A randomised trial of domiciliary welfare rights advice in independent-living, socio-economically disadvantaged people aged ≥60 years

Older people, particularly if in poor health, may be in need of extra income, or support in the form of aids or adaptions. There are state benefits which can be claimed in the UK, but not everyone is aware of them, or capable of making a successful claim. Welfare rights advisers (WRA) can give active assistance with such claims. Given the known association between socio-economic factors and health, it’s plausible that any extra welfare benefits received could impact on health and well-being.

A clinical trial was designed to investigate the effect of welfare rights advice delivered in the homes of people aged ≥60 years living in socio-economically disadvantaged areas of the North East England. Participants were randomised to immediate welfare advice, or waiting for 24-months. Follow-up over 24 months was a trade-off between sufficient time to demonstrate any health impact against the ethical need to allow the control group to access advice as early as possible. It was important to choose a primary outcome that would encapsulate the potential benefits of the advice. Interviews with participants in the pilot trial about perceived benefits had identified the importance of concepts such as ‘piece of mind’, ‘maintaining independence’, and ‘participation in social life’. So, given we were dealing with older people we decided to use the CASP-19. When calculating the sample size of a trial you need to specify what would be the smallest difference in the outcome that would be of clinical importance. This had not been established for CASP-19, but analysis of data from English Longitudinal Study of Ageing suggested that a difference of 1.5 units would be appropriate. Secondary outcomes in our trial were measures of changes in income, social and physical function and cost-effectiveness. There was also an embedded qualitative study.

The results were published recently. 3912 older people were identified from general practice records and invited to take part in the trial: 755 consented and were randomised (381 Intervention and 374 Control), and data was available at 24 months on 562 (74%) of them .The welfare advice was received by 335 (88%) in the intervention arm, but only 84 (22%) were awarded additional benefit entitlements which were predominantly financial.  The mean CASP-19 scores at 24 months were 42.9 in the intervention arm, and 42.4 in the control arm (adjusted mean difference 0.3, 95%CI -0.8 to 1.5). There were no significant differences in secondary outcomes except Intervention participants reported receiving more care at home (53.7 vs 42.0 hours/week, adjusted mean difference 26.3, 95%CI 0.8 to 56.1). Exploratory analyses did not support an intervention effect and economic evaluation suggested the intervention was unlikely to be cost-effective. However, qualitative data from 50 interviews suggested there were improvements in quality of life among those receiving additional benefits.

We found no difference in average health outcomes, but participants were more affluent than expected, and fewer participants than anticipated received extra benefit entitlements. Our findings don’t support the delivery of domiciliary welfare rights advice to achieve the health outcomes assessed in this population. However, better intervention targeting could reveal worthwhile health impacts.

Guest blog by Denise Howel, Newcastle University, UK.

Find out more about the Do-Well Study at https://www.ncl.ac.uk/ihs/research/projects/item/thedo-wellstudyrandomisedcontrolledtrialeconomicandprocessevaluation.html



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