By Peter Molyneux
The establishment of Integrated Care Boards provides an opportunity to look again at how we might bring housing and health services together, and particularly how we might promote better cooperation in the places where we live and work. This has been a recurring theme for the past 20 years. So, what can we learn from our recent past, and how might closer collaboration now be achieved?
Mental health and housing
Given that people who experience mental health problems are more likely to be homeless or live in unstable or insecure housing, good integration between health and housing services is important. Having a suitable and stable place to live, combined with the right kind of support, is a major staging post in someone’s recovery and their ability not just to get well but to live a better life.
When the long-stay hospitals closed there was significant health investment in supported housing projects and rent deposit schemes. The Supporting People programme in the 2000s created a strategic framework around supported housing projects. But because it was primarily driven by social care, health services no longer saw supported housing as an area for which they had strategic responsibility. Indeed, whilst the 1999 National Service Framework for Mental Health recognised the importance of having ‘supported living’ options available, there was no real connection to Supporting People.
Many supported housing providers did manage to deliver housing and support services for people affected by mental health difficulties. However, the term ‘supported housing’ had little resonance in the NHS and, despite efforts to do so, lacks the evidence base and the standards to promote wider adoption. In 2010, the National Mental Health Development Unit sought to outline a series of principles, especially the importance of considering housing needs and options at each stage of a person’s pathway through mental health services. The MHDU were able to quantify the overall benefits, but we still lack a combined quality and economic case sufficiently compelling to encourage adoption at scale.
Since 2013 there has been a significant reduction in Supporting People funding (around 80%). Rather than seeking to step into this space, the NHS has, if anything, moved further away towards residential care and out of area placements. Health care providers have not appreciated what could be achieved with, say, complex rehabilitation needs, in partnership with supported housing. Whilst a number of NHS trusts have developed housing strategies i.e. Greater Manchester Mental Health (GMMH) and Sussex Health and Care Partnership, these remain rare examples.
So, what have we learned?
While housing is not the solution to recovery, there is no recovery without housing. Investment in supported housing, employment support and neighbourhood management can deliver impressive results, helping people to sustain their tenancy and achieve their recovery goals. However, this requires a lot of skill and thought on behalf of a broad range of practitioners. So, what are the steps necessary to address what are longstanding issues?
The NHS needs to see itself as having agency in relation to housing, to see housing services as part of each care pathway and as a potential solution to some of the challenges it faces. While the NHS needs to work with partners, it must take ownership of its part in addressing the issues.
Integration must include those partners, and especially those outside of local authority control, with the assets to help to deliver meaningful recovery for individuals and communities, such as housing, education and employment services.
Supported housing providers need to design clear models for delivery, establish a quality and economic evidence base for their interventions, create and comply with a set of standards, and develop agreed definitions of good practice.
Successful integration between housing and health services is based on a) considering housing needs and options at each stage of the pathway, b) embedding housing expertise in multi-disciplinary teams, c) developing a shared understanding of risk and d) defining a shared approach to quality.
Providing effective housing support to ensure people with mental health problems can leave hospital in a timely way, and that they are both adequately housed and provided with the necessary support, is essential. An economic and quality case is needed to get the necessary buy-in across the system.
Health providers looking for solutions to support people with complex rehabilitation needs in-area could develop community-based rehabilitation solutions for those with complex needs as a result of autism, learning disability or mental illness.
Specialist mental health providers should share skills and build capacity across communities so that work on prevention and promotion can be done by organisations working within communities, thus leaving clinicians to provide more specialist interventions.
Peter Molyneux is Chair of Sussex Partnership NHS Foundation Trust. He is a Board member of the Mental Health Network, the England Liaison for the International Initiative for Mental Health Leadership and a Visiting Fellow at Henley Business School (University of Reading).
He is author of Mental Health and Housing: A Review (2022)