Poverty proofing report podiatry 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 Doncaster podiatry service

Children North East engaged with Doncaster podiatry service during September and October 2024, in order to better understand the experience of families and individuals who are living in poverty. It was the first of the trust services to undergo the Poverty Proofing process.

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 or attempting to access the podiatry service.

Doncaster podiatry service is based mainly at Cantley Health Centre, Middleham Road, Doncaster; with two smaller secondary clinics at Thorne and Mexborough. The scope of practice covered by the service includes minor surgery, foot wound care, foot health education, sports injuries, biomechanics and musculoskeletal assessment. The service works with patients who are considered to be at high risk. This means they have an underlying health condition or illness which puts their legs and feet at increased risk of injury or wounds.

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.

Foot complications are common in people with diabetes. It is estimated that 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives (Diabetic foot problems: prevention and management, NICE guidelines 2019). In addition, there is a direct correlation between levels of deprivation and the risk of amputation, with The National Diabetes Foot Care Report: April 2022 stating that “patients from the most deprived areas had the highest risk of amputation. The rate of major amputations in the most deprived areas was 1.82 times higher and 1.47 times higher for minor amputations when compared to the least deprived areas”.

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 Doncaster podiatry service 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 Service is easy to contact

People generally find the service easy to contact. Text messages contain a phone number for them to ring if needed. The system in place means that the phone is not answered, but rather people leave a voicemail. They will always get a prompt call back or a text message to respond to the query.

• “If I call it’s the answer machine, but they will always ring back, very efficient.”
• “Easy to contact, a few times I’ve rung and left a message and they ring back.”

Staff member: “We have a system where a phone number will come straight through to email, all staff can see it, so it will get picked up on. We can add a note to say that the call has been dealt with.”
So, even if the patient does not leave a voicemail, their number goes straight to email, so staff can see they have tried to contact the service and can contact them back.

5.1.1.2 Staff make themselves available

In addition, staff at the clinic make themselves openly available to patients, encouraging them to get in touch if they have any issues.

• “If something’s come up, I’ve rung and it’s easy. She always says if I’ve got any problems just to ring up.”

5.1.2 Barriers and challenges

5.1.2.1 Incorrect information given by GPs

According to clinic staff, local GPs can sometimes be responsible for giving out incorrect information, telling their diabetic patients that they can receive treatment at the podiatry clinic. In reality, despite being diabetic, they are still only eligible for treatment if they are high risk cases. This can mean an unnecessary appointment and journey for people who will find the cost unaffordable.

• “They take the GP’s word as gospel, then are unhappy when we won’t treat them.”
• “GPs tell them if they’re diabetic that we’ll do it, but that’s incorrect information. They take GP’s word as word of god, but we only see high risk.”

In feedback, it was explained that previous work had been done to inform GPs about correct referral criteria. However, “We’ve found even ones (GP practices) I went to, they are still sending misinformation.” It was felt that there are too many services for GPs to be able to keep track of specific referral processes.

5.1.2.2 Lack of information given at point of referral

There appears to be a lack of information given to people at the point of referral to the podiatry service, in terms of why they have been referred and what they can expect to happen at their first appointment. This impacts people in two ways:

Firstly, staff have expressed a view that many of their did not attends (DNAs) are as a result of people not being fully informed about the reason for their referral. They don’t really understand the importance of getting treatment, so might not turn up.

• “There needs to be better communication from the person who’s referring them, if they have ulcers and did not attend (DNA) we’d ring but if they don’t have a high risk problem then we wouldn’t chase them up.”

Secondly, it was noticed that patients attending the podiatry clinic for the first time were often unaware of what was going to happen during this initial appointment.

• “I’m not sure really what will happen today.”
• “I had to rearrange my first appointment, it was easy to do, I just rang here. I needed to pick a day when my partner could bring me cos I didn’t know if I’d be able to drive.”

This particular partner had taken time off work to bring the woman, when actually this may not have been necessary. Had they been provided with more information in advance about what to expect at this first appointment, they would have been able to make an informed decision about travel arrangements.

5.1.2.3 Limitations of SystmOne and the website

SystmOne limits the amount of information that can be provided to the patient prior to their appointment. Staff have expressed frustration with the system, but responsibility for this lies beyond the scope of the service.

• SystmOne: “only does one letter and limits the ability to communicate the specifics of what’s needed.”
• “We were advised to reduce the amount of letters.”
• “We could put something in the general letter about driving. We have one letter for appointments but it would maybe confuse people when they come for the nail surgery appointment.”

Also, in feedback, concern was expressed about difficulties in navigating the website, since its update.

• “It’s now less helpful, this needs reviewing, the search function for policies no longer works, it needs looking at.”

5.1.3 Recommendations for communication

5.1.3.1 Call-back service

• At the first appointment, ensure every patient is made aware of and understands the call-back system. They need to know the number of the service so they can recognise it and know to answer their phone. If it is a withheld number, they need to know to expect this.

5.1.3.2 Incorrect information given by GPs

• Circulate updated information to all local GP practices.
• Ensure the website provides clear instructions for referral and that it is easy to locate the information.

5.1.3.3 Lack of information given at point of referral

• Make it clear to people, written and verbally, what will happen during their first appointment and if any special preparations need to be made.
• Inform people explicitly of the reason for their referral, to help improve likelihood of attendance.

5.1.3.4 Limitations of SystmOne

• As a trust, investigate whether SystmOne is fit for purpose. Identify any shortcomings and consider what the Trust could do differently to meet the needs of its staff and patients.

5.2 Health related costs

Many of the high-risk foot problems seen at the podiatry clinic are directly related to diabetes. Dietary factors play a significant role in the management and prevention of type 2 diabetes, yet healthy food comes with a cost, which will be unaffordable to those in poverty. 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.

Many other costs associated with foot care are available on prescription, yet this is not a standardised process, with some people having to pay while others get provided. While Doncaster podiatry service provides treatment for those considered high-risk, it does not treat low-risk patients. If people are unable to administer self-care, they may require treatment from a private podiatrist, which comes with a cost. For example, nail cutting with a private podiatrist in Doncaster costs around £33.

5.2.1 What works

5.2.1.1 Prescriptions

There was a cohort of participants who benefited from a core-package that was entirely funded through prescriptions or in-house care and advice. This includes items such as creams, orthotics, rubber shower boots, bandages and insoles.

• “No, I’ve been lucky, my rubber shower boot was sent as a prescription. I’ve got an infection and I can’t get it wet or it will make it worse.”
• “It’s all available on prescription.”
• “Swimming thing, I get orthotics shoes, they are free.”
• “No (I don’t buy them), they supply things.”

The service even offers a shoe-checking service. We didn’t speak to anyone who mentioned it or had used it, but it could be really useful from a Poverty Proofing perspective. Advice could be given around budget options, busting myths about costs and avoiding wasting money on inappropriate shoes, done in a de-stigmatising, universal way.

• “We tell them to show us the shoes they’ve bought, bring them in to make sure they are fit for purpose before they take tags off and start wearing, but some people just won’t do it.”

5.2.2 Barriers and challenges

5.2.2.1 Discretionary costs

Conversely, there was another group of patients who were hit hard by expensive, specialist equipment and treatments that may not be affordable. Much of this was because of GP discretion, with staff explaining that they will sometimes put a request to the GP to get items on prescription, but the GP refuses to put it through. An example of this was one person getting their rubber shower boot on prescription, while another person had to pay for it themselves.

• “A lot of people will say they can’t afford… padding for offloading, not on prescription, it can cost about £20 for a sheet (a semi compressed padding to reduce pain, they rely on it to relieve pain) Also anti-inflammatory gels, on prescription? We put a request into the GP. They can supply antibiotics, but that’s it, otherwise we do a request. Certain list of things they can supply from, easy to send through to the GP, but some can be funny.”
• “I needed some compressed felt for my shoes and they sent it (the prescription) through to the surgery. They weren’t sure if they would provide it as some places do and some don’t provide it. The doctor let me know they don’t provide it here.”
• “I have been (buying things) to keep my foot comfy, footwear is not cheap.”
• “If I was going to get the specialised shoes, then that would be expensive, they’re about £100.”

5.2.2.2 Paying for bandages

A barrier came to light around the mechanism for ordering bandages. The current process of podiatry requesting bandages from the GP and the patient collecting the prescription for this, causes confusion and is misunderstood. The bandages are meant to be brought to clinic by the patient, but instead are seemingly being used at home, resulting in them running out of bandages and being asked to provide their own to the clinic. Two patients described having to provide their own bandages for dressing their foot wound:

• “Yeah last week for the first time I did have to bring my own bandages as they said they are running out of funds here.”
• “In the early days they provided extra bandages to change but now they are asking me to bring them myself.”

In feedback, senior staff said it would make much more sense for the service to be responsible for its own ordering and purchasing, cutting out the middle man.

• “There are barriers around what certain practices can order. It’s a cost for our department. It makes more sense if we purchased all dressings in-house. We may need to change the dressings for infections etcetera. We end up with unused dressings.”

5.2.2.3 Cost of items

There have been times when clinicians have advised patients to get better footwear or creams, which are more expensive. This may not be affordable for everyone. There are also occasions when it may be cheaper to buy certain items over the counter rather than pay for them on prescription. Everyone needs to be made aware of the financial implications of all options, so they can make informed choices and minimise expenditure.

• “Sometimes we might advise better footwear or creams, where people are saying I can’t afford those. Creams can be put on prescription, but sometimes they might be cheaper over the counter.”

5.2.2.4 Low-risk patients left to self-care

Because the podiatry service only takes on high risk patients, many people are left to deal with minor foot ailments and foot care themselves, such as cutting or filing nails. It tends to be the older and less mobile patients who are least likely to be able to provide self-care. Instead, they rely on the help of others. If they have no network of family or friend help, they may end up needing to pay for this care. For those struggling financially, this may not be affordable.

• “I do pay to have someone come out every 8 weeks to do my nails, file them, to cause less problems, to try and ease what they’ve got to do here, it costs about £30. I coincide it with my Personal Independence Payment (PIP). One month the dog goes to the groomer, the next I get my feet done.”
• “If I need to get someone to cut my nails, it’s private now, I have to pay.”

It was explained that the service will educate people in how to file their own nails with a long handled file, and that most people can reach to do this. If the patient does struggle to do it, they are likely to have a carer who helps them to put their socks and shoes on. In the past, the service has done a lot of training for carers working for the council.

5.2.3 Recommendations for health-related costs

5.2.3.1 Paying for bandages

• This process needs to be universal, so that all patients have the same experience.
• Ensure that all patients understand the process of how to get bandages and how they are meant to be used.
• Investigate whether purchasing all dressings in-house would prove more cost-effective and time-efficient to both the service and its patients.

5.2.3.2 Discretionary costs

• Having items available on prescription needs to be a universal experience for all patients, not dependent upon GP discretion. This goes beyond the influence of the service and is for Trust consideration.

5.2.3.3 Cost of items

• Patients need to be explicitly and routinely informed of prescription costs versus costs of buying the same items over the counter, in order to make informed and cost-saving choices. Raise staff awareness on this via Poverty Proofing training.
• Consider starting a “shoe bank” of appropriate footwear.

5.2.3.4 Patients left to self-care

• Educate patients on how to self-care, provide a practical demonstration and an opportunity for the patient to try it the first time under supervision; explain verbally; and provide written and pictorial information to take away. If possible, provide the necessary tools to the patient or put on prescription if this is the cheapest way to get it.
• There are some videos on the website, demonstrating correct self-care techniques and providing patient information. However, they are not easy to find, for example, a demonstration of how to correctly file toenails is buried in a much longer video, so is unlikely to be seen. Consider revamping the website, to make it more user-friendly and visually appealing, with short videos of self-care techniques readily available.
• Provide a mobile service, going out into communities to do minor foot care.

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

Flexibility is a positive feature of the appointment system. The next appointment tends to be made whilst the patient is attending their appointment, which allows some choice over which time 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.

• “We get them in advance. I’ve got the next four appointments. They book them when I’m here, they look at how many I’ve got and give a couple.”
• “They make them when I’m in the treatment room and send text reminders. If I can’t get through I leave a message and they call back.”
• “When I come here she books them and sends them on the telephone. I forget things, it comes straight on the phone.”

One receptionist demonstrated a flexible, logical approach to appointment allocation and was keen to ensure that people were enabled to come at a time that suited them.

• “We have a relatively flexible appointment scheme. With the older people, I won’t give them an early morning appointment, but with people who are working, you tend to find they want an early appointment to get it out the way.”

Patients who travel to appointments on hospital transport are always now given an appointment late morning. This is to ensure that there is plenty of time following their appointment to be collected again by hospital transport, without risking going beyond the closing time of the clinic. Patients can wait up to two hours to be collected after their appointment.

5.3.1.2 Easy to rearrange appointments

People find appointments easy to rearrange. The service does what it can to accommodate the individual needs of its patients, for example fitting them in for an earlier appointment if they are in pain, or working appointments around holidays.

• “Always asks me whether I’d prefer mornings or afternoons. I rearranged, just phoned up, they sorted it straight away.”
• “I got a text and it was for a different day, but my feet were sore so they squeezed me in for today.”
• “Had to change one, my appointment was Monday, but I was on holiday. The original text had a number to rearrange, it’s easy to do.”

5.3.1.3 Appointments are allocated quickly after referral

Once the referral has been accepted, there is a time frame of no more than 4 weeks for the patient to receive their first appointment. All the evidence points to suggest that this is working well.

• “I completed the questions and they contacted me with an appointment the next day.”
• “The referral was from the diabetic nurse. They did the referral. Not long. I got a letter.”

5.3.2 Barriers and challenges

5.3.2.1 Limited clinic opening hours

Clinic appointments start at 8:30am, while the latest standard available appointment is 3:30pm. For those patients who work, such limited clinic hours can be problematic, as it requires them to be able to take the time off work to attend appointments. The flexibility described in the above section may not go far enough for these patients. What makes this even more significant, is that the patient may be required to attend appointments regularly over a prolonged period of time, amounting to considerable and repeated time off work.

• “I’ve had some patients literally say, ‘I have to choose between my feet or work.'”

In feedback, it was explained that the building itself is closed at 5pm. While it is a trust building, it is managed externally to the services in there. It used to be that the domestics would lock up, but now it is the responsibility of the clinicians in the services within the building. Any review of clinic hours will need to take into consideration staff safety and lone working.

5.3.2.2 Location of clinics

Cantley Health Centre is the main podiatry clinic, but there are also two other secondary clinics at Thorne and Mexborough. These other clinics are closer and easier to get to for some patients, yet they are given appointments at Cantley. Patients have not described being given a choice as to which clinic they wish to attend.

• “I’d have to catch an 87 to Doncaster, then one here (Cantley), two buses there and two back. There is a clinic nearer, but I was just given the appointment here.”
• “I try and get appointments in Thorne as it’s closer, but they are normally here (Cantley). All it is, is they only have one member of staff from this clinic at Thorne, so they can’t always fit me in.”
• “I get a lift from my daughter-in-law. I was getting appointments at Cantley until I told them I live round the corner from here (Mexborough). It’s not an issue getting here now.”

Also discussed in feedback was the possibility of adding something to patient letters advising that other clinic locations are available, other than Cantley. Preferred location of clinic could also be a question to ask the patient at the point of referral. However this is done, it is important that patients are made aware of the options in order to reduce costs and time getting to appointments.

5.3.3 Recommendations for navigating and negotiating appointments

5.3.3.1 Limited clinic opening hours

• Consider offering some appointments outside the current hours, maybe evenings or weekends, to accommodate those who struggle to attend during work hours.
• Explore alternative policies around the building closing time, to incorporate longer hours whilst maintaining staff safety.

5.3.3.2 Location of clinics

• Ensure all patients are told about the different clinic locations they could potentially attend, with relevant information given about each, so they can make an informed choice and minimise travel costs and time.
• Explore the when and how to best let patients know this information.
• Explore ways of accommodating increased appointment offerings at Thorne and Mexborough.

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 Teamwork

Doncaster podiatry service very much works together as a team and patients described getting to know different members of that team, especially given the extended period of time many of the patients continue to receive treatment. People spoke of the service feeling like a family, like their friends.

• “More like family friends, I know them so well.”
• “Brilliant, nothing bad to say, absolutely brilliant!”
• “Excellent, can’t fault any of them. Every time I come they smile, I feel comfortable, there’s never an atmosphere.”

5.4.1.2 Patients feel supported

Such positivity, as mentioned above, empowers patients to feel comfortable asking questions. They are happy with the advice and information they receive and the leaflets they are given, describing them as clear and accessible.

• “Their advice is clear and they gave me leaflets on the condition and what I needed to do.”
• “They listen and I can ask if any questions.”
• “I get leaflets given to support me, the information is clear and accessible, I’m happy with my care.”

For the reasons described, seeing different clinicians at each appointment does not present as a barrier for many people. Because they are familiar with the different members of the team, feel happy to ask questions, and are confident that they get the same level of care from everyone, they don’t mind their clinician being different.

• “No it varies, it’s alright. I don’t mind, you get different opinions, sometimes they will get someone more senior if they have any doubts.”
• “No, no they are all different, I don’t mind, it’s not a problem, I’m fine with that, they’re good, they listen and I can ask if any questions.”
• “Sometimes different ones, could be anybody, I’m not really bothered about whom I see as long as they see my foot and tell the next process.”

5.4.1.3 Many routes of referral

There are many routes of referral into the podiatry service, including through your GP, practice nurse, the hospital and self-referral. For many people, their healthcare professional filled in the form on their behalf, while others filled it in themselves. For those who prefer or who need a non-digital version of the form, paper copies can be collected from health centres, clinics and GP surgeries, or people can request an email copy to be sent.

• “It was a paper form. I came in and did it and left it with them.”
• “The nurse at the doctor’s filled in.”
• “Through an accident, the hospital referred me.”

5.4.2 Barriers and challenges

5.4.2.1 Seeing different clinicians

Patients might see different clinicians at each appointment. While this didn’t matter for those patients described above, others said how it can make them feel anxious because each clinician works differently and they said it makes them feel that they end up asking the same questions over and over again.

• “Yes, I prefer it that way (seeing the same person), they get to know you and areas of your feet that are tender. You put your trust in them, if I see different people it makes me anxious as they work differently.”
• “I see one person and they say it’s worse, then another person for a few weeks and they say it’s a lot better so I don’t know who’s right.”

In feedback, the question was raised around how it is decided whether patients see the same clinician or different ones. This was something the service said they needed to discuss together as a team. However, it was explained that sometimes this happens due simply to the required timings of appointments:

• “It depends on what time the patient wants their appointment and what day of the week. If they need to come twice a week they won’t see me both times as I am part time.”

Another point was made relating to real examples over the years of some patients becoming too overly attached to a particular clinician.

• “I didn’t want patients to see the same person all the time as people become dependent on one person. We’ve had people digitally stalk staff so we are conscious that they are with different staff. When the patient needs to be seen is the most important.”

5.4.2.2 Difficulties of neuropathy

The inability to retain information can be a barrier for some diabetic patients who have neuropathy, which means they will not be able to retain the advice they have been given. For these patients, staff try to make sure to give written information and advice, as well as verbal. We discussed the idea of these patients being encouraged to bring a friend or family member with them, who can help support them with another pair of eyes and ears during their appointment. One staff member said that it was not always possible for patients to do this:

• “It might be more difficult for a family in poverty, as their adult child may not be able to afford to take time off work, or be able to afford the travel to come to the appointment with their elderly relative.”

5.4.3 Recommendations for patient empowerment

5.4.3.1 Seeing different clinicians

• Open up gentle conversations at the outset to establish those patients who struggle with change. Add this information to their computer record for all clinicians to see. Adapt relationships and behaviour accordingly to empower these patients.

5.4.3.2 Difficulties of neuropathy

• Ensure all patients with neuropathy are routinely encouraged to bring a friend or family member to each appointment. Explain clearly and ensure they understand why this may be helpful to them.
• Ensure any information or instructions are given in written or pictorial format as well as verbally explained. Refer patients to website videos, if this is relevant.

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 Barriers and challenges

5.5.1.1 No conversations about finances

As explored in the previous theme, the service goes a long way towards establishing trusting and positive relationships with its patients. However, when asked if conversations ever took place about the patient’s financial circumstances and potential need for support, both staff and patients said these conversations did not take place. Interestingly, the majority of patients asked this question, said that they would be fine to have such a conversation as part of their holistic care. They appreciated how this knowledge about patients could help put the right support in place.

• “No, (they haven’t asked) I’d be fine, any help would be a bonus.”
• “No questions about support, I’d be alright about it.”
• “No, they didn’t ask, no, it would be nice sometimes as people daren’t ask.”
• “At the moment I’m ok, but if it was necessary I would have the conversation around finances, I would feel comfortable.”

In training, staff gave some specific examples of times when financial conversations could have a big impact on patients’ circumstances:

• “This guy with serious feet issues, he didn’t turn up for four weeks. We got chatting, he didn’t know that he should be claiming something to be able to come to the appointment (Universal Credit and Personal Independence Payment (PIP)), he had no idea.”
• “Employees don’t know they need to be declaring diabetes with their employers, is that something to bring up with the patients? Are their work aware?”

Opening up these financial conversations universally as part of everyone’s podiatry care, would help ensure people get to find out about any financial support and benefits they may be entitled to as a result of their condition. It would also improve staff understanding of potential barriers to patients accessing care, caused by their financial situation.

During training, when discussing benefits and patient entitlements, one staff member explained how when making a Personal Independence Payment (PIP) application, you “Have to word it as the worst of the worst for Personal Independence Payment (PIP) makes it so difficult.” There is clearly some knowledge and experience within the staff team. Sharing this with the whole staff could empower the team to engage more on this subject with their patients as a universal part of their care.

In feedback, it was suggested that the Trust could provide staff with some training on the basics of benefits and entitlements, in order to empower staff to have routine and universal conversations and be able to signpost patients to support. Such conversations around finances could be added to the existing service template, and even widened to include communication preferences, transport needs, site preferences, comprehension, work commitments, appointment preferences, etc. Perhaps the learning half days could be used to accommodate this training and maybe approach Citizens Advice to deliver it. This could be rolled out across the whole Trust.

5.5.2 Recommendations for staff awareness and guidance

5.5.2.1 No conversations about finances

• Open up financial conversations as a universal and routine part of everyone’s care.
• Share staff expertise or knowledge of financial benefits or entitlements with the rest of the team.
• Have one person employed in some sort of social prescriber role, to be the go-to person for all things relating to financial support, advice and entitlements.
• 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 be completed only once with every new patient, then save the information on the system for any health professional to be able to access.

5.6 Travel

Patients at Doncaster podiatry service can be expected to attend appointments every week over an extended period of time, which can prove to be expensive and time-consuming. 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, more so than choice over where to be treated and digital access to services. 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

There is some free parking at Cantley Health Centre, with additional free parking available at the nearby doctor’s surgery and shops, which the receptionists will direct people to if needed.

5.6.2 Barriers and challenges

Patients are often required to attend appointments every week, sometimes more than once, over what can be an extended period of time, often months, sometimes years. In doing so, they repeatedly face these barriers:

5.6.2.1 Cost of petrol or public transport to attend appointments

• “I live across town. By bus it takes more than an hour, by car it takes about 20 minutes but I’m not a driver. I came in a taxi today, I usually split it between the appointments, taxi one week, bus the next. 12 pound one way for the taxi so it is a lot.”
• “The other side is if you have to get a bus or taxi, you end up looking at money, it’s £10 for a taxi there and £10 back. I’ve not gone anywhere else for appointments; I know it’s a possibility.”

5.6.2.2 The challenges of public transport

Public transport can be a challenge; two buses each way is time-consuming. People who work will need to take more time away from work, travelling back and forth to appointments, potentially losing money.

• “By bus, I live the other side of town. If buses are running okay, the bus only comes once an hour, so I’m waiting an hour. I set off at 10:46am for an appointment after 1pm. It’s not bad in summer but it is in winter.”

Travel to appointments can be physically challenging for patients with physical disabilities or pain as a result of their foot or leg condition. Many rely on family and friends to drive them to appointments, but not everyone has a support network in place.

• “I’ve got the car now, I used to get my wife to change work and bring me, after I had my toe removed I couldn’t drive. I was told it would be a month but the Driver and Vehicle Licensing Agency (DVLA) said I can’t drive for 6 months. It took 8 months to get my licence back.”
• “I get a taxi if I’ve got no lift. Not unless it’s a taxi, I can’t manage two buses with this. A bus is up to 25 minutes.”
• “Pay for taxi, the next time I’ll have to get the bus. It’s a couple of hours on the bus, I have no one to help.”

5.6.2.3 Time constraints of free patient transport service

The free patient transport service is the only viable option for some patients to attend their appointments. Those patients who rely on it, do appreciate it, however there are challenges to using it. It requires patients to be ready for pickup for the two hours before their actual appointment time. Following their appointment, they may have to wait up to another two hours to be collected and taken home. For one patient, this took her beyond the clinic closing time, and she ended up waiting outside to be collected. Use of this service for attending appointments can take up to five hours out of a person’s day.

• “Easter last year, before we decided morning appointments were better, my appointment was 2:30pm. At 4:30pm I was still waiting to be picked up but they were closing early, so I was like do you want me to wait outside?, you know they’re wanting you out.”
• “Have to use the hospital transport, it’s hit and miss. I have to be ready two hours before my appointment, sometimes have to wait two hours after. When you’re dependent on it you appreciate it.”
• “With the hospital transport, sometimes they’ll just sit in the bus and wait for you rather than knocking but I can’t always see them. On odd occasions I could pay for a taxi, it would cost £30 and that’s one way. I wouldn’t be able to afford it as I’ve got multiple appointments a week.”

5.6.2.4 No access to reimbursement through the Healthcare Travel Costs Scheme (HTCS)

Podiatry is classed as primary care, meaning patients are seemingly not entitled to reclaim travel costs using the NHS Healthcare Travel Costs Scheme, which is for secondary care appointments only. However, given the frequency of appointments over an extended period of time in podiatry, travel costs can become very expensive and unaffordable. Many patients are therefore missing out on significant financial support, which would have been available to them if podiatry were classed as a secondary care service.

5.6.3 Recommendations for travel

5.6.3.1 Cost of travel

• Investigate the eligibility of your patients to claim a disabled person’s bus and train pass. This has been used successfully in other services. See disabled person’s bus and train pass City of Doncaster Council.

5.6.3.2 Challenges of public transport

• Explore the Door 2 Door community transport Travel South Yorkshire (aka Leger Bus) service. This may be something to promote to patients who would otherwise find the public transport journey difficult. Provide information and support to help patients join the scheme.

5.6.3.3 Patient transport service

• Ensure all patients are made aware of this free scheme, in case they ever need to use it.
• Ensure transport staff alert the patient of their arrival at their home.
• Continue to prioritise these patients for late morning appointments, to fit in with patient transport timings. Ensure all podiatry staff are aware of the need to do this.

5.6.3.4 NHS Healthcare Travel Costs Scheme

• Investigate with the NHS Business Services Authority whether there might be any special dispensation for reimbursement of travel costs using the scheme, given the frequency of appointments over what can be an extended period of time, in podiatry.

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
• 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.
• Door 2 Door community transport Travel South Yorkshire
• Disabled Person’s Bus and Train Pass City of Doncaster Council

Page last reviewed: May 27, 2025
Next review due: May 27, 2026

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