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Helping health and social care improve outcomes

Ceri Breeze reports on a new study highlighting examples of the benefits that joint working between housing and health and social care can deliver.

A study commissioned by the Association of Directors of Social Services (ADSS) Cymru has identified at least six clear ways in which the NHS and social care services can use social landlords to improve outcomes for the people they serve.

The study is part of action to implement Welsh Government’s plan for health and social care (A Healthier Wales), which aims to ensure people have longer, healthier and happier lives and remain active and independent in their own homes for as long as possible. ADSS Cymru is leading several pieces of work. In addition to examining links between health and social care, and recognising the importance of housing to people’s health and well-being, it commissioned a study to explore joint working with housing.

The small-scale nature of the study means it is by no means the complete picture of joint working. There are undoubtedly more examples in the field. However, it has generated a robust set of examples which are relevant to all areas. These provide a solid foundation for spreading practice and transforming services.

Examples of joint working identified in the study are summarised in Figure 1.

Figure 1: Examples of joint working between housing, health and social care organisations

Title / Theme Housing organisation Key feature(s) of action
Closer to Home First Choice Housing Reducing the need for out-of-area placements
Lighthouse project Taff Housing Association Reducing delayed transfers of care by addressing housing and support needs
Remodelling sheltered housing Cynon Taf Housing Association Alternative use of existing accommodation to meet needs
Remodelling sheltered housing Trivallis Alternative use of existing accommodation to meet needs
Training flats Trivallis Help for independent living for young people leaving care
Well Being 4U United Welsh Social prescribing intervention based on three GP clusters
2025 Movement Various organisations Strategic level forum to stimulate joint working
Mental health pathway Isle of Anglesey/ Ynys Mon CC / BCUHB Improving services and support to prevent cyclical problems
Hospital discharge Conwy County Borough Council (lead) Reducing delayed transfers of care by addressing housing and support needs
Health inequalities and rough sleepers North Wales Housing Association (lead) Improving access and support to people who are homeless and sleeping rough
CARIAD Linc Step down arrangements and alternative pathway

Better health and well-being outcomes are common to all examples. They are achieved by helping people to address social issues affecting them such as housing and debt, as well as physical and mental health and well-being. Problems are often interrelated, which emphasises the importance of the ‘whole system’ approach highlighted in A Healthier Wales.

Effective joint working can help identify and address the root cause(s) of people’s problems not just the symptoms. For example, a mental health issue may present to a GP as the problem whereas a housing and/or related problem, particularly if it could result in losing a home, may also be underlying factors which cause or exacerbate a person’s condition.

With the demand on primary care services, approaches such as Wellbeing 4U, developed by United Welsh and funded by the Cardiff & Vale University Health Board, provide valuable alternative ways of helping people. They allow more time to be devoted to having ‘what matters’ conversations with individuals, identifying and arranging support to help them to work out how to overcome problems and/or manage conditions by building on their strengths. Issues such as housing-related problems, which can themselves impact on someone’s health and quality of life, can be identified and addressed at the same time.

Similarly, other parts of the health and care system are under immense pressure. The study identifies several examples of hospitals and social care working with housing professionals and organisations. They fall into two broad categories: hospital-based and community-based interventions.

Hospital discharge projects such as Taff Housing’s Lighthouse project and a similar development in North Wales led by Conwy County Council contribute to demand management by avoiding blockages in freeing up beds after medical treatment has been completed. Having a housing professional based in hospital and being part of the hospital health and care team realises the benefits of co-location and greater mutual understanding of roles of housing, health and care professionals. The resulting action goes some way towards the goal of the whole system approach and seamless service delivery by public sector organisations.

Housing professionals can prevent non-health matters such as housing from stopping or delaying discharge. They also help ensure discharge into a safe home environment, which supports independent living, and which helps prevent the need for readmission.

The CARIAD scheme, developed by Linc, ensures patients who no longer require a medical bed have an alternative pathway which supports and facilitates their long-term care needs. It enables them to ‘step-down’ from hospital when treatment has finished and when they may require a further period of assessment. It also aims to prevent unnecessary admission to hospital due to short-term illness or injury.

The ‘Closer to Home’ approach by First Choice Housing has multiple benefits. Significantly, individuals and their families benefit from local solutions which avoid out-of-area placements for people with learning difficulties and for people with complex health needs. In addition, after the initial set-up costs, cost savings to the NHS and / or social care can be significant – up to £221,000 per year in this example. The Integrated Care Fund has supported similar developments. A more detailed review of all such developments would be useful. Comparing models and approaches used, and documenting the benefits to individuals and organisations alike, would assist efforts to spread joint working.

Local authorities and housing associations have a wide range of community assets. Needs sometimes change and the alternative use of existing community assets offers considerable potential to benefit the NHS and social care. For example, Cynon Taf Housing and Trivallis have changed the use of some of their sheltered housing to create crisis accommodation provision and new, better, accommodation for people with learning difficulties. The latter allows people with complex needs to live more independently in a community rather than an institutionalised setting as well as offering potential cost efficiencies for local authorities.

The use of housing assets also features in work by Trivallis, which has two ‘training flats’ aimed at young people (17+) in residential or foster placements. Young people are referred if their social worker believes the experience would be a valuable step towards independent living. The trial links with arrangements for care leavers to move to full tenancy via the process for allocating general needs housing.

This joint working between Trivallis and Rhondda Cynon Taf County Borough Council is very much early intervention and preventative. For someone making the transition from care to independent living, such help is vital. The effects and the benefits can last  a lifetime. The extent to which every local authority has such a facility, or has access to such a facility, is not known. The Trivallis example is a long-standing one. Discussions during the study point to similar arrangements being considered elsewhere, for example in Monmouthshire. While the number of care leavers in different parts of Wales will undoubtedly vary, the importance of looking after care leavers and helping them in their transition from care to independent living will be common to all.

Drawing on the examples, there are at least six very clear ways in which the NHS and social care organisations can use, and benefit from, joint working with housing organisations. These are listed in Figure 2.

Figure 2: Six ways in which NHS and social care can harness the benefits of joint working with social housing organisations

·        Using local housing providers to reduce the need for, and cost, of, out-of-area placements

·        Preventing delayed transfers of care (and as far as possible, the possibility of readmission) by addressing housing or housing-related issues

·        Using housing providers to identify opportunities to provide earlier intervention and more support, and options for primary care to address health and non-health issues which affect people’s health and well-being

·        Alternative use of existing local housing assets to better meet the needs (sometimes complex needs) of people who are receiving services and support from the NHS and/or social care

·        Improving the lifelong prospects of care leavers by using local housing provision to help equip them with the skills necessary for successful independent living

·        Improving the way in which services and support are delivered by involving housing providers (social landlords and/or housing-related support providers) in service delivery (i.e. towards more of a ‘whole system’ approach)

The way the developments have come about varies. They are rarely ‘top down’. Often, they are the result of like-minded individuals coming together to work out how they can do better for people. Other reasons include systems failures. For example, the idea of training flats came about after a review of tenancy failures among care leavers spotted that young people were unable to deal with the realities of everyday life such as paying bills, prioritising expenditure and ultimately facing the reality of living alone. It triggered broader thinking across organisational boundaries to find solutions.

Systems failures can be important opportunities for developments which lead to better, more integrated services for individuals. However, while triggers for change, they are a reactive response often requiring considerable resources to be diverted away from day-to-day service delivery.

More preferable is a more proactive approach where services and support are reviewed systematically and in partnership with stakeholders, including service users, to prevent problems from arising and to maximise effectiveness and quality. Reviews can consider how the health, well-being and other needs of individuals are met, or perhaps not as the case may be. Also, which organisations are involved, or should be involved, and at what points.

This would reflect the whole system approach envisaged in A Healthier Wales and would allow a more robust assessment of services against the ten design principles considered necessary to achieve the changes needed. It would also contribute to assessing progress against the five principles of the Well-being of Future Generations (Wales) Act 2015.

And there’s more….

Over and above examples of joint working, the study identified a variety of actions by social landlords which provide other forms of support locally to help people to deal with problems and / or manage their conditions or circumstances.

The help extends well beyond housing priorities such as preventing homelessness to issues of debt and personal budget management, skills, volunteering and employment, substance misuse and anti-social behaviour. Helping people with low-level mental health issues is a common feature of people’s needs.

Much of this support is proactive, including reaching out to people who might not otherwise engage with services and support. Identifying issues as early as possible and acting by way of interventions and preventative action to negate, or at the very least to limit and manage, the problem(s) before they get worse is vital. Given the interface they have with tenants and communities, social landlords are very well placed to do this.

Achieving better outcomes for individuals often generates benefits for others. In some cases, this will be the families of individuals who need and receive help. However, it also extends to the organisations involved. This includes preventing or reducing the need to use, or reuse, NHS or social care services and reducing overall demand. For social landlords, it can help to ensure stable tenancies and reduce the risk of rent arrears.

This form of activity sits very well with the aims of A Healthier Wales and its commitment to more prevention and early intervention. It’s possible such support might be ‘under the radar’ and not perhaps recognised for the role it is playing or the bigger role it could play in future as part of a more co-ordinated, cross sectoral approach.

This tenant and community support was an element of the study and therefore, the sample nature of data collected must be emphasised. For example, Rhondda Housing Association runs, and funds, the Hapus Pawb project in partnership with Cambrian Village Trust. The core of the project is a six-week interactive course to improve tenants’ social, health and well-being. People are reached by home visits or by calling direct, and referrals from housing officers, maintenance staff and other front-line staff.

Reported benefits include better mental health, improved mood, self-esteem and confidence. By facilitating social and community interaction, it is also helping to tackle loneliness and isolation. Some of those who have participated in the project have gone on to act as mentors to new people joining the project.

Cynon Taf Housing Association has 13 staff in support roles. Early intervention and prevention are core elements. Basic needs such as food in the cupboard and money in the meter are fundamental. Without those and setting aside the potential health problems that could result, it can be difficult for someone to maintain a tenancy.

The association helps people in several ways, including the basics of budgeting, action to ensure appropriate benefits are claimed, and helping people into employment or moving them towards employment, for example by volunteering. Tackling issues such as a lack of friends, family or support in the community support and helping them to engage in social activities is also important and help tackle loneliness and isolation. Low level mental health issues including stress and anxiety are common. The association works with Merthyr and Valleys MIND with one of its staff co-located with housing staff.

The frontline staff of social landlords are being utilised more and more to spot tenants who may need help or issues which need to be addressed and referred to health or social services if circumstances warrant. Coastal Housing has refocused the role of its frontline staff and moved away from what was originally a reactive approach in which, if nothing heard from a tenant, the assumption was that everything was alright. That approach did not uncover the loneliness and isolation, mental health problems, alcohol misuse and other problems such as hoarding which people experience, sometimes alone and in silence. Now, no assumption is made that no contact means nothing is wrong, or no help is needed. It has a far more proactive approach.

Such activity provides better intelligence and increases the association’s capacity to understand tenants and their circumstances and its ability to help them. If frontline staff locally can help someone – and they are often able to – there is signposting to in-house service or to external services and providers, and grassroots community support connecting with others who can share skills (community assets). The approach aims to be restorative, working closely with tenants to help them achieve what matters to them rather than doing things to, or for, people.

Spreading the practice and benefits

An important part of research is not merely a report’s findings but what is done with them after publication. Does it sit on the shelf or are the findings given serious consideration by organisations individually and in the various fora which exist to promote partnership working and more integrated public services?

Many factors can help or hinder effective joint working. The benefits are clearly recognised among social landlords and there is commitment and enthusiasm to do more. Positive and negative issues came to the fore during discussions. If issues or barriers can be addressed, it will at least support but more likely stimulate more and/or better joint working between housing, health and social care organisations

Spreading good practice and innovation remains a challenge. People in all parts of Wales deserve good, and consistently good, services and support. The report’s findings provide an opportunity to achieve this by building on what’s already in place and making the much-needed ‘whole system’ approach a reality.  The seven Regional Partnership Boards are in a prime position to drive increased joint working in all areas, benefitting individuals and their families by transforming the way health and social services are delivered.

Ceri Breeze is a former Welsh Government senior civil servant. Prior to retiring in 2017, he led departments in various roles, including housing and public health. He is an associate with Practice Solutions Ltd and holds voluntary roles with two national organisations.  

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