Discussing poverty within primary care consultations: implications for mental health support

Asking questions about socioeconomic circumstances

Research has shown that many patients from low-income backgrounds feel uncomfortable and disempowered within clinical encounters and are less likely than wealthier patients to voice their concerns, particularly in relation to stigmatised issues like poverty and mental health.^10,16 Health professionals interviewed felt that it was uncommon for patients to share their circumstances without explicit prompting:

‘It’s very rare that patients bring this [socio-economic circumstances] up other than for benefits forms.’ (GP10)

Research suggests that avoiding rather than normalising conversations around issues such as mental health and poverty can exacerbate stigma and result in ineffective or potentially harmful treatment responses.¹⁶ However, we found that the impacts of poverty on patient health and practice workload were not regularly discussed within practice teams. A minority of health professionals, in particular GPs, felt that asking about these issues was not within their remit and might trigger complex issues which they lacked the skills or resources to properly address. However, other interviewees reported lack of confidence and fear of offending as the main barriers:

‘There’s a perception that maybe they [patient] don’t want to be asked and don’t want someone prying around too much in the personal, deeper personal information. But actually, I don’t think that’s true. I think people do want to be asked and I just think [health professionals] think they can’t ask.’ (GP20)

Asking patients sensitive questions around suicide and substance use is mandated by guidance recommending risk assessment of patients with emotional concerns. Yet as one GP emphasised, really understanding the issues patients faced required consideration of a broader set of concerns, and active listening going beyond a ‘tick box’ approach:

‘The social history is just like a tick box sometimes […] the medical students for example just ask about smoking, drinking — they think that’s a social history, but it’s not. There’s so much gambling, debt, the family structure and things. So, it’s about trying to go a bit deeper at the beginning.’ (GP5)

The DeStress-II training contains scripts and prompts to acknowledge and help validate patient circumstances and open up space for non-judgmental discussion (see Figure 1).

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Figure 1. Examples of scripts and prompts within the training

GPs said the training had helped them to understand the broader challenges patients may be facing, and how they could use these scripts or prompts to engage in discussions which normalised patient responses to their mental distress as ‘what most people in your situation would feel’ rather than framing them as psychological problems necessarily requiring medical or therapy-based solutions:

‘I thought the scripts given in the training about saying we are in this together, we can work together, I can support you — those scripts were quite useful.’ (GP02)

‘I found [training] really thought provoking […] And it really made me think about what the patient’s journey actually is when they get to the surgery, all that comes before it, rather than just thinking about them being sat in front of you for those 10 minutes […] [the training] allowed me to think about and give myself permission to ask those questions.’ (GP20)

Avoiding assumptions

Several GPs stressed how coming from very different backgrounds to their low-income patients meant that inaccurate assumptions could be made when questions relating to broader socioeconomic circumstances were not explicitly asked. GP10 stressed how important it was for health professionals to be continually aware of this difference, and the influence this might have on patient decision-making:

‘Most doctors and healthcare professionals don’t come from a background where [poverty] is really experienced. So, I think we have to keep saying that our patients are on average quite different to us […] you know my washing machine broke and I didn’t have any money in the bank. That’s fine. Umpteen companies will offer me credit to buy a new one. But that isn’t true for a lot of our patients who have no personal or family or social safety […] and people will think differently about their choices.’ (GP10)

The importance of avoiding assumptions was also highlighted by this GP as he explained how the current cost-of-living crisis meant financial problems could affect a wide range of patients:

‘I think it’s easy to make assumptions in both ways. I’ve got patients who are on extremely low incomes, but who are really canny with their money and have always lived on very low incomes and are very effective in their use of that income to manage their life in the way that they want to. And other people, particularly where incomes have gone up and down, who I think often find it much more difficult.’ (GP10)

Rethinking appropriate support

Health professionals described how the DeStress-II training had helped them to better understand how mental health could be impacted by poverty-related stressors. This then prompted reconsideration of the types of support likely to be appropriate. One GP explained that he now felt able to recognise mental distress as being triggered by broader socioeconomic challenges rather than as something he would have previously defined as ‘clinical depression’ and ‘going to a single route of treatment’, through antidepressants. Questioning the appropriateness of prescribing medications for mental distress caused primarily by socioeconomic stressors was also raised:

‘It seems a lot of it [mental distress] is to do with poverty and financial benefits being stopped, people being made redundant. A lot of people’s problems we probably shouldn’t be going anywhere near antidepressants for them. People come and say ‘I have been feeling really down, I’m feeling this’, [we say] ‘here have a prescription’. Questions need to be asked.’ (Care coordinator)

Feeling confident and comfortable asking about socioeconomic circumstances early in the consultation process was also considered necessary to ensuring that potentially vulnerable patients received appropriate support and were prevented from entering a ‘revolving door’ of health concerns:

‘It’s almost a safety net where if you don’t ask, they don’t open up and [you] leave a patient vulnerable. And that’s where I think, you know, the revolving door comes — they keep ringing for a physical or functional illness, which is really stemmed from some form of mental health, psychological trauma.’ (Advanced nurse practitioner)

Asking patients about broader life circumstances and underlying stressors during initial consultations was also seen as vital when follow-up consultations were likely to be dominated by questions around medication experience and adherence:

‘If patients have already gone down that route of medication, then the underlying issues can get left alone, or stay hidden because once the medication has started all the focus is, on the medication working or not working, less dose, put the dose up, change the medication.’ (Clinical pharmacist)

Several health professionals described how their post-training confidence to ask questions had led to deeper insights about patients’ everyday challenges and had facilitated better signposting to support. Finance was an area that was especially challenging to raise, despite recognition that this would be central to people’s circumstances and mental wellbeing. Describing how he had previously ‘skirted around’ this issue, one GP explained how, through asking, he had been better able to understand the extent of the problems faced and provide more appropriate support for his patient:

‘I’ve asked the question and been quite surprised they actually haven’t got enough money for food. I thought, oh God, I thought things were bad, but I didn’t think they were that bad […] but they would have never told you that unless you actually asked specifically. So just in terms of food vouchers and things that’s been quite surprising to me, how many people have been so grateful to have been asked about it and accepted it [vouchers]. And we think the people are ‘gonna feel stigmatised’, but actually, you know, they're very grateful for the offer if it’s made.’ (GP05)

While in this example, the GP was able to offer practical support via vouchers, this was not, under current resource constraints, always felt to be feasible — indeed, as reported elsewhere,¹⁷ inability (perceived or actual) to offer practical responses to support patient needs was identified as a barrier to asking questions in the first place. However, a survey with low-income patients (n = 107) experiencing mental distress undertaken as part of the wider study found that empathic listening and ‘feeling heard’ were core factors contributing to positive consultation experiences, suggesting that practical support was not a prerequisite to good practice.⁶

GP18 showed how, by asking such questions, they gained valuable insight into the stressors exacerbating their patient’s poor mental health, which led to a much broader discussion than would normally have been pursued:

‘I did a consultation with someone I hadn’t seen before […] I was aware that I very much delved into his circumstances more than I perhaps would have done before the training. So now I’m aware that he’s suddenly got two children living with him who were living with their mum and this breakdown in relationship happened and she was in trouble with police and social care […].’ (GP18)

In this case, GP18 explained how these insights helped them to see a wider range of support options were likely to be appropriate for the patient, and how recording it in the patient’s notes would help provide context for future consultations:

‘He came with quite specific ideas about what he wanted in terms of medication, but the outcome was that yes, medication seemed appropriate, but let’s also look at whether you could get support from the social prescribing team, whether there’s a role for social care as well […]. If I hadn’t done the training and he’d come in and said ”I’ve had a relapse of my depression I want to go back on the sertraline”, we’d have had a discussion, but I’d have been like “okay then, here you go, let’s see you in 4weeks”.’ (GP18)

The GP also felt that this discussion had provided opportunity for the patient to feel heard and to recognise the relevance of their circumstances on their mental wellbeing:

‘I think [he felt] quite pleased that someone was showing an interest. And I don’t think he’d really thought of the relevance of his social circumstances to the anxiety and depression that he was experiencing.’ (GP18)

Practice team working

GPs explained how better understanding of patients’ circumstances helped them to recognise and appreciate the role of the social prescriber and/or link workers in the practice team, including practice-based links to external agencies like the Citizens Advice Bureau, with several explaining they had increased referrals once they better understood the role of socioeconomic circumstances in patient distress:

‘When the initial role of social prescriber came, I was very wary and […] we felt we will not use them […] But it was interesting that how, especially when we talk about poverty- related issues or mental health, I do feel they do play important role and we must involve them as a part of our team.’ (GPNT02)

Increasing referrals were confirmed in interviews with other practice staff who felt their role was better understood following the training. Staff in supporting roles also explained how the training gave them the confidence to ask patients questions which had in turn helped relieve pressure on GPs:

‘Before it would have been a case of whether they were on antidepressants or not – if they were telling me they’re depressed, I was telling them that they needed to see a GP. Now I’m emboldened to ask questions and try and identify what the issue is. Okay, if it’s to do with poverty then let’s try signposting and the social prescribers. […] And yeah, I’m getting a better response – more than just trotting out the old ‘we need to book and see a GP’ line.’ (Healthcare assistant).

‘Before they’ve come in and said, “I’m feeling this way”, I’d then straight away have to go and get a GP […] Now I feel so much more confident in saying “right, this is what we’ll do”.’ (Practice nurse)