FinWell: London financial diaries

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

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

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)

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?