Together for Mental Health
The new Welsh Government Mental Health and Wellbeing Strategy – Together for Mental Health – launched in October last year sets out an ambitious vision for the mental health and wellbeing of the population of Wales. Siân Richards, a former NHS Chief Executive and currently Mental Health Strategy Lead in the Welsh Government and Ewan Hilton, Executive Director at Gofal, discuss some key principles of the strategy and consider why housing providers have such a pivotal role in helping to deliver on the desired outcomes of the strategy.
Siân: Together for Mental Health takes a new and exciting approach with a whole population perspective to mental health and wellbeing. It is therefore about improving the mental wellbeing of all people in Wales through a public health focus on prevention and early intervention, as well as about improving experiences of and services for people with mental health problems.
Rather than us having separate strategies for children, adults of working age and older people, this Strategy covers all ages which should mean we can manage transitions much better.
Perhaps most importantly, as emphasised in the title TOGETHER for Mental Health, this is a cross-Governmental Strategy, it recognises that improving mental health and wellbeing is not just about the NHS and Social Services; it is about all areas of government, embracing public, third and independent sector organisations. In our holistic approach in Wales we look at 8 areas of life, each of which is fundamental in supporting good mental health and wellbeing.
Ewan: As you know Gofal and the mental health sector more widely warmly welcomed Together for Mental Health. In particular we welcome that the strategy is built around a set of high level outcomes that will enable the real and lasting impact that actions contained within the strategy are having on people’s lives to be measured. For the first time outcomes over process and crucially outcomes that are built around the user’s experience of using services are driving the strategy.
Siân: Yes this is an important and extremely positive shift. We will ensure that this Strategy is not just words gathering dust on the shelf. A Delivery Plan was issued at the same time as the final Strategy with clear accountability and timescales for action. Responsibilities cover all areas of government and all sectors. Implementation is being overseen by a new Partnership Board. Membership includes a senior housing policy official, a representative of the all-Wales Chief Housing Officers’ Group and an RSL Chief Executive.
Together for Mental Health’s success will be measured against a challenging set of high level outcomes. This means that we should be able to measure the real and lasting impact on people. Developing outcomes from a service user lens is central to this and we will shortly be piloting this approach across all ages, including with a housing provider.
Ewan: It is fantastic that for the first time we have a strategy that commits to improving whole population mental health and wellbeing as well as improving services to people living with serious and enduring mental health problems.
Siân: Of all the areas raised in our extensive engagement with service users, housing came out as their priority. It is clear that if people are in a safe and sustainable home, it makes so many areas of their lives easier to manage and is critical to independence.
Ewan: We all know that poor housing and homelessness can be the cause of, and exacerbate mental health problems and that mental health problems can be the cause of people experiencing housing difficulties and indeed homelessness.
Traditionally, the housing sector and health have not had a great record of collaborative working. I think housing has not necessarily been on health’s agenda and mental health perhaps not high enough on housing provider’s agenda. I think that I can see signs of that changing. How do you feel the housing sector in Wales has engaged with both the development of the strategy – but also since its launch in the delivery?
Siân: The real difference is that Together for Mental Health is owned by and places clear responsibilities on all government departments. Housing actions are therefore not something added onto the list by mental health colleagues but have been developed by housing officials and will be embedded in their policy, strategy and legislation, including the forthcoming Housing Bill. It is crucial that we continue to work with our housing colleagues inside and outside of Welsh Government to ensure this fundamental part of the strategy is delivered.
Ewan: I think that the Wales Audit report Housing services for adults with mental health needs was a wakeup call for the Welsh Government and housing providers which resulted in a flurry of activity. I think the strategy has had a similar effect; our challenge is to keep that activity going and ensure mental health and housing issues continue to be seen as a high priority. There are some great examples of collaborative working beginning to appear. For example Cardiff and Vale UHB and local housing association Chief Executives have begun meeting to explore ways to work better together. Gofal has been invited to the table in recognition of the need for improvement and further development of mental health accommodation and support services. And I’m aware of other similar collaborations being established aiming to do similar things.
Siân: Together for Mental Health places an expectation on all agencies to come together and do things differently. It is really good to hear of new approaches to working together beginning to happen. We need to share and learn from these areas of good practice.
Ewan: You’re right – that’s why I’m particularly interested in exploring new ways that the third sector, housing providers, health and social care can work together to create innovative’ low cost solutions to complex problems. More specifically how the third sector can come to the table as an equal and with something valuable to offer. I’m thinking specifically about access to social investment, for example WCVA’s Wellbeing Bond which can provide both revenue, and more importantly capital loans to support third sector / public sector partnerships. There is also the potential for us to form partnerships that can access significant tranches of European funding that would support important employment, training and skills work – another fundamental pillar of the strategy. I would agree it is time to think differently about how we come together, work together and deliver better together and I feel that Together for Mental health gives us a very real and exciting opportunity to do just that.
Siân: Changing the relationship between organisations to one with greater levels of equality, accountability and responsibility can only be a good thing. Health Boards, local authorities, housing providers and third sector mental health organisations will all be working with groups of the same people, perhaps duplicating services, maybe not communicating vital information or joining up services. Addressing such issues should deliver significantly improved outcomes for people and more cost effective services.
Ewan: So imagine we are sitting here in twelve months time having a conversation about mental health and housing. How will we know things have improved?
Siân: We will have moved forward when the joint working we have talked about here is no longer noteworthy, when it is no longer seen as innovative good practice but rather as the normal way of doing things. Then we really will be together for mental health.
Ewan: And I would like to be hearing stories of things improving directly from the mouths people using services; people who may be seeking work or requesting help with their housing. I would like to see signs that the stigma and discrimination peoples’ experience is reducing and overall mental health wellbeing is improving.
Maybe this is more than a year ahead – but I would like to see Wales as a country where all people, across all sectors and all communities understand the contribution that improved mental health and wellbeing makes not just to individuals and their families, but also to Wales as a whole. Mental ill health costs Wales around £7.2 billion a year. There is a strong economic case for getting this right. So in say three year’s time it would be great to be celebrating not only improving people’s lives but also evidencing the wider economic benefit.
Gofal\’s website is www.gofal.org.uk
Together for Mental Health is online at http://wales.gov.uk
Hospital at home – remember the bricks and mortar
Siobhan McClelland considers how hospital at home features in Local Health Board plans and makes the case for housing as an integral part of this approach.
In the latter part of 2012, Local Health Boards in Wales were involved in wide-scale public engagement exercises on their plans for the reconfiguration of hospital services. The results of these exercises and the decisions emanating from them continue to dominate the headlines and generate strong feelings. However, there is a strong direction from the Welsh Government that these changes need to happen with the First Minister himself warning that the Welsh NHS faces collapse without the reorganisation (1).
One of the trade-offs for the controversial changes to hospitals is, as the Hywel Dda plan Your Health Your Future (2) states:
‘Providing much more care at home … the right services with the right capacity in place in our community … better access to facilities nearer to where people live.’
And this is echoed across the Health Boards of Wales. Much emphasis is placed on maintaining the independence particularly of older frail people with, for example, Abertawe Bro Morgannwg University LHB developing ‘proactive community care’ where practitioners identify older people at most risk of deterioration and seek to allow them to stay at home through the use of key workers and technology (3). Whilst part of this agenda is the provision of services in more locally accessible facilities, increasingly our definition of a hospital may include our own homes.
Hospital at home is a generic term usually referring to home based nursing and rehabilitation services to prevent admission to or facilitate early discharge from hospitals. Whilst much of the focus has been on care for people with long term conditions, particularly older people, there are wider applications which have included:
- enhanced early supported discharge
- chemotherapy at home
- End of Life Care
- intravenous antibiotic therapy for cystic fibrosis
- diagnosis of Type 1 diabetes in children
Hywel Dda LHB have taken the concept of Hospital at Home a stage further with their proposal for the development of Community Virtual Wards. The LHB proposes that groups of people should be identified who have high health care needs and whose risk of deterioration could be avoided if the right support was available much earlier. These ‘patients will receive care in the comfort and convenience of their own home from skilled professionals and support staff. The wards will be operated by highly trained staff using cutting edge technology such as telehealth monitoring’ (2).
This does raise the question however of whether this will actually be the most cost effective way of delivering care. Hospital at Home care has been pioneered in the United States where there has been some evidence of improved quality of care, reduced length of stay and higher patient satisfaction scores. However, it is the economic impact of this model of care that is of most interest in increasingly financially stringent times. The evidence as yet is limited and indeed contradictory, with both reduced and increased costs emerging. The Cochrane Library is increasingly bringing together a number of systematic reviews evaluating the effectiveness of different ways of delivering health care services including those provided in peoples’ homes.
A recently updated Cochrane Review of assisted early discharge for people with acute exacerbation of chronic obstructive pulmonary disease (COPD) provided some promise for those who hope that this development can both improve patient outcomes and reduce costs (4). COPD is the fifth leading cause of death in the UK and one of the most common reasons for an emergency admission or readmission to hospital. The study found that this assisted early discharge scheme resulted in a statistically significant reduction in the relative risk of readmission to hospital after 1-6 weeks compared to inpatient treatment. However, there is clearly a need for better and more robust evidence if the case is to be made that this will truly be cost effective.
As importantly, if the vision of Hospital at Home is to be achieved then it needs the partnership working of integrated care which underpins it to include housing services. The statement in the Betsi Cadwallader LHB plan Healthcare in North Wales is Changing (5) quite rightly states that ‘Healthcare is not about bricks and mortar but about services’. However, the bricks and mortar of those homes are an essential pre-requisite to the delivery of those services and need to be an integral part of any future solutions.
Siobhan McClelland is Visiting Professor Health, Policy and Economics at the University of Glamorgan and can be contacted at smcclell@glam.ac.uk
References
1 – BBC Wales Sunday Politics Show 3 February 2013
2 – Your Health Your Future: Hywel Dda LHB (2012)
3 – Changing for the Better: ABMU LHB (2012)
4 – Jeppensen E et al Hospital At Home for Acute Exacerbation of COPD Cochrane Database of Systematic Reviews 2012 Issue 5
5 – Healthcare in North Wales is Changing: Betsi Cadwallader LHB (2012)
Providing an alternative pathway
The National Housing Federation has recently published a report showing local authorities, housing providers, GPs and acute trusts working together to provide an alternative care pathway which reduces the demand an individual has for other services, as well as improving their quality of life.
Providing an alternative pathway tells the real stories of five people who receive integrated care, housing and support. Although seated in the English policy context, the overall messages are equally relevant to those working in Wales. Joint working between housing, health and social care can:
- avoid or delay a move to residential care
- reduce admittance to hospital and avoid readmission
- reduce the demand for assessment and treatment centres
- prevent the need for domiciliary care
- prevent health emergencies and reduce demands on A&E
- prevent mental health deterioration and overall deterioration in health and wellbeing
The case studies set out in the report, which provide practical examples of bringing together housing, health and care, deliver savings of between £2,946 and £17,992 a year compared to less integrated pathways.
So how can this type of integration happen? Different local areas will develop different answers to this question, but the report identifies a number of emerging common themes.
In the short-term
- Understand the routes people take through local services. Where can closer working with housing providers give better results? Meet with local housing providers to discuss how housing can prevent or directly address health and social care pressures
- Identify what knowledge and intelligence you need to know, and plan for how to use housing to improve care outcomes and reduce demands on the NHS
- Talk to local specialist housing and care projects, home improvement agencies, and other frontline services to understand where barriers exist and where outcomes are being limited by fragmented services. For example, are hospital and care staff working closely with housing support staff to deliver reablement services effectively, helping to discharge people home quickly and prevent readmissions?
- As reductions in spending are planned and implemented, local authorities, health and housing providers should openly discuss the implications on different elements of the health and care system, identifying alternative ways of meeting local needs in the area
In the longer term
- Include housing options and housing-based services in local market statements to ensure housing providers are recognised as local partners in providing accessible care services that help people maximise independence
- The NHS, housing providers and local authorities should work together to understand where costs build up in different parts of the care and health system, and to recognise the value of safe and settled homes, housing-related support and home-based care services across primary and secondary care
- Adult social services departments and housing departments should work together to establish and maintain a register of adapted housing as part of their oversight of the local care market. A clear, up-to-date understanding of specialist local housing stock will also help authorities manage and respond to the impact of the Welfare Reform Act on residents in specialist housing with care
- The health and wellbeing boards should address both housing needs and the role of housing and related services in their Joint Strategic Needs Assessments and local clinical commissioning plans in meeting local priorities and improving health and wellbeing
- Health and wellbeing boards, housing providers and local authorities should work together to identify the need for specialist and accessible housing, which could take the pressure off local hospitals and residential care homes. This should then feed through into local planning strategies and priorities
- Information and advice services across housing, health and welfare must ensure that individuals in need of care are aware of housing options and housing-based services as part of the local care market
The report is available online at www.housing.org.uk