienced relational trauma, so trust is huge for them. When we can get them in the building it is the trust building, being open, accepting.”
  • “I found them approachable, it’s generally not a huge effort to get him to come in, which means something.”
  • “So friendly and understanding, they give you time and space to form the bond you need.”
  • “All the lovely words that come to your mind: lovely, kind, supportive, caring, all of them and we have dealt with quite a few, all have been amazing. There are quite a few young ones, they are cool, and the girls feel right at home. They come across as normal people.”

5.4.2 Barriers and challenges

5.4.2.1 Concern for care leavers

Again, this barrier was identified by staff, who expressed concern about the welfare of care leavers. They described how there is often a lack of social support, that these young people can become isolated, and that sometimes they cannot even begin to think about their mental health because they have got no money and find themselves facing new challenges.

5.4.3 Recommendations for patient empowerment

5.4.3.1 Concern for care leavers
  • Can this barrier be linked in to the trust promises? For example, promise number 8: Research, create and deliver five impactful changes to inequalities faced by our population in accessing and benefitting from our autism, learning disability and mental health services, Promise 9: linking care leavers to employment opportunities.

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

As mentioned earlier, staff generally show a level of understanding around patient financial struggles and will adapt what they do to try to meet patient needs.

5.5.2 Barriers and challenges

5.5.2.1 Staff are not engaging in financial conversations with all patients

It is not a current part of the service offer for staff to try to get a sense of families’ socio-economic circumstances. Staff have some poverty awareness and as we heard earlier, are conscious when advising on care plans and are taking steps to make some resources freely available.

  • “We ask about work but not always about financial circumstances.”
  • “Not something that I would think to ask unless it was glaringly obvious.”

Coming through consultations is the idea that if someone does not ask for help, then we assume all is well. However, it is well-documented that stigma, shame, and not wanting anyone to know that you are not managing, are factors making it highly unlikely for a person in poverty to ask for help (Inglis et al. 2022). By universally and routinely talking about finances as part of care, the service are going to be truly embedding the ethos of not making any assumptions about someone based on how they present. It will help alleviate the stigma and ensure that support is given where it is needed.

  • “If individuals are in poverty, I wonder their difficulty in sharing this with practitioners and whether for some their struggles go unnoticed.” (staff survey response)

There are also assumptions being made that patient families have “probably already been asked about that stuff by the Getting Advice team.”” Some staff spoke of their young people and families getting Disability Living Allowance (DLA) and applying for Personal Independence Payment (PIP).

  • “We would support families, we ask each other, can we do Personal Independence Payment (PIP) forms with people or is that a social worker’s job? But what about the ones that don’t have the social worker?”

Family circumstances can change at any point in time, so it is not enough to engage in one financial conversation at the start of treatment. It needs to be an ongoing conversation. When asked, the majority of patients and families said they wouldn’t mind being asked about their financial situation. It is a vital part of holistic care.

  • “No, they haven’t asked, but it would be fine to speak to them about it.”

5.5.3 Recommendations for staff awareness and guidance

5.5.3.1 Staff not engaging in financial conversations with all patients

  • Open up financial conversations routinely as part of everyone’s care.
  • Provide a basic level of benefits training across the whole trust, to empower staff in having financial conversations.
  • Develop a trust wide template screening tool to universally and routinely screen on the broader determinants affecting people’s health.
  • It would be helpful as a service if we knew the local organisations, charities and food banks with contact details so they could routinely be given in a leaflet to families if required. (idea from staff survey)
  • Develop a making every contact count approach (MECC).

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

5.6.1.1 Free car parking available

Two car parks, very close to St Nicholas House, offer two hours of free parking. Staff are aware of this and will ensure their appointments don’t overrun, in order not to incur any unnecessary parking costs.

5.6.1.2 Flexibility of staff to travel to patients

Staff are responsible for their own appointments and will be flexible in order to reduce the travel burden on young people and their families.

5.6.2 Barriers and challenges

5.6.2.1 Distance and cost of travel

People can travel for many miles to get to St Nicholas House, as it is the only base in a relatively large geographical area. For many young people attending the child and adolescent mental health service, their anxiety prevents them from using public transport, meaning taxis are the only remaining option, at significant expense. Also take into consideration that many of these young people are attending with a parent or carer, who will also be liable for travel costs.

  • “You would struggle if you didn’t have a car.”
  • “Something for travel, if you don’t have a car, it is hard. If you lived as far away as we do, then I don’t know how you would get here.”
  • “Transport links are poor. It’s typical in this service for young people to come to us, but we can go to them or meet them at a community venue.”
5.6.2.2 Lack of awareness of the NHS Healthcare Travel Costs Scheme (HTCS)

There is little to no knowledge of this scheme from neither patients nor staff. There was no evidence of it being advertised within the service.

  • “I know nothing about the travel reimbursement scheme. Years ago we could claim it back through petty cash but it was a bit of a nightmare and caused a lot of friction, but then we would have to claim it back too from the trust.” (staff)
  • “One person comes on the bus. I don’t know of a way to give her the cost of the ticket. I would offer to go to her instead, go to Costa. I would pay and claim back the cost of a coffee.” (staff)
5.6.2.3 Transport for looked after young people

There are times when the local authority is relied upon to provide transport for a young person to get to their child and adolescent mental health services appointment. This might be because the foster carers haven’t been able to bring the young person themselves, so have put them in a taxi to travel alone. However, staff have said that it is not always appropriate to do this. There are social workers available, who can support with transportation, so it is important that they are fully utilised.

  • “The young person may leave with big feelings and it’s not fair to put them in a taxi.”

5.6.3 Recommendations for travel

5.6.3.1 Distance and cost of travel
  • Prioritise the scoping out of community venues, to provide more flexibility of appointment locations that are safe and appropriate for both young people and staff.
  • Information needs to be shared widely and consistently with all staff to improve their awareness of the hubs and the process for using them.
5.6.3.2 Lack of awareness of the Healthcare Travel Costs Scheme (HTCS)
  • Promote the claiming back of travel expenses and normalise this in everyone’s roles.
  • As a trust, develop a process for claiming back travel costs that is de-stigmatising and easy to use.
  • Advertise it to patients, ensure all staff know about it, and how it works.
  • Consider the possibility of introducing pre-loaded travel cards or similar for people who may not have the money upfront.
5.6.3.3 Transport for looked after young people
  • This is an area to investigate more thoroughly, to ensure that the policy around this is appropriate and suitable for all looked after young people.

6 References

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

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