An update from the Effective Services Group (ESG) on the results of a commission to evaluate a multi-agency response in the Vale of Glamorgan to help vulnerable people with mental health problems to find and keep a home.
Collaboration between organisations concerned with housing, support and mental health services in the Vale of Glamorgan in 2013 led to the development of an integrated dispersed supported housing scheme for people with severe and enduring mental health problems. The evaluation report – Evaluation of the Vale of Glamorgan Dispersed Housing Scheme[1] – was published in March 2016:
The scheme is run by a multi-agency group, which agreed a housing and support service model appropriate to the needs of those with severe and enduring mental health problems. The group is made up of representatives from the Supporting People team at the Vale Council, Gofal Cymru, Newydd Housing Association and specialist rehabilitation provided by the Intensive Rehabilitation and Integration Service (IRIS) from the Cardiff and Vale University Health Board. They work together to assess suitable clients for the scheme, offer them their own tenancy in the Vale of Glamorgan and, together, develop and provide them with care and support. This hybrid model of support enables clients with mental health problems to take up their own tenancy supported by a fully integrated care and treatment plan. The first tenant signed up in March 2014.
The collaboration came to the attention of the Effective Services Group[2] in 2014 when it was identified in research for the report Prevention Through Early Intervention: Helping people with mental health problems to find and keep a home[3]. Published in 2014, the report recommended similar action in other areas. In line with the available research evidence, it concluded that integration and partnership working involving housing interventions can make a real difference to people’s lives.
The Group wanted to gain a better understanding of good practice interventions that have a positive impact for both individuals and services. It also wanted to identify key factors in housing support interventions which promote continued recovery and enable the individual to live successfully in the community. The Welsh Government’s internal research programme within the Social Research Division, Knowledge and Analytical Services, was commissioned to undertake the evaluation. Commissioning the evaluation of the scheme gave the opportunity to draw lessons from it and understand implications for future sustainability and wider introduction.
The Welsh Government’s researchers worked closely with the core membership of the multi-agency group in the Vale of Glamorgan to design the evaluation, which investigated the implementation of the scheme and relating this to its emerging outcomes.
Is the collaboration effective?
This collaborative approach to developing the scheme is a continuing and evolving process and there has been a learning curve for all involved. IRIS works from the care and treatment plan and Gofal works on the areas identified in the client-led mental health recovery STAR[4]. There is considerable synergy between these plans but they are not ‘one plan’. The staff share the information with each other and IRIS staff are starting to learn how to apply the STAR tool. The IRIS care plans, however, are held on the NHS Paris data system, to which Gofal does not have full access.
Inconsistent access to information can at times lead to duplication, misunderstanding and instances of miscommunication, despite all partners being willing and committed to sharing information to allow the service to function effectively.
Overall what makes the difference is the joint assessment of a client at the referral point and the communication about the development of the care and treatment plan. The collaboration supports the development of a person-centred integrated care package and seeks to ensure there are no gaps in the service.
The collaboration allows a more streamlined approach to ensuring needs do not go unmet which could lead to breakdown in mental health and tenancies.
Is the scheme making a difference?
The scheme’s working model of delivering collaborative and integrated services has so far proved successful. A number of staff described the support package as a ‘safety net’, providing clients with the opportunity to have and develop their independence, but with the safety of the support provided by Gofal, IRIS and other agencies around them.
The joint assessment and development of an integrated care and support plan identifies a wide range of support needs for each individual client. It is the time and space that practitioners have to build relationships with clients that allow the development of more person-centred care. The development of a structured individual plan and the time and autonomy to work with each client allows gaps in needs to be both identified and filled and at times for more subtle needs to be picked up. The scheme also allows clients to receive this support in their own home and without unmanageable risk to their mental health or tenancy.
From the clients’ perspective, there is also evidence of positive outcomes at this early stage. For example, since the beginning of the scheme to the end of the evaluation there were no hospital re-admissions due to relapse in the mental health condition of clients and there has been no breakdown in tenancy. The scheme staff reported that the integrated nature of care allows them to pick up issues before they escalate to crisis situations. The model seems to allow for more appropriate interventions in a more timely fashion and the flexibility allows potentially damaging situations to be dealt with more effectively.
The analysis undertaken in the evaluation looked at a wide range of outcomes for both the service itself and the clients. The evidence shows that the scheme appears to be meeting its intended outcomes and objectives. Examples include improvements in the independence and confidence of service users; the stabilising of the environment provided by the integrated care can create a break for issues that can escalate into crisis. Visits from Gofal and IRIS allow issues that may cause stress to be picked up early, such as problems with finance or medicine non-compliance and the early intervention helps stop them from escalating and becoming problematic.
Challenges
The biggest challenge remains the lack of suitable one-bedroom flats. Alternatives such as using three- or four-bedroom shared accommodation could be used as an extra step for a short period in the transition from acute care to independent living.
Other challenges remain around social isolation and loneliness, substance misuse and client dis-engagement. But practitioners remain clear that the purpose of the service they provide is to understand and minimise risk through risk management and harm minimisation.
Availability of resources may affect future sustainability as the scheme is reliant on a number of public funding sources. Practitioners believe that based on existing resources the scheme is viable, sustainable and replicable.
Replication
The mechanisms of delivering the dispersed housing scheme are a combination of established professional expertise and new ways of working as a result of collaboration and integration. The dispersed housing scheme is a coherent intervention with a strong logic behind how it intends to achieve its outcomes.
The future
Practitioners suggested the need for more frequent communication. Establishing a Vale hub as a base for all dispersed housing scheme practitioners to use in the locality would enhance communication, use practitioner time more effectively and potentially work more efficiently if the hub offered a drop-in centre for clients on the scheme.
The dispersed housing scheme is a pilot that is evolving. Its size is limited, and the unique nature of clients’ mental health makes it difficult to generalise based on the initial findings of this small scale evaluation. However, the model of delivering collaborative and integrated services has so far proved successful with evidence of the scheme’s ability to deliver person-centred and joined-up care within the client’s home environment. From the start of the scheme to the end of the evaluation there were no client hospital readmissions due to relapse in mental health. The model seems to allow for more appropriate and timely interventions. Client independence and confidence is improving and there are also improvements in clients’ mental health, daily living skills, physical health and self-care and taking responsibility. Further testing of this service and other similar ‘floating support’ models are needed to assess the longer-term outcomes of the collaborative, integrated approach to individual care for both the service and clients.
Public service organisations should consider the application of this model, which is working, to other settings where individuals with high-level needs could benefit from person-centred, integrated care delivered collaboratively by health, housing and other relevant support agencies for example, alcohol and substance misuse. Public service organisations should investigate how this working model can be replicated and adapted to work in other locations, particularly looking at integration between housing and health services, and should investigate potential funding models needed to expand this model in situ and in other areas/settings.
Developments since the evaluation
The service has continued to show its ability to deliver on better outcomes. Whilst one service user has been admitted to hospital since the end of the evaluation, they have been able to successfully return home. The ability of the service to respond to crisis in mental health in a planned and responsive manner has resulted in a number of key benefits:
- Shorter hospital stays than on occasions prior to accessing support from the dispersed scheme.
- Seamless provision of support on discharge.
- Avoidance of homelessness and access to related services
- Avoidance of delayed transfer of care.
Two service users have reached a degree of independence enabling the withdrawal of support by the dispersed project. A key aim of the service was to enable service users to remain in the accommodation provided by the scheme rather than enforce a further move-on. In both cases the service users have been granted supported assured shorthold tenancies by Newydd Housing Association, enabling the retention of links to the community and familiar support networks established whilst supported by the scheme.
New Developments
In April 2016, Gofal was successful in winning a contract to provide further supported accommodation in Penarth and Barry. This provides the opportunity to expand collaborative working arrangements across a further 11 units of shared supported housing. Dialogue regarding this potential development will continue through 2016.
Contacts for further information
- Welsh Government LGPartnerships@wales.gsi.gov.uk
- Vale of Glamorgan Council PToms@valeofglamorgan.gov.uk rvincent-newson@valeofglamorgan.gov.uk
- Newydd Housing Association dina.williams@newydd.co.uk
- Cardiff & Vale Health Board david.willicombe@wales.nhs.uk
- Gofal sarahscire@gofal.org.uk
HOW THE DISPERSED HOUSING SCHEME OPERATES
Referrals are primarily received from mental health services serving the Vale of Glamorgan Including, community mental health teams (CMHTs), acute and rehab in-patient services as well as serving clients already under the care of IRIS. Other services provided by Gofal will often play a role in identifying suitable referrals in dialogue with care managers in the settings listed above.
Joint assessments are made by Gofal and IRIS using their respective assessment tools to reach a decision on suitability for the scheme.
Appropriate accommodation is sought and during this time Gofal and IRIS work with the client offering support and getting to know them.
This period of transition allows rapport and trust to develop and the negotiation of an integrated care and treatment plan for each client, supplemented by an outcome focussed recovery STAR.
Overall the client has interventions and care plan that covers physical health care, therapeutic needs and crisis interventions.
Each client is offered a supported assured shorthold tenancy sourced through Newydd Housing Association either in, or close to, Barry town centre.
Clients have the opportunity to view the property before making a decision. Newydd seeks to ensure the tenancies are sustainable for the both the client and the surrounding communities and Gofal takes responsibility for decorating and furnishing the accommodation.
Each client’s ongoing individual needs are met through day-time support from Gofal Cymru and evening and weekend support from IRIS, although the support is not a 24 hour service.
Early in the tenancy Gofal’s involvement is intensive, helping the client to set up their own home, helping them feel safe, getting benefits in place and so on.
As each client becomes more independent and confident Gofal’s support may decrease to one or two visits per week.
[1] gov.wales/statistics-and-research/evaluation-vale-glamorgan-dispersed-housing-scheme/?lang=en
[2] ESG is focused on developing new ways of delivering public services that have the potential to make a difference to peoples’ lives at the same time as making better use of public money. It has an explicit focus on services which support the most vulnerable people in our society, and aims to improve the effectiveness and efficiency of public services for these groups by identifying, promoting and supporting the development of successful collaborative approaches.
[3] gov.wales/topics/improvingservices/public-services-leadership-panel/nwp/effectservices/?lang=en
[4] The mental health recovery STAR covers ten key areas managing mental health, physical health and self care, living skills, social networks, work, relationships, addictive behaviour, responsibilities, identity and self-esteem and trust and hope.