Illustration depicting four women from our case studies

Multiple long-term conditions

FinWell: London financial diaries

1 February 2021
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12 min read

Addressing the twin challenges of poor health and financial difficulty

Introduction

We know there are deep inequities in the length and quality of people’s lives. And that people’s money, work and housing all contribute to them. These inequities disproportionately impact people living in urban areas, including our place in South London.  

Too often the circumstances of people’s lives are dealt with as if they were separate from their health, which means we miss chances to support people to live healthier and longer lives.

They often find themselves in extremely precarious situations, with fewer options to manage the unexpected events that can lead to spiralling financial and health issues.

To effectively address this situation, we need to understand exactly how low income and poor health reinforce each other in the everyday lives of people on low incomes with multiple long-term conditions.

This is why we partnered with Glasgow Caledonian University’s  Yunus Centre for Social Business & Health to review the ways in which money and health interrelate in the lives of people in urban places, such as the London boroughs of Lambeth and Southwark.

This work offers a real-world description of how, why and for whom financial health and long-term conditions interact and recommends practical ways to weaken the links between poor health and poor finances, and reduce health inequalities.

Poor people are planning until payday at the end of the week and rich people are planning for their grandchildren.

A public health policy specialist who informed the study

Why financial health matters 

At least 5 million people across the UK living with long-term conditions such as diabetes, cardiovascular disease or a psychological illness are now also facing financial difficulty due to COVID-19. 

These 5 million people regularly interact with a variety of organisations:  lenders, landlords, employers and health and welfare agencies. Unfortunately, many of these organisations work in isolation and do not take people’s twin challenges of health and finances into account.

People living with the dual burden of long-term health conditions and financial ill-health are less likely to have the ‘bandwidth’ to deal with financial and health decisions because of the immense pressures and stress they already face every day. This greatly increases the risk of them progressing from one to multiple long-term health conditions.

Better understanding the financial issues faced by individuals with long-term conditions will help us inform interventions to support people’s physical and mental health. With these interventions, we can slow the progression ‘from one to many’ and improve the wellbeing of those already living with long-term health conditions.

 

Fig. 1
Chart showing people believe their health affects their finances more than the other way around

Meet the households

We spoke in-depth to four people to understand how their health and finances interacted. Read their stories.

Andrea Daliya Luisa Shannon

My mental health…all depends on my finances. If I'm in a really good bubbly, positive way, my finances are bound to be more stable. If I'm under the weather mentally my [bank] balance is up and down, I can't concentrate on what I'm spending. It’s just a mess.

Cyra

What we've learnt

1. Health and finances interconnect

Some people living with long-term health conditions do not have a safety net for coping with sudden drops in income or permanently low wages. Managing their livelihoods and multiple sources of income can be exhausting.

Most of the participants said their financial life was easier before their health conditions worsened and they could no longer work. People on low incomes with long-term health conditions usually find saving extremely hard which affects their resilience to financial emergencies.

The balance between income and expenditure is delicate. During the six months of the study, participants had to carefully prioritise between essentials such as appliances and repairs, bills, council tax, housing, childcare, legal expenses and food. And many people living on low incomes with long-term conditions continue to make these difficult financial decisions today.

“I think sometimes if you’re financially okay, your health seems to be a wee bit better, you seem to be more happier. So mentally, you’re a little bit more happier. And when you’re financially strapped and you haven’t got enough money, it makes your mood a lot less … it makes you more depressed. So you feel more depressed and so therefore your ailments seem to be more prominent, I think in some senses.” (Ayleen)

Case study: Daliya, 27, seeing with new eyes

Daliya

2. ‘Temporary’ borrowing is not a solution

Many people living on low incomes with long-term health conditions have to use more complex financial management strategies than the average person. However, these often aren’t enough to overcome structural barriers or avert ‘cliff-edge’ moments when unexpected delays in income or essential expenditure cannot be met. Mental and sometimes even physical health suffer as a result.

People often have informal social networks that offer some help. But turning to family and friends isn’t a solution that can work for everyone as it can depend on where you live and who you know: financial, health and social inequalities can compound each other.

People with insecure or low incomes make extensive use of financial services to help them smooth difficult times when their money is not enough. This requires an enormous amount of mental ‘bandwidth’.

On average, people on low incomes in our place make 12 major financial decisions every month, such as deciding between taking out or paying back a loan, or paying for insurance.

For people on low incomes with long-term health conditions, these decisions are hard because of the urgency, serious implications and large sums of money involved – on top of managing their mental or physical health.

“That’s how I survive. I survive on the loans.” (Sofia)

Case study: Shannon, 55, talking about work and health

Shannon

 

Fig. 2
Chart-showing-people-turn-to-friends-and-families-first-in-financial-hardship

3. Employment and health

The employment situation of people with long-term health conditions has a key role to play in the relationship between finances and health because these conditions are a substantial barrier to being able to access good work.

Those living with long-term health conditions can have two or more medical appointments per week, which only the most flexible employers are willing to accommodate. Those looking for jobs say that the lack of support with affordable and reliable childcare, or their other caring responsibilities, is a substantial barrier for them.

Good working conditions and healthy environments are particularly important for people that have just been diagnosed with a long-term condition as these can prevent their health from deteriorating rapidly. Promoting meaningful and flexible working conditions and healthy work environments is also vital to ensure that individuals can access and maintain appropriate formal employment to support their income.

“I found that when I was in employment, it was a lot better. I didn’t have the issues that I have now. I think because even though you get a set wage, when you get benefits, you have to work it out to a tee. You prioritise more than one thing, and I think that’s where I struggle with my finances.” (Anya)

Case study: Luisa, 28, living one day at a time

Luisa

4. Affordable, healthy homes are rare

Homes that are good for health are accessible, affordable, in good condition and secure. These are also few and far between.

When maintaining health and work are a struggle and income from welfare payments fluctuates, securing a home is hard. People on low incomes often struggle to afford to rent their accommodation in London’s private rental sector. If they do, they have very little money left for the month. Housing benefits help, but are not enough.

The low quality of private housing and the complex processes around accessing social housing can have a profound impact on people’s health.

Not only does poor quality housing exacerbate health issues, but the process of searching for social housing can be onerous and slow. The more challenging the process, the more of a mental health burden and strain this puts on people with long-term health conditions.

“I had to go to the doctor…to take pills, because I was having a bad time. I was being evicted…and I guess that is only one day left for them to kick me out. I know they weren’t going to leave me in the street but they [Lambeth Council] waited until the last day…to give me one” (Cassandra)

Case study: Andrea, 44 years old, dreaming of a better place

Andrea

5. Public services are currently not up to the challenge

Public services have a long way to go in providing people with the basic building blocks needed to manage and thrive.

Access to health and social care, and other essential services, such as childcare and legal advice, are clear mediating mechanisms with the power to make situations better or worse. During the London Financial Diaries, many participants diarists experienced ‘cliff edge moments’ in which sudden changes in their circumstances required different kinds of services and urgent support.

Each of our participants struggled to access public services such as welfare benefits, healthcare, housing and social services.

Accessing public services is often difficult for people with long-term health conditions – those with poor mental health can struggle to leave the house and are not comfortable repeatedly telling their story to strangers.

We found that advice and support services are missing opportunities in design and accessibility for people living on low incomes with long-term conditions. Depending on the service needed, sometimes support was simply unavailable.

People who were not fluent in English can also face challenges accessing and receiving appropriate support.

To reduce these barriers, it is crucial to avoid introducing punitive measures which make life harder for individuals living in low-income communities, such as cutting or reducing welfare benefits. In addition, improving the availability and accessibility of good quality and free primary health, social and child care will not only aid communities with low incomes, but also further cooperation and relationship between creditors, welfare providers, regulators and healthcare providers.

“It’s so difficult just to get an appointment with the doctor. You go there and they say there are no appointments on the system…“ (Charles)

If from when you are little you are told by your environment that you cannot [succeed], that you are limited because you don’t deserve it, limited by your background, because you don’t have money, and you believe that in your mind, that is going to limit you and make you think that you are useless.

Diarist

Opportunities

The four personal stories we explore highlight practical opportunities for different organisations to improve the health and financial health of people with long-term conditions. Here is a summary of the recommendations from the case studies:

Housing

  • Local authorities should engage with landlords in the bottom third of the private rental market, because they serve the lion share of vulnerable people, including those with health conditions. Options include expanding selective licensing schemes, strengthening tenant/landlord mediation and increasing enforcement. An example of this is our work with Kineara.
  • Local authorities should further align Discretionary Housing Payments with their population health strategies: for example, for people with disabilities or health conditions to make deposits to secure more appropriate homes, including in the private rental sector.
  • Commissioners of money/debt advice and health advocacy should support providers to identify trusted local partners who can jointly deliver more appropriate support for non-English speakers.

Welfare and benefits

  • The Department for Work and Pensions (DWP) should work with local Job Centres to ensure referrals are made at the right time to local organisations that can help claimants plan for changing financial circumstances.
  • DWP should develop a definition of ‘vulnerability’ that encompasses long-term conditions in partnership with people with lived experience and organisations that work with them, and that weekly payments are provided by default rather than on application.
  • DWP need to smooth any reductions to benefits over three payments rather than one, especially for beneficiaries with historically higher rates of reinstatement upon appeal, such people with musculoskeletal and respiratory conditions seeking mandatory reconsideration or independent appeals related to Personal Independence Payments.
  • DWP and Job Centres should improve supportive language in notifications, informed by behavioural science, to encourage uptake of local money/debt advice and other FCA-regulated support when amounts of benefits paid to claimants change substantially.

Regulated borrowing

  • The Financial Conduct Authority (FCA) should assess whether their guidance on affordability assessments is being followed by lenders and whether new rules are needed, for example regarding the higher living costs facing many people with long-term health conditions.
  • When supervising firms on treating vulnerable customers fairly (based on guidance consultation document CG20/3), the FCA should prioritise support and enforcement activity with firms that are likely to have high numbers of customers on low incomes, as these are likely to have multiple characteristics of vulnerability.

Healthcare decision makers

  • Health commissioners should capitalise on opportunities of Integrated Care System development to strengthen collaboration and develop practical solutions to integrate healthcare and the social determinants of health. One example of an integrated approach is a project led by King’s College London to embed debt advice in Improving Access to Psychological Therapy services.
  • Healthcare providers and their commissioners should resource meaningful patient and public engagement structures that have the power to make a difference and cement citizens’ voices into healthcare decision-making at all levels. Strategies should be developed to ensure they are not dominated by a limited number of voices, and that they reflect the population they aim to serve, including priority groups who experience the worst health outcomes. Fair by Design’s partnership with Toynbee Hall is one example of including experts by experience in commissioning/investment decisions. 
  • Healthcare providers should develop new ‘referral pathways’ and integrated models to enable clinicians and healthcare professions to signpost patients to financial support. One example of a ‘health pathway’ to financial support is our COVID Financial Shield project. 
  • As Primary Care Networks continue to roll-out social prescribing, they should work with GPs and Link Workers to ensure there is sufficient focus on working age adults and on supporting financial health.
  • Healthcare commissioners should ensure there is sufficient funding to services which support people with their financial health, such as 1:1 money, debt and benefits advice services. This is vital to ensuring functional social prescribing structures, which can address health inequalities and support people at risk of financial difficulty.

Wider system changes

Our research also highlighted several more complex, structural opportunities for meeting the needs of people with multiple long-term conditions:

  • How can we improve precarious work conditions of low paid jobs in essential industries, so that people with long-term conditions can stay in employment?
  • How can we make financial services, including affordable credit, simpler and more accessible for people with long-term health conditions (including mental health conditions) than high cost and pay day lenders?
  • How can appropriate financial advice and support get to those without the networks, knowledge or trust to access them?
  • How do we break down silos between organisations addressing inter-connected financial health, physical health, and mental health problems?
  • What can be done to help Government bring forward the planned Affordable Homes Government investment?

Next steps

People living on low incomes with long-term conditions interact with a range of organisations in the course of their daily lives:  banks, lenders, money, debt and other advice agencies, GPs, community and mental health services, employers, landlords, and Job Centres and welfare officers.

It is crucial that creditors, funders of debt services, regulators, and decision makers in welfare and healthcare systems recognise their role in furthering financial, mental and physical health of people with multiple long-term conditions.

The insights from this study highlight practical opportunities for these organisations to better support people.

The diarists were last interviewed in March 2020, just as COVID-19 was officially declared a pandemic in the UK. We know that the impact of the pandemic hasn’t been felt equally, and that they are likely to be amongst those hit hardest by COVID-19 and the associated social and economic crisis.

From our home in Lambeth and Southwark, we provide financial, strategic and practical support to organisations, groups and individuals who are committed to achieving health equity in inner-city areas. Please contact us to explore how we can practically work together to address the systemic health and social inequalities facing people like Andrea, Daliya, Luisa, and Shannon.

References

Biosca, O. et al (2020), Managing finances and multiple long-term conditions: eliciting the perspectives of individuals living on low incomes. Unpublished research study. Yunus Centre for Social Business and Health, Glasgow Caledonian University.