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Long read

Illustrating the relationship between poverty and NHS services

Key points

  • People living in poverty find it harder to live healthy lives, harder to access NHS services, live with greater illness and die earlier than the rest of the population.

  • Poverty and the effect it has on health and on the NHS is not new, though the recent rise in deep poverty, cost-of-living increases and high pressure on NHS services are all worsening the problem (6 in 10 of people in the most deprived areas report that the cost-of-living squeeze is impacting their health) and adding to the financial cost to the NHS.

  • Poverty is a complex problem that will affect different groups in different ways. For example, child poverty is rising particularly sharply, negatively impacting children’s health now and throughout their lives.

  • NHS staff are also impacted by poverty in different ways. They can experience poverty directly themselves, as well as treating patients who are experiencing the effects of poverty.

  • Poverty makes it harder for people to access services (nearly one in five low-income adults report skipping essential dental care due to the cost), and services do not always reach those in poverty. This lack of access means people living in poverty are getting sicker and accessing services later – accident and emergency (A&E) attendances are nearly twice as high in the most deprived groups, and emergency admissions 68% higher.

  • Greater illness and less access to care contribute to worse health outcomes – the mortality rate in the lowest Index of Multiple Deprivation (IMD) decile is almost double that of the highest.

  • The NHS has a role to play in addressing poverty, both as an employer and as a provider of public services. There are examples of good work under way, such as poverty-proofing services (making sure every stage of the patient pathway is accessible to more deprived groups), but more needs to be done to support better access and better outcomes for those living in poverty.

  • The NHS can only treat the symptoms of poverty; broader government, economic and civic society action is needed to treat the causes.

Introduction

Currently it is estimated that more than one in five people in the UK are living in poverty. Living in poverty has a profound impact on people’s health and how they use NHS services. From greater prevalence of a wide range of diseases and difficulties in accessing health care, to later treatment and worse health outcomes, poverty affects every stage of the patient journey.

As well as taking a significant toll on individuals, poverty also leads to additional costs for the NHS. In 2016, the Joseph Rowntree Foundation (JRF) estimated the cost of poverty on health care (ie, additional public spending due to greater health care need and use) at £29 billion (£34 billion in current prices). Since that report, the situation has got worse: the number of people living in poverty has increased since 2015/16, and the proportion of those people living in deep poverty has risen.

This long read looks at the link between poverty and each of the following:

  • prevalence of ill health

  • difficulties accessing health care

  • late or delayed treatment (and higher NHS costs)

  • poorer health outcomes.

These four issues can be seen across a wide range of NHS services, from emergency care to dentistry. As well as highlighting this breadth, it is hoped that this long read will provide stimulus for local and NHS leaders to consider the role poverty plays when making plans to manage and improve services. To that end, it signposts some existing resources that may help tackle the issues.

Taking action on this is one of the biggest things we can do to influence and shape health outcomes and inequalities.
Senior leader in population health, integrated care board

Mental health: Compared to the least deprived areas of the UK, among people living in the most deprived areas:  the depression rate is 2 x higher 2 x as many people are in contact with mental health services 3 x as many people are in hospital (and 5 x as many stay more than 60 days) 2 x as many people die by suicide    Bowel cancer: Compared to the least deprived areas of the UK, among people living in the most deprived areas:  prevalence of bowel cancer is 36% lower fewer people take part in screening (64% vs 75%) fewer people are diagnosed early (42% v 55%) the mortality rate is 25% higher .    Covid-19: Compared to the least deprived areas of the UK, among people living in the most deprived areas:  cases of Covid-19 were 1.5 x higher there was lower vaccine uptake (79% vs 93%) hospital admission rates due to Covid-19 were 3 x higher the number of people dying with Covid-19 was 2.5 x higher

Methodology

This long read draws on four main sources. First, a literature review of work focusing on the relationship between poverty and health. Second, quantitative analysis of secondary data sources, such as NHS England, the Office for National Statistics (ONS), and the Office for Health Improvement and Disparities (OHID). Third, semi-structured interviews with senior NHS staff working in this space to understand how poverty is impacting on services at the local level and what is being done to tackle it. Fourth, expertise from JRF on poverty and how it has changed over time.

Poverty and prevalence of ill health

Living in poverty makes it harder for people to manage their health well. For example, it is more difficult to eat healthily. If money is short, spending on a healthy diet becomes a substantial expense. In addition, there is a negative relationship between income and access to cooking facilities (8% of households with an income below £10,000 per year have no cooker and 16% have no freezer), and a positive relationship between deprivation and the availability of fast-food outlets – nearly one in three food outlets in the most deprived areas are fast food, compared to one in five in the least deprived areas.

It is therefore unsurprising to see a strong relationship between deprivation and poor diet. Given the link between diet and ill health, it is also unsurprising to see a strong relationship between deprivation and a range of diet-related health problems, including cardiovascular disease and diabetes.

Other ways in which being poor negatively impacts health include housing, both in terms of unhealthy or dangerous homes, and difficulties in heating homes properly. Poverty or deprivation can also contribute to mental illness, as struggling to pay bills, afford food or find suitable housing are all inherently stressful.

Although these problems predated the cost-of-living crisis, there are signs that the crisis has worsened the situation. Food insecurity is increasing, and in a 2023 survey, 25% of households in the most deprived quintile of areas reported eating less fruit and fewer vegetables because of cost-of-living increases, compared to 8% of the least deprived quintile. Rising energy bills are also a problem.

Cost-of-living pressures are impacting more on health in more deprived groups

These issues contribute to the recent increase in very deep poverty, with 6 million people in very deep poverty in 2021/22, up from 4.5 million two decades ago. Approximately 3.8 million people experienced destitution in 2022, 64% higher than 2019. The impact of poverty on health will be even more acute for these people.

Another recent change is the rise in zero-hours contracts and less stable employment, which may also affect health, with a 12 percentage point difference in self-reported good health between employees with good job security and those without.

Child poverty

Childhood has an impact on an individual’s health throughout their life and a childhood lived in poverty has a negative impact. For example, Adverse childhood experiences (ACEs) are correlated with poverty, and negatively impact health in later life, increasing the risk of illnesses from cardiovascular diseases to cancer. Children in deprived areas start to experience health inequalities early on, for example, higher obesity rates, greater exposure to tobacco retailing, and poorer mental health.

These issues impact on children’s health (and therefore on the NHS) in childhood and throughout their lives, and can create a self-perpetuating cycle – children in poorer households may experience poorer health, which limits their education or employment opportunities, which continues to trap families in poverty throughout generations. Childhood illness can also be a trigger to send a family into poverty, for example, if parents have to give up work to care for their child.

It is therefore especially concerning that child poverty is rising. Deep poverty has also risen, with a million destitute children in 2022, 88% higher than 2019. This increase can be seen starkly at the international level. Here, the UK has seen the greatest increase in child poverty rates out of the 39 high or upper middle-income countries in the European Union (EU)/Organization for Economic Cooperation and Development (OECD).

Child poverty has risen more in the UK

Complexity of poverty

That deprivation contributes to greater prevalence of illness, which in turn contributes to higher NHS activity, is intuitively understandable, but this association is not always straightforward. For example, people in more deprived areas, despite being substantially less likely to consume alcohol, or to drink risky amounts (more than 14 units a week), are nearly twice as likely to be admitted to hospital due to alcohol-related problems. Why this happens is not clear. This inverse relationship makes the point that the association between deprivation, prevalence and NHS activity can be complex, and that decreasing the prevalence of an illness or risk factors, while good for people, may not decrease NHS activity.

Another complexity of poverty that makes finding solutions harder is that nobody experiences poverty in isolation – everyone experiences a range of influences on their health, such as their location, age and ethnicity. This is especially problematic for people who belong to multiple marginalised groups, as they often experience additional health disadvantages when their different social inequalities intersect.

NHS staff and poverty

Poverty among NHS staff is a large and growing problem. 71% of providers report that staff struggling to afford to travel to work is a significant issue, and 42% report that staff are struggling to afford to eat at work. This affects staff health, which in turn affects the NHS in terms of increased sickness absence. Recruitment and retention are also a problem, with 68% of providers reporting that staff are moving to other sectors due to the cost of living.

As well as being impacted by poverty directly, staff are affected by dealing with the impact of poverty on their patients. Interviews with NHS stakeholders emphasised the moral injury this causes staff, especially as they can generally only treat the symptoms of poverty rather than the underlying causes. This long read cannot explore this issue more fully, but the impact of both treating and experiencing poverty on NHS staff needs to be acknowledged

We all know the stories about nurses using food banks. But how does working with patients who are in poverty affect staff who feel unable to do anything about it?
Senior leader, network of NHS trusts

Poverty and difficulties accessing health care

It might be expected that greater prevalence of ill health in poorer or more deprived groups would lead to higher NHS activity around people in these groups. But this is not always the case, especially at the earlier stages of the patient pathway, such as people accessing services that prevent health conditions deteriorating. There are two sides to this lack of access – barriers that prevent people seeking treatment, and a lack of resources to provide this treatment.

Poverty makes it harder for people to access care

The NHS is reactive to its core, you effectively have to knock on the door and say, ‘I want help’. One of the dilemmas of this space is, how likely is that to happen?
Chief executive, NHS trust

Poverty creates practical difficulties in seeking treatment. The cost of travelling to hospital, waiting on the phone for a GP appointment, using the internet to access online services (14% of the lowest socio-economic grade do not have internet access at home, compared to 2% of the highest), paying NHS charges etc, can all be prohibitive for those living in poverty.

As well as these challenges, the stigma of poverty can lead to a reluctance to come forward for treatment, or to seek help more broadly, for example accessing financial advice. And there is a relationship between deprivation and a lack of trust in public institutions, including the NHS, which again leads to a reluctance to access health care. These make the problem harder to solve for the NHS, as simply improving access to existing services won’t help those people who are reluctant to come forward for help

For a lot of people living, particularly in intergenerational poverty, there’s no expectation that public services will be any good or understand this space. It’s kind of wired in that you’ll be useless.
Chief executive, NHS trust

The NHS does not always reach those in poverty

While there is no clear relationship between deprivation and the provision of several NHS services, such as diagnostic waits, there are relationships in other areas – for example, people who live in the most deprived areas of England are twice as likely to wait more than a year for non-urgent treatment. This is a variation of the inverse care law – that those who most need medical care are least likely to receive it.

In primary care, there are fewer GPs per patient in more deprived areas, consultations are shorter, and continuity of GP care is worse. This feeds through to patient satisfaction – for example, in 2023, 80% of patients in the most deprived quintile felt they had enough time at their last GP appointment, compared to 87% in the least deprived quintile.

Finally, NHS systems and administration can be more challenging to navigate for more deprived patients. Interviews with senior NHS staff gave a range of examples, from complex forms to reclaim travel expenses (which assumes people can pay these expenses in the first place) to patients in hospital missing out on social prescribing because this is only available via the GP. All this means that only 61% of people aged 65 and over in more deprived areas are satisfied with being able to access services when needed, compared to 69% in the least deprived areas.

The poorer you are, the more likely you are to be in unstable housing, the more likely you are to be moving around, the less likely it is that your local hospital will actually have contact details for you.
Senior leader, network of NHS trusts

It is important to note that while more deprived areas shouldn’t be underserved, even if this was corrected, the impact of poverty on illness and NHS services would not be solved. While there are things the NHS can do in this space (assuming they have the capacity and funding), alleviating the root causes of poverty is not a problem for health services alone.

Impact of access difficulties

[Over-presenting] that’s the bit we talk about, I’m equally worried about the other end of it, which is nobody presents, either because they can’t, because to be honest they’re on £8 a week, they can’t get to services, or because they think they’ll be dismissed.
Chief executive, NHS trust

These issues contribute to the lower use of preventive services in more deprived areas, such as lower uptake of cancer screening services and lower child vaccine rates. This association continues in a wide range of community or non-urgent services. A 2022 survey of those aged 65 and over found that those from lower social grades had fewer dentist, GP and non-urgent hospital appointments, despite being more likely to have a long-term health condition.

The cost-of-living crisis is worsening the issue. In 2023, 8% of lower-income adults reported not getting prescriptions or other medicines because they were unable to afford it, and 19% reported skipping essential dental care.

There is a risk that this problem may become even more acute given the current shift towards digital and remote care, which more deprived groups, who are more likely to experience digital exclusion (a million people cancelled their broadband in the past year as they could not afford it), could struggle to access.

If people cannot access the services they need when they need them, they may either access other NHS services (there is a strong correlation between deprivation and patients reporting that they used other NHS services as they had problems making an appointment with a GP), or they may get sicker and need more costly services.

Patients are using other NHS services if they cannot access the GP

Unmet need

Unmet need, which describes where people who need medical care do not receive it, may be a particular problem for more deprived groups. For example, in 2021 the undiagnosed diabetes rate was double in the bottom IMD quintile compared to the top.

A recent JRF survey found that of those in the bottom income quintile whose health has been negatively impacted by the cost-of-living crisis, only 33% had accessed mental health services, and 39% physical health services, and that there were a range of reasons why they had not accessed care.

This presents a challenge for the NHS in finding those with an unmet need for health care, ensuring treatment is tailored to their needs, and dealing with the short-term increase in demand that may result if people are more able to access the care they need. However, this increase in demand may be offset by a decrease in demand for later-stage services, because if illnesses are caught earlier, they can often be treated more easily and cheaply.

There are a range of reasons why people do not access health care despite their health worsening

Poverty and late or delayed treatment (and higher NHS costs)

Poverty contributes to greater prevalence of poor health, and thereby greater need for NHS services. And poverty contributes to difficulties in accessing these services at the early stages of illness. This leads to an inevitable but costly outcome, both in terms of financial cost to the NHS and worse outcomes for patients – an association between poverty and use of more-acute NHS services.

Dental care is a good illustration of this. The challenges of eating healthily while living in poverty contributes to a higher incidence of tooth decay among people in more deprived areas. Lack of access to NHS dentists has been well documented in the media recently, especially in more deprived areas. Another barrier is NHS dental charges, which vary from £25.80 to £306.80. These factors combine to result in substantially higher tooth extraction rates for people in more deprived areas.

Greater prevalence of dental decay and inability to afford dental care contribute to more tooth extractions

A general dentist service attendance costs the NHS an average of £192. NHS providers cost a major surgical tooth extraction in hospital at £3,915. Facilitating access to dentistry at an earlier stage could therefore save a considerable sum, as well as being better for patients. But this problem is worsening. Between 2018/19 and 2021/22, there was a 47% fall in routine dental examinations for non-paying adults but a 14% increase in urgent treatments.

Looking at a comprehensive measure of admissions to hospital, there are more admissions of patients in more deprived areas than in less deprived – unsurprising given the greater prevalence of ill health with deprivation. However, this difference is entirely driven by emergency admissions – planned admissions are lower for more deprived areas.

Emergency hospital admissions are higher for more deprived groups

Later-stage and more costly hospital visits can also be seen in more A&E attendances – people in the most deprived IMD decile are nearly twice as likely to have attended A&E in 2022/23 than the least deprived decile. And it can be seen in higher numbers and longer stays in critical care (one of the most intensive uses of NHS resources, with some of the highest unit costs – more than £2,000 per bed day).

Critical care number of stays are greater, and stays are longer for more deprived groups

These higher emergency hospital admissions, higher A&E attendances, and higher/longer critical care stays show that people in poverty access care later, access more unplanned care (ie, at the emergency stage), and access more intensive care for longer. This has a negative impact on patients and is more expensive for the NHS than if people had been treated earlier.

There are signs that this problem of late access has worsened in recent years. While this was a problem before the Covid-19 pandemic and remains a problem now, the interruption of service delivery due to Covid-19 did not help matters. Take early diagnosis of cancer – during Covid-19, the proportion of early cancer diagnoses fell more sharply for patients in more deprived areas (from 53% diagnosed early in  March 2020 to 41% in May 2020, while the least deprived quintile of areas went from 58% to 52%).

The cost-of-living crisis is also exacerbating the problem; in a 2022 survey of NHS providers, 56% reported an increase in people delaying seeking help due to the cost of living. Another example is an increase in hospital admissions for malnutrition and nutrient deficiencies (more than 800,000 admissions in 2022/23). This leads to higher costs for the NHS – Future Health estimated that health problems due to malnutrition cost £22.6 billion a year.

Poverty and worse health outcomes

Poverty and deprivation give rise to greater ill health and can make it harder to access NHS services. As well as increasing pressure on late-stage NHS services, this worse health and later treatment leads, inevitably, to worse outcomes for people. Between March 2021 and January 2023, the age-standardised mortality rate in the lowest IMD decile was almost double that of the highest.

Higher mortality rates are found not just in diseases that are more prevalent in more deprived areas, but also in diseases that are less prevalent in more deprived areas. For example, dementia is 1.4 times less prevalent in the most deprived areas compared to the least, but deaths from dementia are 1.6 times higher.

Mortality rates are higher for more deprived groups, despite variation in disease prevalence

Higher mortality rates mean that life expectancy is lower in more deprived areas. Men living in the most deprived areas can expect to live 9.7 years fewer than men in the least deprived areas, and women 7.9 years fewer. These inequalities in life expectancy are increasing; between 2015–2017 and 2018–2020, female life expectancy decreased by 4.8 months in the most deprived decile but rose by 1.2 months in the least.

Not only do people in more deprived areas die sooner, they also live a higher proportion of their lives with health problems. 60-year-old women in the most deprived local areas have a similar level of diagnosed ill health (ie, not including any unmet need) as 76-year-old women in the least deprived.

People living in more deprived areas live less of their lives in good health

Multimorbidity

Multimorbidity – multiple long-term conditions – is a problem across the whole population (one in four people have two or more health conditions) but is noticeably worse for people in more deprived areas. In 2018, 28% of 65–74-year-olds in the most deprived quintile of areas had four or more long-term conditions, compared to 16% in the least deprived quintile. The disparity starts early – in 2019, the median age of multimorbidity onset was eight years younger in the most deprived IMD quintile compared with the least deprived – and is growing.

This high and rising multimorbidity is adding pressure to NHS services. Research from The Health Foundation found that people with four or more conditions had an average of 8.9 outpatient visits and 24.6 GP visits over a two-year period, compared to 2.8 outpatient visits and 8.8 visits to the GP for people with one condition.

Both patient outcomes and NHS pressures are worsened by the challenges that come from managing multiple health conditions. The access difficulties discussed above, plus barriers to health literacy and the ability to navigate the NHS (especially where services are not designed for those with high levels of need), are all compounded by having to attend multiple appointments and navigate multiple systems for multiple conditions. These challenges are often greater for people in more deprived groups, and can lead to a vicious cycle, where the challenges in managing multimorbidity can increase health problems.

Inclusion groups – people who are homeless

All these issues are more severe among inclusion health groups – those who are socially excluded, such as sex workers, Gypsy, Roma and Traveller communities, vulnerable migrants, etc. One such group are people who experience homelessness. 82% of people who are homeless report being diagnosed with a mental health issue, eight times higher than the general population. And 66% of those in temporary accommodation report that their living situation has a negative impact on their health.

As well as causing or exacerbating ill health, homelessness makes it harder to access medical services. Only 37% of women who are homeless were up to date with breast screening in 2018–21, compared to 62% of the general population.

As with deprivation more widely, later-stage NHS activity is higher for people who experience homelessness. 48% of people who are homeless had been to A&E at least once in the previous year. These challenges in seeking and accessing health care mean that men who experience homelessness die at just 45 on average35 years earlier than the England average.

What can the NHS do to tackle poverty?

Despite the scale and complexity of the problem, the NHS can make a difference, through raising awareness of poverty in patients among staff, taking action to meet the needs of those experiencing poverty and using its voice to advocate for tackling poverty. The box below provides resources for the sector, including examples of what the NHS is currently doing at the local level to try to mitigate the effects of poverty on health – from providing practical support in accessing services to building trust and removing stigma.

We’re investing quite heavily in neighbourhood-level groups who can do that advocacy work and that support work and that befriending work that doesn’t say, ‘Oh gosh, you’re poor, we’re going to do something to you.'
Chief executive, NHS trust

Resources for the NHS in tackling poverty

Reports

Examples of NHS work

  • Building trust at the neighbourhood level

    • Wessex Cancer Alliance’s Communities Against Cancer project: partnering with a voluntary infrastructure body which provides training, support and grant funding to support community groups in raising awareness of cancer within their communities in ways that are appropriate for them. Targeted towards those experiencing health inequalities, including those on low incomes.

    • Norfolk and Waveney Community Voices: using trusted communicators to speak with communities who may not already engage with the NHS to hear what is important to them in health services and other issues that affect health and wellbeing, such as housing and employment.

  • Helping people navigate the NHS or access wider support

    • Southampton Hospital’s Patient support hub: providing a single point of contact for additional support before and after a visit to hospital.

    • The Warm Home Prescription Scheme: partnering with charities and using the government’s Household Support Fund to pay the energy bills of up to 150 people with cold-sensitive health conditions who are struggling with heating costs.

  • Using data to find and better understand those in poverty

    • Tackling fuel poverty in Cheshire and Merseyside: supporting people with respiratory illness who are living in fuel poverty. Drawing on data which identifies the population cohorts at greatest risk of harm, multidisciplinary teams (NHS, voluntary, community and social enterprise organisations, and local authorities) work together to reach out to high-risk groups with targeted interventions.

  • Poverty proofing services to ensure accessibility

    • Sale Central Primary Care Network: running drop-in sessions with a community health adviser for those facing barriers to accessing traditional services. This provides advice to improve health and wellbeing, and links to broader support services, such as financial advice.

    • Children’s Hospital Alliance’s Was Not Brought Programme: using AI to identify children at risk of not attending appointments, and providing tailored support such as free transport or appointments in schools.

  • Making the most of any contact with deprived groups

    • Bolton: employing social prescribing link workers in every primary care network to share advice with people in poverty, for example, by directing them to financial and debt advice, housing advice and skills training.

  • Understanding the complexities of poverty

  • Supporting NHS staff in poverty

    • Identifying need and targeting support: using a survey of staff and focus groups to target support to those who need it, such as providing free breakfasts to some employees, offering budget management workshops, and training managers to support their staff.

Tackling poverty can be seen as less urgent than, for example, bringing waiting lists down. In interviews, senior NHS staff stated that while there is widespread agreement that tackling poverty is important, this does not always translate into concrete action or funding.

Fundamentally, what we are held to account on the at the end of the day is waiting lists and the achievement of targets and the delivery of balanced budgets.
Senior leader, network of NHS trusts

NHS action to mitigate the effects of poverty is needed both for people and populations and to lessen the long-term pressure on the system – this should not be less of a priority than seemingly more urgent, or more measurable, aims. Previous work from The King’s Fund has shown ways the NHS can embed improvements in access for those in poverty or experiencing other health inequalities. But for sustained change to take place, long-term, multi-agency approaches are needed, as well as a willingness to change or replace current systems – this is not a quick or easy fix.

Conclusion

Poverty has a significant impact on people’s health, their need for health care, and their use of health care services. That people in poverty experience worse health is bad for them, bad for the economy, and bad for the NHS. The NHS needs to do more to deliver services that people living in poverty are more easily able to access and navigate – some good examples already exist at the local level. However, while the NHS can help manage the health consequences of being in poverty, taking action to lift millions of people out of poverty requires sustained investment and prioritisation across national government, public services and wider business and civic society.

About this report

This work was commissioned and funded by the Joseph Rowntree Foundation. JRF provided advice and information, but views expressed and any errors are those of the authors only.

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