Crossing barriers and hitting a brick wall
20 December 2004
An imaginative project found a cheap way to make sure patients receive the disability benefits to which they are entitled. So why don't policy makers implement it, asks John Kirwan, Professor of Rheumatic Diseases?
Arthritis is the most common physical reason for people, especially the elderly, becoming disabled. Overcoming such problems involves extra costs, but disabled people often have low incomes. You might think therefore, that doctors and nurses who look after people with arthritis would encourage their patients to apply for benefits, but they are often unaware of the details of their patients’ functional difficulties and are unclear whether they would qualify under the complex social security legislation.
There are three important barriers to claiming Disability Living Allowance and Attendance Allowance, the main disability benefits.
1 Identifying patients who are likely to succeed in gaining an award if they apply (after all, we don’t want to raise patients’ expectations inappropriately, nor to flood the Department of Work and Pensions with inappropriate claims).
2 Filling in the long and complicated application forms, for which many people need advice and which can take up to two hours to complete.
3 The psychological barrier faced by many, especially the elderly, of feeling they are asking for charity and moving into unfamiliar territory.
In collaboration with colleagues at the University of the West of England and GPs in Bristol’s Air Balloon Surgery, Kirwan and his team in the University’s Academic Rheumatology Unit tested out a way of breaking down all three barriers at the same time. First, they used a simple, five-minute, 20-item questionnaire (called the Health Assessment Questionnaire or HAQ) to try to identify those patients with a high likelihood of success if they applied for benefits. Second, they offered high-scoring patients an appointment with a Welfare Advice Worker (often a Citizens Advice Bureau volunteer) to help them complete the application form, and third, this service was provided at the Outpatient Department attended by the patient, or at their GP’s surgery.
Disability benefits are not claimed by aproximately half of those who are eligible
A pilot study was conducted at the Bristol Royal Infirmary and the Air Balloon Surgery. More than three quarters of patients identified as being eligible, applied for, and were awarded, disability benefits. These initial results were encouraging, but would the same system work in other places outside teaching hospitals and big cities? A much larger study, planned and coordinated from Bristol, was tested out in four other hospitals and ten general practices in other parts of the West Country. The preliminary results of the pilot study were confirmed and strengthened, and 163 people were awarded benefits within three months of applying. In total, more than £350,000 a year is now being paid to patients who were previously unaware that they qualified for benefits. It’s not often that a research project actually produces an income for the participants!
A conference of interested parties was convened, including the GPs and rheumatologists who took part, the Nuffield Foundation, and the Department of Work and Pensions. It took a hard look at the results and concluded that the system should be widely implemented. However, there is a catch: it costs money to provide the space, advice and administration. The NHS is strapped for cash and cannot find resources to support social benefits. An economic analysis was undertaken as part of the research project, and found that the cost of providing the whole system was less than one week of benefit payments for each patient. This is not much to ask when patients will probably be on benefits for life. Perhaps the Department for Work and Pensions could fund the exercise, as it is certainly committed to encouraging uptake of benefits? But it seems the Department is only allowed to pay out benefits, not pay out to help people apply.
This looks like a case of joined-up thinking by the researchers, but where is the joined-up thinking from the policy makers?
So there we have it: an imaginative collaborative research project, which surmounted the barriers between hospital and general practice, between health and social care, and between the public sector and the voluntary sector. It found a way to help the right people take up the benefits they deserve, in line with government policy. But it cannot find a way to be implemented. This looks like a case of joined-up thinking by the researchers, but where is the joined-up thinking from the policy makers?