See the article below "How do I begin to help a family living in poverty?" on Information on how to get started with talking to families.
Follow the flow chart for information on how to get started with introducing screening and sign posting into your hospital.
Watch a PowerPoint presentation with embedded audio explaining the project journey of the London North West University Healthcare Teams "Family Wellbeing Project"
How do I begin to help a family living in poverty?
Adapted from a paediatricFOAMed article Call to Arms: Fighting Child Poverty Together Part 2 – PaediatricFOAM
Hannah Zhu, Emma Sunderland, Akudo Okereafor, Guddi Singh
Poverty can seem like a huge mountain of a problem and we can feel small and powerless against it. We see children living in poverty in A&E, clinic, inpatient wards and intensive care units EVERY day. We each have a key role in identifying and reducing the impacts of poverty for every child we see. We need to treat their poverty as key risk factor for disease, if we want to improve their child’s quality of life and long-term health outcomes. Just as screening is important for other adverse risk factors like smoking or domestic violence, we must also screen for poverty. By identifying low-income families, we can connect them to community resources. Community support is vital to help increase participation, provide essentials and empower families to thrive together.
"How should I discuss poverty with my patients?"
"How do I ask sensitively? Do parents even want me to?"
By using a ‘framing statement’ like…
“Since the pandemic more parents are having difficulty paying bills and have worsening debts, is this something that has been worrying you?”
…you can reduce stigma and encourage parents and carers to trust you to divulge their struggles.
Talking about income is a delicate subject you cannot tell who lives in poverty by looking at them. Incorporating simple screening questions that ALL parents and carers are asked can help identify families who need help. Parents are often relieved that we recognise the impact of poverty on their family’s health and that we want to offer them assistance.
Another approach is to use the routine family and social history you ALREADY take to identify risk factors for poverty. These include: families with three or more children, single parents, unemployment and/or parents with chronic physical or mental health conditions. If you’re familiar with the HEADS psychosocial assessment tool for adolescents you can adapt this to both identify and discuss the impact of poverty with families with children of all ages (see the templates page for more examples)
The adapted “HEADS” tool for poverty
Home: Who lives at home with you? What is your house like?– Chronic physical or mental health problems, >3 young children, single parent– Housing concerns: pests, leaks mold, cold, overcrowding
Do you work? What is your job? How is your child doing at school?-Unemployment/low income, asylum seekers, travellers.
-Developmental delay, poor school attainment, poor attendance
Do you have any hobbies? Have you been on holiday in the last year?-Lack of disposable income for hobbies, holidays or transport
What did you eat yesterday? In the last year, have you worried that your food would run out before you got money to buy more?-Lack of (healthy) food, unable to afford fresh fruit and vegetables
-Parents missing meals to feed children
-Free school meals
Have you ever had a social worker? Has anyone ever hurt or threatened you?-Reasons for social worker could give insight into current and previous vulnerabilities.
Consider what support they already have? Are they receiving benefits?
-Physical, emotional, sexual abuse or neglect warrants further investigation and referral as per local pathways.
How can I help the child in poverty and their family?
Sometimes just being understanding of the family’s social and financial situation and empathetically managing their child’s healthcare in that context can be enough to transform the quality of the child’s care.
There are other specific action you and your teams can take:
SIGNPOSTING parents/carers to services that focus on the social determinants of health is an increasingly important skill for all health professionals. This may involve directing them to: sources of financial support, both from the state (such as statutory benefits and social security entitlements) and third sector organisations (local food banks, childcare support, and other practical services). (see the links to organisation's page for more information on sources of support for families). Your local council website is a good place to start to identify resources locally available. Consider what is available via your local "early help" service and consider a referral (click here for an example of what is available via "early help" in one local authority).
ADAPT and ADOPT the resources leaflets found on the templates page.
EMPOWER FAMILIES and encourage their strengths on an individual level (personal resilience, knowledge and skills) or community level (family and social networks, schools and clubs, and third sector organisations).
Case Study: James
Situation: James, 11, laceration to R ankle in A&E.
Background: James is 11 years old and has never had friends come over to his house because he is embarrassed that he shares a bedroom with his two younger sisters. He knows his parents can’t afford dinner for his friends if they did come so he plays outside most afternoons. Earlier, an older boy bought him chicken and chips and James had been bragging when he fell from the damaged fence in a small car park; his parents warned him not to go to the local park for fear of gangs.
Assessment: His father works two jobs and mother works part-time. They struggled last month to buy essentials as there was a leak in their flat and substantial repair cost.
Recommendations: Wound care PLUS give 1-2-3 resources leaflet. Tell them about local food banks and direct to Citizens’ Advice and debt advice help. James’ father apologises he’s getting upset and we acknowledge his challenges and offer encouragement. Food Bank also has budgeting workshops and ‘cooking on a budget’ sessions. Risk of grooming and criminal exploitation – highlight the contact number of local youth workers and warn about gangs and county lines risk.
As paediatricians, we meet and care for more and more families living in poverty every day. Being familiar with local and national poverty-busting resources and knowing how to offer them can provide practical and tangible help to families. Let’s empower parents to get the help their families deserve and help to break the cycle of poverty for future generations.
Key learning points
We all need to play our role in fighting child poverty. For every patient, we can:
Screen – consider using a framing statement like: ““Since the pandemic more parents are having difficulty paying bills and have worsening debts, is this something that has been worrying you?”
Ask and listen – consider using our adapted HEADS for your social history (Home, Employment/Education, Activities, Diet, Safeguarding/Support)
Prescribe resources – consider 1. Income support 2. Providing essentials 3. Encouraging participation and improving quality of life.
“Mothers and fathers are raising respectful, eloquent young men and women, who, in reality, are part of a system that will not allow them the opportunity to win and succeed.”
Why treat children only to send them back to the conditions that made them sick?
Professor Sir Michael Marmot
Introducing a Screening and Signposting to resources project into your clinical department
You might find this flow chart helpful but it’s important to remember that often projects like these are not linear and
can be approached in a variety of ways. Click here for a link to a word document version.
We are planning on including links from each stage to blogs and top tips written by paediatricians who have been through this process to help you if you get stuck. But feel free to post a question in the discussion forum or drop us an email.
Using quality improvement methodology
Click here to view the team at Northwick Park Hospitals Plan-Do-Study-Act (PDSA) cycles for an example of how to apply QIP methodology to your project,
Project management Software
You might want to use project managing software such as ClickUp to keep track of your progress and share information between your team.
Identify key stakeholders
Although you may need to develop your project idea before you address key stake holders in person, it is important to think about who you will need as partners early on if you want your project to be successful and sustainable.
Depending on your hospital / department this may vary, but may include
Colleagues who are keen to help with introducing screening an sign posting.
SHOs and registrars (They are at the front line asking patients and families questions about their social circumstances and screening for poverty. See links to screening questions, clerking proformas and questionnaires in the templates section)
Nursing staff (especially important if the nursing team will be involved in the screening of patients)
Senior nursing team
Nurse educator team
For example in Bristol the safeguarding team had great ideas on how to link screening into existing ways of supporting families for example through the “cause for concern e-form” which, with family consent, is away of highlighting that the family is in need of additional support which may come from the hospital LIAISE team or the social services “early help team” for example.
Existing support services for families
For example in Bristol Royal Hospital for Children the LIAISE team already offer practical support on accessing income and essentials to families who have children who have been admitted for prolonged periods of time. Through linking up with LIAISE we are planning on ways to expand to offering one-to-one practical support as well as sign posting to resources via our leaflet.
Local council partnerships.
You may have funding available in your region to support projects that try to increase integrated care, linking medical services with social services and charity partners. A good place to start could be to search for your local Sustainability and Transformation Partnership and key contacts working for families and young people. Although these partnerships have received mixed reviews from those evaluating the provision of health and social care, they are part of the NHS long term plan and likely to be part of the policy landscape at least for the foreseeable future.
Many GP services have social prescribing services for adults. Some CCGs have social prescribing resources for young people too.
If your hospital has a local university they may have departments with relevant expertise as well as experience in research and knowledge of funding opportunities.
For example the University of Bristol, Bristol Poverty Institute has been a useful point of contact for linking with local organisations and partners within the council as well as considering opportunities for funding in the future.
Emailing the organisations you are planning to include on your resources leaflet is important to check that they are happy to receive referrals but can also be an important way to learn more about what resources are available for families.
2. Design your screening questions.
These questions are adapted from an evidence based tool created by HealthLeads (see the link in the templates page for more information)
Social Needs Screening Questions
1. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food? Y N
2. In the last 12 months, has the electric, gas, or water company threatened to disconnect the supply in your home? Or have you been worried that you wouldn’t be able to pay your bills? Y N
3. Is your housing unstable or are you worried that in the next 2 months, you may not have stable housing? Y N
4. Are any of your needs urgent? For example: I don’t have food tonight, I don’t have a place to sleep tonight Y N
5. If you answered YES to any of the questions, would you like to receive assistance with any of these needs?
3. Design your resources leaflet.
Adapt and adopt the example leaflets available on the templates page.
You may want to use a booklet format or a one page poster format. As well as leaflet you may want to have resources available as posters viewable in the emergency department or war. In the future the WHAM team are planning on developing a web resource for families.
Looking on your local council website can help identify what resources are available locally. We would recommend taking bit of time to familiarise yourself with the organisations and what they have to offer.
This page has links to several organisations supporting families which you may wish to include in a leaflet of resources.
Patient participation and feedback from families is really important. If you have access to patient participation groups its great to get their input. Or you could to get feedback from families and improve and refine your resources as you progress through the Plan-Do-Study-Act cycles of a Quality Improvement Project
Depending on where you work you may need to get any new documentation checked with the information governance team.
4. Tell people about your project, find template teaching resources for grand round / journal club on the templates page
5. Introduce and Evaluate: Find more information on how to implement a QIP project in the article Poverty in Practice: Using quality improvement in paediatrics to improve identification and support of families living in poverty Also available on the reports and research page.