The impact of hardship on primary schools and primary and community healthcare

In line with other research, the need for additional emotional support because of hardship came through particularly strongly. When we explored this though the qualitative research with primary schools serving deprived areas, staff described how coming to school hungry and tired is directly connected to some of the challenging, disruptive or dysregulated behaviour they are having to manage. 

One teacher in West Central Scotland said: 

"If children aren’t ready to learn, they’ve not had their breakfast, they’re hungry, or they’ve had a really troubling night… then you can see a huge shift in terms of focus and readiness… you tend to find those are the children that cry the most and their behaviour is their way of saying they need help."

In addition, they talked about children who needed comforting at school because they were worried about how the constant struggle to make ends meet affects their parents.

Pupils are emotionally not ready to learn in a classroom due to what they experience outside the classroom.

Deputy head, Greater Bristol

Poor housing and temporary accommodation make matters worse

Housing, and homelessness, frequently came up as a contributing factor in the qualitative research. Children living in overcrowded houses had an impact on their ability to learn, with no space for doing homework. Overcrowding, and sometimes having no bed of their own, was seen as a driver of tiredness. In addition, many participants talked about trying to support families facing the threat of eviction and homelessness. Some also had pupils living in temporary accommodation, with families all living in one room and travelling long distances to attend school, adding to tiredness and the need for emotional support.

A school receptionist in Greater Bristol told us:

"I’ve definitely noticed so many more families that have been put into temporary accommodation. We’ve got some families who are being forced to travel across the city because the temporary accommodation is so far away which means they’re having to leave home at least an hour and half before the school day starts."

A few participants worked in schools that had high numbers of asylum-seeking and refugee children. Not only had these children often had traumatic experiences, they were also frequently living in inappropriate, overcrowded accommodation or hotel rooms.

Hardship has grown worse: it is now an everyday occurrence

7 in 10 primary school staff across Britain agreed they often see pupils experiencing hardship, a figure that increased to almost 9 in 10 (87%) in areas identified as somewhat or very deprived. This was borne out in our qualitative research, where staff talked about hardship being an everyday occurrence.

The issue of pupils going without the essentials was regarded as having got significantly worse in the last 2 years. Pupils coming to school tired or hungry because of hardship had increased substantially according to 68% and 64% of staff respectively. 78% of staff also said there had also been increased need for emotional support because of hardship and 72% said there had been increased incidence of poor mental health because of hardship.

Rising hardship has multiple implications for primary schools. It has implications for how they support and respond to families and pupils experiencing hardship, it has knock-on impacts for other pupils in the school and it has an impact on the wellbeing of staff, as we explore below.

Responding to pupils (and families) experiencing hardship

Schools are doing what they can to mitigate the impacts of hardship in various ways. But staff describe feeling that families are looking to them for help with hardship, in the absence of other options.

Trying to meet pupils’ basic needs 

Primary schools are providing additional support to try and make sure children experiencing hardship are ready to learn. There has always been an element of this in the work schools do, particularly in deprived areas, but this research reveals its extent and the impact it is having on delivering education. 

In the survey we asked staff about the types of support their school offers to pupils and families experiencing hardship, beyond education. Much of this support relates to referring pupils and families to crisis support and the provision of free or subsidised food such as extending the free school meal offer and providing breakfast clubs. One third of primary schools say they are even providing a school food bank, and a quarter say they are directly providing other essential goods such as toiletries, energy top-up vouchers, beds and bedding.

The need to respond to hardship was most acutely experienced by staff working in more deprived areas, who felt they were having to do more than ever to support pupils and families with their basic needs.

A deputy head in Greater Bristol said:

"You feed them, you clothe them, you tell them where to go if they’re homeless. It’s literally everything. It’s not even about teaching or learning. It’s about keeping them fed, keeping a roof over their head ... School has never had to do so much of that before as they do now."

Staff providing essentials out of their own pocket

The survey shows staff are so concerned about children experiencing hardship that they frequently dip into their own pockets to try and support children. Almost 4 in 10 (38%) say staff provide for pupils and families out of their own pocket.

Drawing on the qualitative research, this would often involve providing food, but material goods such as clothes, underwear, books and toys were also mentioned.

A teacher in Edinburgh and the Lothians said:

"We provide a ‘cereal club’ or I have a snack drawer. I pay for that out of my own pocket. I don’t get reimbursed in any way, shape or form, because it’s not expected. But you know for a fact, if you don’t provide it, then who will?"

In some cases, staff clubbed together for food or gifts to make sure families were able to celebrate occasions such as Christmas or Eid. Our findings suggest it is becoming a kind of new normal for families to have to rely on the generosity of school staff to meet their basic needs or participate in cultural celebrations.

Trying to support families in crisis

And it's not just the children. In the qualitative research, primary school staff regularly experienced parents and carers facing crises and breaking down in tears at the school gates. The staff were being looked to for advice and help on issues including homelessness, benefits, domestic abuse, visa renewals and mental health support.

Staff in the focus groups thought this was partly a positive response to schools being accessible and widely trusted institutions. But it was also put down to the demise of other services, such as Sure Start in England, resulting in a lack of support and early help. Other services, such as mental health support, were highlighted for having long wait times in both England and Scotland.

The overriding sense was that families struggled to find alternative sources of face-to-face support, so they ended up at the school gates. This led staff to worry that they were not always the right people to provide the help.

A deputy head in West Central Scotland told us:

"You’re trying to support these children and families in a job that I know nothing about, I don’t know about all the benefits that people get, you’re desperately trying to get them help but that help is very, very minimal out there just now."

Sometimes schools were able to form partnerships with community organisations or charities to help offer support, but this depended on what was available in the local area. It was also seen as a precarious form of support, as it usually depended on short-term charitable or project funding.

Creating jobs to respond to hardship

Almost all the schools whose staff participated in the qualitative research were using some of their budget to create jobs specifically to respond to demands that arose wholly or in part from hardship. Examples that were given included schools employing people specifically to liaise with other services such as housing, mental health and social services, employing people to provide advice and support directly to parents and employing their own counsellors, mental health support workers and play therapists to support children. But they still felt unable to keep up with demand.

A teacher in Tyneside said:

"They aren’t 5 minute conversations you have with parents when they’re in crisis, it was taking up most of the morning, so we’ve actually had to employ two members of staff who are available to deal with those situations when they arise. And most of them are that parents are struggling with bills, food or getting children to school, have been made homeless and moved out of the area."

The impact of hardship ripples through primary schools

Experiencing hardship not only affects the children concerned. It also has knock-on effects for the work of schools. Staff at primary schools told us how having to respond to high levels of hardship takes up time, resources and, ultimately, affects all the children in the class.

In response to the survey, half of primary school staff (51%) identified greater demand for resources, such as workers’ time, as an impact of hardship on their school. In addition, almost two thirds (65%) either agreed or strongly agreed that hardship made it harder for them to do their job well, a figure that rose to three quarters (74%) in areas identified as somewhat or very deprived.

Dealing with hardship takes time away from teaching

Having to deal with the consequences of hardship takes up a lot of workers’ time. When children come to school hungry, cold, wearing ill-fitting uniforms, or feeling upset and worried about a situation at home, it takes time just to get everyone physically, mentally and emotionally ready to learn. In the qualitative research, primary school staff described how this frequently dominates the start of the day. 75% of staff in deprived areas said hardship made it harder to do their job well.

Similarly, having to manage a disruptive or dysregulated child or help a parent in crisis also eats into time for learning. Several examples were given of teachers having to ask teaching assistants to try to deliver lessons while they dealt with other issues.

A teaching assistant in Greater Manchester said:

"The teacher has to go out and deal with a child or a parent. What that means is then I have to quickly jump in, quickly read the lesson plan and deliver the lesson while that teacher’s gone… When I have to go in there and kind of takeover last minute, I’m not delivering something as good as what the main teacher would do and so then that’s having a negative effect on the children."

Some even reflected that the challenges of managing hardship had become dominant over the job of providing education.

Hardship is a massive strain on actually doing the job of delivering education, like that’s almost not at the forefront of what we do at the moment.

Teacher, Greater Bristol

When we asked primary school staff to imagine what it would be like if hardship was not an issue facing their school, they often talked about how it would improve outcomes for all children, not just those directly experiencing hardship

A deputy head in Tyneside told us: 

"I can’t actually imagine what that would be like. To be able to start your teaching day at 9 o’clock and teach a lesson and get on with your job of teaching those children. And those children to be ready to learn. Standards would be raised."

Resourcing support for hardship leaves less for fun and enriching activities

Being sensitive to the hardship pupils are facing, and mitigating the effects of hardship, affects what schools can offer to their pupils.

Some primary schools across Britain are cutting back on fun and enriching activities to divert resources into supporting pupils experiencing hardship. In the survey, a third of staff said their school had cut back or stopped school trips so they can fund or provide support to pupils experiencing hardship. Almost a fifth (18%) said their school had cut back on or stopped enrichment activities, clubs, celebrations and own-clothes days for the same reason.

The heavy burden of hardship

Dealing with the impact of hardship is not the only pressure that schools are under, but it is a significant addition to the burden.

As part of the survey, we asked about a list of issues that are sometimes said to be challenging for schools, and to what extent each was a challenge in their school. Supporting pupils whose families cannot afford the essentials, such as food and heating, was identified as somewhat or very challenging by 73% of primary school staff. It was the fifth most frequently selected, behind workload, funding, supporting pupils with special educational needs and pupils experiencing mental health issues. It was more often regarded as a challenge than pupil absenteeism, safeguarding, maintenance of buildings, staff recruitment and retention, and large class sizes.

However, several of these issues are interrelated, and hardship intensifies some of the other pressures. As shown above, it adds to workload and puts pressure on school resources and funding.

A deputy head in Greater Bristol said:

"I think hardship is quite high up there [on a list of pressures facing schools], but it’s also an underlying reason for other things that we’re having to deal with too."

In addition, staff in the focus groups discussed the link between hardship and the high levels of pupil absence from school. A lack of material goods, such as winter coats and raincoats, as well as not being able to afford transport, were all given as examples. Some participants also drew connections between hardship, trauma, poor mental health and special educational needs.

I’d say it [hardship] is one of the main factors affecting social, emotional and mental health.

Teacher and SENCO, Tyneside

Hardship is adding to the burden that primary schools carry. Addressing it at source would ease their load.

Impact on staff

Overall, the additional pressure that hardship creates weighs heavily on staff. They feel a great sense of responsibility for and commitment to the pupils in their school, but worry that they are not equipped to give families the support they need. They also do not feel equipped to get to the root causes of the problems families face – something that requires wider policy action.

Hardship adds to high stress and low morale

So many pupils experiencing hardship adds further pressure to an already stressful job. Across Britain, 6 in 10 staff (60%) agreed they felt increasingly under pressure at work because of the number of pupils experiencing hardship. This rose to 7 in 10 in areas identified as somewhat or very deprived.

This additional pressure has an impact on staff, with 6 in 10 (59%) saying it increased stress on staff and/or increased low morale among staff. Around half (48%) said it led to worsening staff mental health and/or wellbeing. These figures were higher in areas identified as somewhat or very deprived (66% and 54% respectively).

In the qualitative research staff talked about feeling like they are never able to do enough or do a good enough job because they were trying to perform so many roles at once.

A teacher in Edinburgh and the Lothians said:

"You don’t feel like you’re doing any of them particularly well because you’re trying to put fires out or do things all over the place. You have a never-ending to-do list, you never switch off. It’s not a job you can leave at work."

This was also reflected in the survey findings, where three quarters (75%) of staff agreed when they see evidence of hardship, they find it difficult not to take it home with them. This rises to 81% in more deprived areas.

Staff were particularly likely to worry about children during the long school holidays. So much so that some schools have established out-of-hours phone lines families can use if they experience an emergency in the holidays. In the focus groups participants discussed how this is a well-used service by families, but one that means teachers do not fully get the break they need.

For a substantial minority, 2 in 5 (39%), the impact of hardship is a factor that is contributing to them thinking about leaving their job. This is a concerning finding given the recruitment and retention challenges already facing schools.

No longer ‘just’ a teacher

Rising levels of hardship combined with the erosion of other support services has changed teaching.

Our focus group participants discussed how the social work side of their role had expanded, as had the time spent filling in forms and liaising with other services to try and get support for families. They also described taking on more of a nurturing or parenting type of role, providing emotional support and comfort to children, and sometimes having to teach them basic life skills when they start school too, such as going to the toilet on their own or using a knife and fork. This took time away from their core vocation of providing education.

A teacher in Tyneside told us:

"Families are relying on schools more and more for emotional support, the social worker side has increased so much that it almost runs alongside our main role of teaching and learning, as the learning cannot take place if children are coming into school unable to learn due to outside factors."

A third of staff say their school has cut back on school trips to fund or provide support to pupils experiencing hardship.

Staff participating in the qualitative research reflected on how this compounds the disadvantage that pupils experience.

A deputy head in Greater Manchester said:

"We cannot provide as many extracurricular opportunities such as trips and visits as we would like… we cannot ask our parents to pay for them. It just results in our children getting a raw deal and not having as many life opportunities even though we really do try our best."

Support for hardship sometimes affects resources to support wider educational achievement

Some schools were facing impossible trade-offs between resourcing activities that respond to hardship and those that support wider educational achievement. While supporting children facing hardship does contribute to educational achievement by increasing readiness to learn, the limited nature of school budgets means it can come at a cost to other activities. This included funding for additional staff, learning resources and organising educational activities such as small-group support for children struggling to make progress with literacy or maths.

A teacher in West Central Scotland told us:

"The ‘middle of the road’ kids. Certainly, if we weren’t having to run breakfast clubs, homework clubs, all these different things, especially in the morning, then our support for learning assistants or deputy heads would be able to run those support clubs or those attainment groups [for them]."

Not a level playing field for schools

The connection between poverty, early childhood development and educational attainment is well established, and it was experienced first-hand by participants who worked in schools serving highly deprived areas (Farquharson, McNally and Tahir, 2022). Despite working hard to bridge the attainment gap and having high aspirations for their pupils, staff felt the scale of hardship hindered them.

In other schools, the majority of children were nourished, ready to learn and enjoyed trips and experiences outside of school. By contrast in deprived areas a huge effort goes into simply getting children fed, emotionally regulated and ready to learn.

You can see the kids that are struggling, the kids that are worried, and that’s definitely increased. But the expectations on us haven’t changed, even though the playing field has.

Teacher, West Central Scotland

It was felt these radically different contexts were not adequately reflected in school inspection regimes. This further ratcheted up the pressure and stress around school inspections.

Hardship affects all the children in the class

Dealing with the consequence of hardship eating into time and resources has a ripple effect. Strikingly, in the qualitative research, primary school staff spoke about hardship affecting all the children in a class, not just those directly experiencing it.

A deputy head in Tyneside told us:

"[There are] children I would have liked to have sat and had a little chat with just to make sure they’re okay but my time is just taken up with other children. Or I’ve got to speak to parents who are coming into school really upset... and I get to the end of the day and I think there’s children that I haven’t had time to spend with... It affects all the children in your class. Hardship affects every single child."

Staff reported high levels of poor mental, physical and dental health due to hardship among their patients. On average, they also estimated a large proportion of their patients were being negatively affected by poor-quality housing, or unable to maintain everyday hygiene because of hardship, both of which they felt were connected to ill health, as we outline further below.

What is more, these manifestations of hardship had been on the rise: more than three quarters of healthcare staff said they had seen an increase in patients experiencing poor mental health because of hardship over the last 2 years, and more than 6 in 10 had seen an increase in poor physical or dental health. A majority (55%) said they had seen an increase in patients experiencing hunger over that time period.

These experiences were directly connected to patients’ increasingly poor health in the qualitative research. Examples shared included patients experiencing respiratory conditions due to living in poor-quality homes; worsening dental health because people cannot afford toothpaste; and conditions linked to poor diet, malnourishment and vitamin deficiencies being seen more often.

A practice nurse in Greater Manchester said:

"Problems are always worse in the winter. Especially with chronic diseases like respiratory problems, especially if people are suffering with hardship and not being able to afford bills and they’re living in cold houses, damp houses, the elderly... everything’s kind of flaring up and exacerbating."

Mirroring the survey findings, the qualitative research emphasised concerns about growing levels of mental ill health, exacerbated by patients’ financial worries and stresses.

A GP in Greater Manchester said:

"I see patients experiencing hardship regularly. Probably several per week. Often they will tell me or, if I visit them at home it becomes obvious due to poorly furnished homes. Often stress is a presenting complaint and it is financial worry that underlies the mental health issues."

Hardship can prevent people from accessing treatment

As well as making people more likely to need treatment in the first place, hardship was also preventing people from following medical advice when they did receive it, in some instances creating a compounding cycle of worsening health outcomes. 

On average, workers said that nearly half (49%) of the patients they had seen had not followed medical advice or had delayed seeking help due to hardship in the last 12 months, while around 2 in 3 (65%) said this problem had been getting worse in recent years.

Again, this was echoed by the workers we spoke to, who gave examples including a patient being unable to afford a prescription for antidepressants (which patients can be charged for in England, although prescriptions are free in Scotland), and someone unable to follow advice to get out of bed for their health due to being unable to afford the heating.

Unfortunately, hardship is causing patients to not pick up their prescriptions due to not being able to afford them, which then creates further health concerns.

Nurse, Greater Bristol

Another common example was hardship leading to missed appointments. On average, our survey respondents estimated 45% of patients had, at some point in the last 12 months, been unable to attend planned appointments because of hardship, for example due to travel costs. Nearly 6 in 10 workers (59%) said they had seen this problem increase over the last 2 years.

Some groups of people are more likely to face hardship

Overall, the picture painted was one of patients experiencing hardship, and increasingly facing worsening health problems because of it. But in the qualitative research staff said some people in their communities were more likely than others to be affected by it.

This included, but was not limited to, refugees and asylum seekers, people with English as a second language, elderly patients, and carers. There were particular challenges for some of these groups in escaping hardship and achieving security, for example, the barriers to work and low levels of financial support provided to people seeking asylum were noted.

Patient demand for services is changing

As hardship increases, our research finds that it is also increasing and changing the nature of patients’ demand for services: the reasons they turn to primary health services, and the help, advice and support they are looking for.

Hardship is increasing people’s need and demand for services

Hardship is having a tangible impact on patient demand: across Britain, half of healthcare staff (49%) said that hardship specifically led to increased demand for services. 4 in 10 (40%) said it led to a greater requirement for resources, such as workers’ time. And it is possible that the true increase in need due to hardship may be even higher: barriers to accessing healthcare due to hardship may mean that some patients do not present to their local GP or other services for help at all, even if they need it, or potentially end up facing health crises, and having to present to emergency services such as A&E.

This picture of hardship ramping up need and demand for healthcare services, and adding to services’ burdens in terms of pressure and workloads, was echoed in our focus groups.

Deprivation and hardship go hand in hand and have a significant impact on GP services. Demand is much greater in areas of hardship. It definitely increases my workload.

GP, West Central Scotland

As discussed above, hardship worsens health and is a barrier to patients being able to fulfil medical advice and attend appointments. This in turn leads to rising pressures for services as repeat appointments are needed and patient health outcomes worsen due to delays in receiving care. This then has a knock-on impact on other patients seeking appointments in busy surgery schedules.

A GP in West Central Scotland said:

"One patient with a cardiac problem has missed over a dozen appointments and says it’s because he can’t afford the transport – it’s a two-bus journey each way. This means multiple appointments with me going round in circles as we haven’t had the investigations to make a diagnosis. This then wastes multiple NHS appointments which is frustrating."

Patients are turning to primary and community healthcare for support with a range of issues

Healthcare services are becoming a first port of call for many people experiencing hardship, according to staff in the qualitative research. They thought this was because these services were potentially more accessible and easier to navigate than others; patients might be less aware of other services or support systems; and because they had an existing relationship or feeling of familiarity with healthcare services in their community. This makes them feel like a safe place to seek advice and support.

A nurse in the Bristol region said:

"Definitely for adults the GP is more accessible. If you’ve got young children you can either go to their schools or health visitors to access that support… whereas for adults it’s difficult to know where else for them to turn."

A GP in West Central Scotland said:

"I feel the impact of people living in hardship is significant. As we are readily accessible we are often seen as the first service to contact even though it is clearly a social issue. This puts pressure on an already busy service and can lead to difficult conversations where there is little we can practically do other than signpost and provide support."

Patients facing hardship are also turning to services for new and different forms of support. When we asked staff about what their patients were experiencing as a result of hardship, on average they told us that half (51%) of their patients had required non-medical support, such as debt or housing advice, at some point in the last 12 months. A similar proportion (48%) had requested prescriptions for everyday items such as baby formula and incontinence pads at some point in the last 12 months.

This means that growing numbers of health appointments are being used for things like writing prescriptions for everyday items, providing referrals, filling in forms, and other signposting to services which can help patients with non-medical issues like housing or debt. This was echoed by staff we spoke to. 

A nurse in Greater Bristol said:

"Some appointments are taken up for us to sign forms for benefits and grants for people living in hardship because they need to be signed by a professional. Obviously, I’m happy to help with this but it’s frustrating that this blocks appointments for patients who need an appointment for health concerns."

We’re finding that we’re now kind of a support network, rather than actually treating medical conditions.

Practice manager, Greater Manchester

In a context in which our social safety nets are fraying, and other essential crisis and support services may have been cut, patients will understandably turn to visible and trusted avenues for support, such as their local GP or community healthcare service.

Patients increasingly need more complex forms of support due to hardship

Overall, worsening health due to hardship and difficulty accessing healthcare because of costs is changing the nature of patient demand, with people seeking help for more complex health issues.

People who experience hardship face more complex and chronic health conditions, and worse health outcomes, than those who do not. This is borne out in the wider evidence base on health inequalities. For example, in England there is a stark 19-year gap in healthy life expectancy between the most and least deprived areas (Mallorie, 2024; Imison, 2023). Staff reflected on this causal chain during focus groups.

A GP in Greater Bristol said:

"For many patients, they have to make a choice to either pay for medication or food for a week, or maybe for heating bills. If they decide not to pay for medications, their health is likely to deteriorate. This puts burden on the GP practices as their needs increase."

This adds to the pressure on health services. Across Britain, over a third (36%) of staff we surveyed in healthcare agreed the delivery of core services had become more complex because of hardship, rising to 41% for staff who worked in areas of higher deprivation.

How services are responding

With patients’ demand for services increasing as a result of hardship, many primary healthcare services are having to change their provision in response. 

As we discuss below, this often includes services having to expand into new areas of provision in response to the pressure to provide a crisis ‘safety net’ for patients. In some cases, this reduces their ability to focus on the job of healthcare.

Services are being forced into a new role of providing crisis support

With more people turning to healthcare for help with non-medical issues, focus group participants based in deprived areas highlighted how much more of their role was being taken up by referring and signposting people to additional services. While this would likely always form part of the role of healthcare staff, there is a significant and increasing pull towards supporting people with issues outside of the core remit of health services, because patients may feel they have nowhere else to turn for urgent help.

A nurse in Greater Bristol said:

"A lot of my role is signposting patients for support with benefits and checking if they could be exempt from paying for prescriptions. This is in addition to our core service."

A district nurse in Edinburgh and the Lothians told us: 

"I just seem to be spending a lot of time [signposting people] during my day which then means I can’t do other things. We signpost and refer to befriending services, to food banks, to Social Care Direct. We start getting involved in patients’ finances which is not really our role as such but it’s starting to become our role."

When we asked staff about what forms of support, if any, they provided to patients experiencing hardship, half (49%) said that they offer a food bank. Around a quarter said that they directly provide non-food essential goods (such as hygiene products and energy top-up vouchers), while a similar proportion say they offered a baby bank, or access to essentials for children and babies. This means primary health services are increasingly playing a core role in local crisis support services.

While many services are trying to step into what they see as a gap, some workers still feel at a loss as to how to support people, particularly in the wider context of squeezed healthcare funding – and worried about the capacity and expertise of healthcare services to provide this kind of support. Other services will be unable to pivot to respond to hardship due to resource constraints or other challenges, meaning patients experiencing hardship may be going without this essential support.

In some cases, staff provide essentials out of their own pocket

While some responses to hardship are happening at the organisational level, staff are also feeling forced to respond as individuals. More than 1 in 5 (22%) across Britain told us that staff provided for patients experiencing hardship out of their own pocket.

We heard difficult, and in some cases harrowing, stories in the focus groups of staff and teams providing money and essentials themselves. In one instance, a staff member and colleagues had personally provided support to a mother who had recently lost a child and needed to move out of dangerously poor-quality housing with her children. Staff had a range of examples of support being provided by individuals.

A district nurse in Edinburgh and the Lothians said:

"I have had a colleague bring in her husband’s underpants (new and unopened) for a patient who couldn’t afford to buy any. She just gave them to him in a bag saying she bought too many."

It is increasingly becoming normal for people facing hardship to have to rely on the individual financial support of their local GP, district nurse or surgery receptionist.

Services are also responding by hiring new and additional staff

While a majority of services are responding to hardship through referrals and signposting, others have responded to growing need by hiring additional specialist staff, such as social prescribing link workers (who can be funded through the Additional Roles Reimbursement Scheme) and welfare advisors.

More than 4 in 10 (45%) healthcare workers we surveyed told us that their service responded to hardship by offering advice services located within their surgeries or health centres, rising to over half (51%) of professionals working in areas with greater deprivation. In some areas of Britain healthcare services have long-standing and embedded interventions around hardship, such as Scotland’s Deep End project; in other areas these are much newer service responses (University of Glasgow, 2019).

Staff reflected that having specialist staff to support people experiencing hardship could help lift some of the pressure and workload that came from trying to do everything themselves.

A practice pharmacist in West Central Scotland said:

"Having community link workers in the practices has made a huge difference to patients and staff. Staff have someone they can refer patients to who have social issues; and patients can get the support they need."

Expanding service provision to respond to hardship comes at a price

There was a strong feeling from workers that hardship had a significant, negative impact on them delivering in their role. More than 6 in 10 told us that patients experiencing hardship makes it harder for them to do their job well.

The additional load that hardship creates for healthcare providers ripples through the system and can have an impact on patients who are not directly experiencing hardship. Longer and more complex appointments for people experiencing hardship can cause schedules to run behind and pull staff away from seeing other patients. In addition, the new forms of demand created by hardship affects appointment availability. The result is increased waiting times.

A GP in West Central Scotland said:

"If you’re dealing with a lot of people who are struggling because of hardship then that can have an impact on other people’s health needs as well because you just aren’t able to see them."

As staff grappled with how hardship was changing the services they provided, some reflected that more time spent on non-medical issues meant less and less time spent on healthcare. This affected their ability to deliver a good service.

A GP in West Central Scotland told us:

"I feel quite strongly that we are there for medical concerns and the high volume of activity created through hardship can be detrimental to our ability to provide good medical care as we are very time pressured."

Trying to bear the weight of increasing hardship while keeping services running effectively sometimes meant other services and forms of provision fell by the wayside. A quarter of workers across Britain said that hardship meant they had to reduce some services in order to deliver others, while around a third (32%) said it meant they had less time for training and development. Some workers we spoke to shared examples of services and initiatives, such as a catheter clinic, that had to be stopped so that staff could respond to other needs.

Hardship detracts from long-term responses

Without the additional pressures created by hardship, staff thought they would be able to prioritise longer-term health needs and provide more proactive health advice to their patients. In the qualitative research they shared worries about how realistic it was to expect patients to prioritise their longer-term health when they were going without absolute basics.

A GP from Edinburgh and the Lothians said:

"It’s all very well running chronic disease clinics or advising people on eating healthily or exercise, but really people don’t have the basics, don’t have access to a cooker, transport, they’re not going to be able to do any of these things."

When we asked healthcare staff to reflect on how ending hardship might affect their service, they said it would reduce some of the pressures, through less need for appointments, fewer prescriptions for everyday items, fewer mental health and other health issues arising, and more opportunity for patients to manage chronic health conditions and proactively think about improving their physical and mental health and wellbeing. 

A social prescribing link worker from Tyneside said that without hardship:

"the whole ballgame would be totally different, without a doubt… we could then look at a health service, because at the moment we’re looking at an ill service, people go to the doctors because they’re ill."

How primary and community healthcare staff are affected

In addition to the impact of hardship on patients and the services they rely on, there is also a heavy toll on healthcare workers. Increased pressures, expanding workloads, worsening morale and some staff considering leaving their jobs due to the pressures caused by hardship all came up in our research. 

Hardship is ramping up pressures on staff through workloads and worries

Rising hardship is ramping up pressure on staff, and affecting workers’ ability to keep on top of their jobs. More than 6 in 10 (64%) said that they feel increasingly under pressure at work due to the number of patients experiencing hardship. 

Half of the healthcare workers in our survey (49%) said that patients experiencing hardship was leading to increased stress and/or low morale among staff, while more than 2 in 5 (43%) said it was leading to worsening staff mental health and/or wellbeing. 

Staff shared their experiences of feeling trapped between the twin pressures of a desire to help people, and a lack of time, resources and expertise to do so effectively.

A practice nurse in Edinburgh and the Lothians said:

"I can offer some limited advice to patients who are suffering hardship, but this is only a temporary fix and I have to research where to send a patient to seek support. This takes time. I don’t have time."

Despite their best efforts in many circumstances, healthcare staff worry they can never do enough, not least because the help they offer will not necessarily tackle the root of the problem for patients for whom hardship is a key cause of their ill health. This led to feeling disheartened, helpless and frustrated.

These worries stay with people, with two thirds of staff (65%) saying they found it hard not to take hardship home with them. In the qualitative research people talked about feeling unable to switch off.

A practice nurse in Tyneside told us:

"Sometimes you can take it home with you. You’re constantly thinking about these patients, so you’re not really letting go at the end of the day, you’ve got these patients in your head all the time, wondering if there’s anything else you can do. If you do try and help them then it adds on more stress to your working day as well because you’ve got other patients to see, but you’re stressed out about trying to help these ones, which adds to your mental wellbeing as well."

Warning lights are flashing for recruitment and retention

For a significant minority of staff, the pressures flowing from patients experiencing hardship meant they were considering leaving their current role. More than 2 in 5 (43%) healthcare workers reported this, rising to more than half (52%) of staff working in areas with greater deprivation. The impact of patient hardship risks exacerbating the health service’s recruitment crisis.

While many staff shared elements of their role that they found fulfilling and rewarding, others clearly felt overwhelmed by the rising tide of hardship faced by many of their patients, and its effects on demand. Some people also shared frustrations that tackling non-medical issues was preventing them from focusing on the health professions that they had ultimately trained for and chosen to work in.

The heavy burden of hardship

Hardship is not the only pressure that healthcare services are experiencing, but grappling with the weight of hardship adds to their burden.

We asked staff to consider a list of possible challenges for their services, and consider how far they thought each was a challenge for their own. 72% of healthcare staff told us that supporting patients who cannot afford essentials, such as food and heating, was somewhat or very challenging for their service. This was the sixth most frequently selected option, behind greater demand for services, staff workload, funding, staff recruitment and retention, and waiting times. It was more frequently identified as a challenge than patients delaying seeking medical advice or treatment, patient safeguarding, or maintenance of buildings.

But as our wider quantitative and qualitative research has shown, these challenges can be difficult to unpick from one another. Our evidence shows hardship is clearly connected to greater demand for services, staff workloads, waiting times, and even questions around recruitment and retention given the impact of hardship on staff stress, morale and wellbeing.

An advanced practitioner in Greater Manchester said:

"It’s all kind of interlinked, it all plays into one another, because obviously you’ll be seeing there’s a greater demand on the service… with patients who are in hardship. Because of a lack of funding these patients are then having to wait for referrals, appointments to be seen, and lack of funding in other services means that they can’t always get the help and support that they need. So it’s all kind of interlinked, one impacts on all of the others."

Hardship is clearly a heavy additional burden on services and staff, and one which urgently needs to be lifted.