Poverty and the health and care system

Health and care systems can mitigate, reduce and prevent poverty’s effects on health, but to do this they need to be much better at sharing and acting on data.

Our long read with the Centre for Progressive Policy sets out the data available, explores existing good practice, and what needs to happen next.

Our partnership

Introduction

Poverty causes ill health, drives inequality in health outcomes and increases use of health services. In addition to the personal stresses it causes, poverty is also expensive, in direct costs to the state and in lost opportunity and productivity. The health and care system treats the consequences of poverty, and can be a powerful tool to help mitigate, reduce and prevent its effects on people’s health.

The King’s Fund and the Centre for Progressive Policy (CPP) have brought together partners from the health and care sector and the CPP’s Inclusive Growth Network to explore existing good practice in mitigating, reducing and preventing poverty including the scope for data to enable this work and support cross-agency partnerships.

Data has long played a role in how public services respond to complex problems, but the growth in personal data, the ability to share and link datasets from different sectors and improvements in analytics have expanded what is possible. The Covid-19 pandemic saw a large-scale mobilisation of these connections, as local government, the voluntary, community and social enterprise (VCSE) sector, and the NHS brought together community and vaccination data to direct service expansion targeted to reach excluded communities during the Covid-19 vaccine programme. With the potential for that collaboration to be applied to other systemic issues, and within the context of recently launched integrated care systems (ICSs), The King’s Fund and the Centre for Progressive Policy have explored how data and its analysis can galvanise shared action to tackle poverty.

The NHS is reorganising much of its national data and digital landscape in responding to the Wade-Gery review. Earlier in 2022 The Health Foundation summarised five key barriers to better use of data in health and care: lack of linked data, underuse of the analytical workforce, a focus on the wrong problem, challenges of scaling up, and the biases and risks arising from under-represented groups within the data. Facing up to poverty brings with it those barriers – and the work reported here shows how local partnerships are surmounting those difficulties.

The urgent case to prioritise action

The Joseph Rowntree Foundation estimated in early 2022 that more than 1 in 5 of the United Kingdom population were living in poverty, which equates to 14.5 million people, including 4.3 million children. Poverty has risen among those of working age, and more than 2 out of 3 households in poverty have at least one adult in work. This is set to worsen with high inflation making the cost of living increasingly unaffordable. This deepening and widening of poverty will affect the health and behaviours of people who use the health and care system including its staff, with the Joseph Rowntree Foundation estimating that more than half a million employees in the health and care sector were already in poverty at the beginning of 2022, and The Health Foundation estimating that more than a quarter of the UK’s residential care workers lived in, or were on the brink of, poverty by the end of 2020.

'The Joseph Rowntree Foundation estimated in early 2022 that more than 1 in 5 of the United Kingdom population were living in poverty, which equates to 14.5 million people, including 4.3 million children.'

Clearly poverty affects health in many ways, from affecting the ability to purchase health-enhancing goods and services, to having an impact on decision-making around health, to the psychological effects of stigma. Those in, or at risk of, poverty should be able to access the NHS, receive treatment and care appropriate to need, as others do. Yet, as the inverse care law describes, there is a tendency for services to exclude those most in need. The distribution and delivery of NHS services does not, arguably increasingly, reflect the needs of those living in the deepest poverty adequately.

The economic cost of failing to tackle poverty is significant too. People in poverty have higher risks of poor health but all too often the system only engages when they present with more acute, complex needs. The Centre for Health Economics found that the cost of poverty to hospital inpatient care alone was £4.8 billion per year while the Joseph Rowntree Foundation estimated that poverty cost the NHS and social care systems more than any other part of public services: a staggering £29 billion per year. Through worsening physical and mental health, poverty also holds people back from accessing high-quality jobs and puts additional pressure on unpaid carers, reducing the productive capacity of the economy. At a time when public service expenditure is under scrutiny, doing more to prevent the health impacts of poverty is a good deal for the taxpayer.

Opportunities in new health and care structures

The introduction of ICSs provides a specific opportunity to go further. ICSs became statutory bodies in July 2022, tasked with delivering and co-ordinating approaches to health between agencies. The principles behind the creation of ICSs include contribution to wider economic and social value in the community; and ICSs are required in law to act to reduce health inequalities through the ‘triple aim’ of improving health and wellbeing, through the quality of services provided or planned and through sustainable and efficient use of resources.

ICSs comprise two parts: an integrated care board (ICB), which is responsible for planning most NHS services within the geography of the ICS; and an integrated care partnership (ICP), that includes wider partners whose work and responsibilities affect health (and poverty). ICPs set the strategic direction to which integrated care boards respond.

The creation of ICSs provides scope for resetting the relationships between NHS, local government, the VCSE sector, and important pan-ICS bodies such as Mayoral Combined Authorities (MCAs), which can take advantage of devolved powers and funding streams from central government. Drawing on the assets of all partners, ICPs and ICBs have a significant opportunity to go beyond aligning health and care services; and to work with partners, such as those in the Inclusive Growth Network, to help tackle poverty and improve population health. Emerging evidence, in this case from Greater Manchester’s experience, is starting to show how devolution, and innovation is making a difference to health outcomes for the poorest, with life expectancy out-performing comparators.

The importance of data and metrics on poverty

Relevant and timely data on poverty is important to help mobilise and direct ICSs work through wider partnerships. Data is important in helping to identify emerging trends in health and care demand, which helps systems to design appropriate responses. Increasingly there is also a need to use data on poverty to react in real time to spot emerging hotspots of unmet need. Appropriate data, alongside qualitative intelligence, is critical to understanding where intervention is needed and if efforts are succeeding. This applies to NHS England’s approach to inequalities through Core20plus5 (that is, the most deprived quintile (the ‘core 20’); locally identified populations with additional needs (the ‘plus’); and five specific clinical areas) and across wider efforts to reduce inequalities and tackle poverty. Understanding for example, how to select the ‘plus’, and how this is related to poverty, and how any efforts across Core20plus5 activities are having an effect, or not, is reliant on good data, analysed well.

What routine poverty data is available to inform ICSs?

There is no single headline measure of poverty in the United Kingdom, and available measures have pros and cons (see Table 1). The government abolished the previous headline measure in 2015 promising to consult on a new measure. Current approaches cluster around ‘absolute measures’, ie, whether people have the income available to meet a set of identified needs, or ‘relative measures’, ie, how far adrift of the incomes of the rest of society, for example, usually below 60 per cent of median income.

'Data is important in helping to identify emerging trends in health and care demand, which helps systems to design appropriate responses. Increasingly there is also a need to use data on poverty to react in real time to spot emerging hotspots of unmet need.'

The two most-widely used indicators for poverty are based on the Family Resources Survey in conjunction with benefits data: the proportion of households below average income and the proportion of children in low-income families. These are derived from questioning household samples about their income and expenditure. These statistics are of limited use for detecting real-time changes in local poverty, as they are only available with a lag, but are useful as indicators for strategic planning, helping to focus discussions, allow for geographical comparisons and benchmark long-term changes.

However, these measures alone are not sufficient for tracking poverty today. Fast-rising inflation is shifting the poverty line, yet both relative and absolute proportion of households below average income and children in low-income families measures of poverty are focused solely on incomes and are decoupled from the cost of living at a time when the price of essentials are rising, making the cost of living unaffordable for increasing numbers of people.

Other proxy measures for poverty such as universal credit claimant data, and numbers of children in receipt of free school meals are often more timely and routinely available at place level. Beyond single measures of poverty are indices that help assess the risk that certain places are in, or will experience, poverty. CPP’s cost of living vulnerability index shows which local populations are vulnerable to being pushed into poverty, as well as highlighting those already experiencing high levels of deprivation. It combines six variables to construct a vulnerability score, including: fuel poverty, food insecurity, child poverty, claimant count, economic inactivity and low pay. The index and underlying data are available at local authority level, but some of the data is based on academic analysis rather than official statistics, meaning regular updates may be less reliably available. Nevertheless, such composite indices could be useful in helping local health and care systems identify at a glance those at risk of falling into poverty. The table below summarises key characteristics of existing poverty measures and proxies.

Table 1 Official poverty measures and proxies

Beyond these sources of data, private sector collaborations may offer access to important near-real-time data, with utilities and credit data providing insight into ceased payments or dramatic changes to consumption which might provide warning signs of financial difficulty. See Measuring chaos for more detail on existing poverty measures and their advantages and disadvantages.

What data is available at individual or household level?

Local authorities have access to individual data that more directly measures poverty, including benefit and Council Tax data as well as social care, housing and school census data.

ICSs and combined authorities do not hold or automatically have access to individual data. Local authorities, and other possible ICP members, such as local police and VCSE organisations will hold individual-level data, making ICPs a valuable forum for structuring the sharing of information. Private sector collaborations may also offer access to important near-real-time data, for example, credit risk data. The extent to which it is appropriate to share individual-level data will depend on whether clear public benefit can be demonstrated to balance concerns about privacy and ethics.

Using poverty data to inform awareness, action and advocacy

Some local health and care systems and their partners in CPP’s Inclusive Growth Network, are already using data in various ways to help tackle poverty and its effects on health and care. What can we learn from them? In previous work on poverty and health, The King’s Fund developed a framework to help understand how the NHS can have an impact on poverty and its effects: through raising awareness of the impacts of poverty on people’s health and access to care, taking direct action on poverty and in being a strong advocate for tackling poverty.

Awareness

Raising awareness of poverty across organisations is a common characteristic of our case studies. Greater Manchester Health and Care Partnership’s population health team has been working to support a local charity to raise awareness of poverty and its effects with local partners and national departments (see below). In other places, such as Buckinghamshire, where statutory and VCSE partners have just launched the Bucks data exchange, the VCSE sector is leading the way, collaborating with the local council and others to share data on financial insecurity and health and wellbeing to help these organisations target their services.

Action

An excellent example of how data is being used to inform action on poverty is Sheffield Children’s Hospital, using local data to proactively identify those children most likely to be subject to poverty and therefore less likely to attend for care, to the detriment of their health (see below). The hospital is also part of a wider network of children’s hospitals, the Children’s Hospital Alliance who are using data in innovative ways to be better design and provide care including through the Paediatric Accelerator Programme. Another example is the London borough of Barking and Dagenham Council who have developed a tool called One View that pulls together individual level data from across the council system and can be used to direct individuals to relevant services and information, for example providing information to those in social housing at risk of falling with information to help keep them safe.

Advocacy

Advocacy for those in or at risk of poverty, and speaking out for those who are less heard is often more effective and impactful when it is supported by clear data.  Since 2017 in Scotland there has been a statutory duty on NHS board and local authorities to jointly publish Local Child Poverty Action Reports. Glasgow City Council has been able to use individual level tax and benefit data to advocate for parents within the benefit system to maximise their incomes and work towards reducing child poverty (see below).

The full set of seven case studies from this work is available on the Inclusive Growth Network site. Cross-organisational partnerships, is a key theme running across all of our examples. This points to the fact that the support received by people and communities should be more than the sum of its parts, and the value of civic leadership and a place-based approach to addressing the links between poverty and ill health. The West Midland Combined Authority for example is working with the academic sector to predict the risk of homelessness while Leeds City Council’s Social Progress Index used to understand and inform policy on inclusive growth and wellbeing was built on work from an earlier partnership with the University of Leeds.

Looking to the future: what’s needed now?

There are three key opportunities for ICSs to make progress on tackling poverty in the coming year as new structures embed. Given the scale of the poverty challenge, and the very direct impact that it has on health outcomes and NHS demand, there is a need for all three to be seized in 2023. Data is not the only step to driving action, but it needs to be a more emphasised stimulus to action.

• Including poverty measures in shared outcomes frameworks for ICSs

• Embedding poverty into ICSs’ population health strategies

• Collecting and sharing poverty data more systematically between partners, making use of ICPs.

Including poverty measures in shared outcomes frameworks for ICSs

A commitment to developing shared outcomes frameworks for ICSs by April 2023 was set out in the integration White Paper, which argued:

Shared outcomes bring organisations and the people they serve together… The right outcomes will encourage local innovation and positive change.

There is a strong case for poverty measures to be in these frameworks given the long-term impact on health and care demand and the financial cost of poverty on public services. But which ones? Our view is a balance across the three types below.

• Metrics to frame longer-term objectives for poverty reduction and prevention – of currently accessible options, our work implies that CILIF data offers the best blend of authoritative official data, with insight that can be used to direct service delivery. Intervention in childhood is crucial to setting people on positive economic and health journeys across the life-course.

• Metrics to capture and assess achievable medium-term outcomes. Such indicators should include:

  • measures of the extent to which health and care services are reaching out to those in need, challenging the contact model of healthcare and shifting to an anticipatory and preventive model

  • the recruitment of people with lived experience of poverty and from deprived communities. Acknowledging their role as anchor institutions in the local economy, NHS bodies could learn from places like North of Tyne combined authority, which have included social disadvantage as a protected characteristic

  • the housing status and condition of the communities that the health and care system serves, with ICPs taking a data-led interest in the warmth, tenure, and suitability of homes.

• Locally determined metrics that are monitored by both the health and care system and their public and third sector partners. This will enable agencies to design genuinely collaborative strategies based on a real understanding of local needs. For example, poverty-focused ICSs could put into action previous housing actions suggested for STPSs and monitor them through data, adopt relevant metrics from the public health outcomes framework, or local sources as our case studies demonstrate. Joint Strategic Needs Assessment (JSNA) data from health and wellbeing boards can give vital local information on poverty.

Embedding poverty into ICSs’ population health strategies

We identified three steps, that we believe have helped some local partnerships, including ICSs, to move forward on tackling poverty, often as part of a wider focus on population health.

Focusing policy explicitly on poverty

Our case studies demonstrate that an explicit policy focus on poverty itself drives action, with leaders in this space such as the Children’s Hospital Alliance, Glasgow City Council and North of Tyne Combined Authority all having done so. Collectively, they and others show how local governments and NHS organisations are mitigating, reducing and preventing poverty in some places and for some groups.

The scale of impending poverty requires a clear strategic approach, each integrated care partnership should consider the role it wishes to play in shaping local conversations about poverty within the forthcoming five-year ICP strategies. These must include those with lived experience,  through participatory processes to inform local prioritisation of poverty, such as the Poverty Commissions and strategic plans launched in Devon, North of Tyne, and Morecambe Bay.  Marmot cities have typically used such approaches in developing their plans. Seizing the moment to make prevention, mitigation, and reduction of poverty and its health impacts part of the purpose of these statutory partnerships will frame the contribution that could be made across the health and care system.

Investing in analytic capacity and insight on poverty

The NHS and local government have powerful analytic and intelligence teams and wider resources and insight at their disposal but health-centred analysts are rarely ‘pointed towards’ poverty and its effects; and there are currently relatively few strategic partnerships between these analytic teams, or with combined authorities. The ambition for the population health intelligence team in Greater Manchester Health and Care Partnership, is to create leeway ‘to be curious’ about data and integrate it with other insight, to spot emerging trends and issues relevant to poverty and health. Other ICSs should look to this example, making the most of national resources to support this work for example the NHS Analytics Unit.

Using data insights to inform anticipatory models of care

As we have undertaken this work, it has become clearer that clinical system change to address the cross-cutting issue of poverty faces real barriers. The change will demand professional leadership to shift the dial towards a more anticipatory model of care, understanding and being curious about the lived experience of poverty and how it changes health and presenting behaviour, and leadership that responds to the data and intelligence explored here.

As a consequence, ICSs, need to deploy more anticipatory care models at neighbourhood level, and the Fuller stocktake into the future of primary care recommended the formation of neighbourhood level teams with this in mind. This will require innovative funding across organisational boundaries and greater risk-taking. At a time of perceived pressure on service providers, inviting such action, curiosity and commitment is a particularly difficult ask.

Collecting and sharing poverty data more systematically between partners, making use of ICPs

People we spoke with repeatedly told us that what is measured drives action and that sharing data, had changed the nature of joint working and better directed resource to those in most need. A blend of data types and sources will be needed to make sense of the local environment; and there is a trade-off to be made between perfect-quality data and good-enough to make better decisions. Data quality, coverage and interpretation on poverty is an important issue (see above table for example on coverage) and data quality improvement needs to be an ongoing priority. We have witnessed how the use of even imperfect data has led to increasing awareness, action and advocacy around poverty and health. Local and regional government has generally been ahead in collating, interpreting and connecting data on poverty, the NHS needs to more often be around the table as a participatory partner.

Health and care systems must:

• recognise the leadership role of local authorities in population health management: much poverty-relevant data is held outside the NHS in local government; this needs to be brought more strongly into population health management initiatives

• think actively beyond the public sector for insight: private sector held data is some of the most frequent and sensitive data to poverty, and for those at-risk of falling into poverty. In Leeds, part of the West Yorkshire’s ICS, suitably anonymised private sector debt and payment information may offer trend and spatial insights closer to real time than statutory datasets.

• use ICPs as a forum to discuss research and disseminate insight, particularly where it is not possible or desirable to share individual level data.

A barrier to progress however is being clear on the legal framework for sharing data, especially at individual or community level.  As more places and organisations seek to expand their understanding of the complex impacts of poverty and their responses this is an area where more attention needs to be paid by local partners, sharing experience of this is therefore very important.

Conclusion

There is an urgency to the need for the health and care system to act on poverty and its health effects. A looming crisis lies ahead. Health and care systems can mitigate, reduce and prevent poverty. To do that they need to be much better at sharing and acting on data. Data can bring partners together, and enable a real-world focus on what works, and what each can contribute.

In spite of the limitations of the measures of poverty we have discussed above, there are many examples of local teams using data to help them focus on responding to poverty and its effects, but more need to join them. This requires action from NHS England and other system leaders too, and data on poverty also needs to be baked into systems, structures and shared outcomes frameworks, alongside the lived experience of those suffering and at-risk from it.