Themes
- Addressing health inequalities – housing and community inclusion
- Early intervention and prevention
- Partnership working
Background
Hampshire and Isle of Wight Healthcare NHS Foundation Trust (Hampshire and Isle of Wight Healthcare [1]) is a mental health, learning disability and community trust in the southeast of England, serving a population of 1.5 million people.
The trust's service design and delivery has a strategic focus on population and health equity, and a new leadership function has been created to drive this agenda across the trust. Work has already commenced on shaping the priorities for the new trust and this includes embedding NHS England’s Patient and Carer Race Equality Framework (PCREF) (NHS England, 2023). The merging organisations have already agreed to prioritise reducing health inequalities within their quality objectives. Underpinning the focus on population health is executive-level support and direction, with the trust employing a director for population and health equity, alongside an associate director, who together have worked to embed an organisational culture in support of the population health agenda.
Housing and community inclusion are key areas that impact mental health and wellbeing, and the trust has designed several targeted interventions. The trust recognises that by focusing on upstream, preventative action to tackle the wider determinants of health – including addressing the social pressures in an individual's wider life – it can alleviate demand for services in secondary care and emergency settings. The trust’s view is that by acting as an anchor institution within its local area it can work effectively with partners, such as local authorities and VCSE organisations, to see positive change.
Step out – supported accommodation pathway
In 2020 the trust created Step out, a supported accommodation pathway to enhance flow out of the inpatient rehabilitation estate in Southampton. The trust works in collaboration with a social landlord to identify suitable housing options in the community. The 'housing first' ethos means the trust works closely with patients to understand their housing needs – such as availability of transport links, proximity to social connections and employment opportunities – to ensure the individual is placed in the right accommodation.
This encourages stability and long-term residence, with the aim of alleviating patient stress over insecure housing, improving patient recovery and preventing unnecessary hospital re-admissions. The local authority has allocation rights into around 95% of the landlord’s available housing stock, meaning the landlord has around 5% of their stock to use at their discretion – such as for innovative solutions like the Step out pathway. There are no housing costs to the trust as they are covered by patients' housing benefits. However, the trust provides the community teams who support patients to manage their transition into community-based accommodation. Unfortunately, not all local authority boroughs in the area have the same levels of housing allocation, which prevents the trust from expanding this initiative wider – despite widespread support among local authority partners.
To date, the trust has supported nine patients into homes within the local community. The small overall figure reflects the person-centred approach taken, the time taken to find accommodation to suit the needs of the patient, and the challenges of the local housing environment. But feedback from the patients has been overwhelmingly positive, reporting it has broken the cycle of moving in and out of hospital care.
"It’s the greatest support that I could ever have – it provides that platform for you to push on, to become independent."
Alongside the improvements to patient experience, the trust has been able to discharge patients three months earlier than usual via this supported pathway, leading to efficiency savings and improved patient flow through their mental health units.
Embedding early-intervention mental health support in housing
While the Step out intervention focuses on managing patients out of hospital and into accommodation, since 2021 the trust has implemented a complementary initiative by employing clinicians within local authority housing teams. Their work is predominantly focused on individuals in temporary accommodation, people who are homeless, or those at risk of homelessness. The overall aim is to encourage them into independent long-term living, targeting those in earlier stages of illness and preventing patient admissions that occur because of challenges with sustaining affordable and safe housing.
Most of the clinicians are employees of Hampshire and Isle of Wight Healthcare, with honorary contracts in the local authority. This ensures the clinicians can access records of both organisations and to clinical registration and learning and development via the trust. The funding for these roles is, mostly, via the Rough Sleeper Initiative grant funding programme available to local authorities. This grant funding pays for the clinician's salary, office costs and expenses.
The clinicians engage individuals in health-led conversations that consider their holistic health and wellbeing needs. An evaluation of the project found over two-thirds of people in this population group were not previously known to secondary care mental health services and had unmet health needs prior to the trust embedding clinicians within local authority housing teams. The clinicians don’t hold an NHS caseload so can dedicate time and resource to prioritising the needs of these individuals, referring or signposting those requiring support to the most appropriate services. The clinicians can be flexible and responsive with their time and provide tailored support, ensuring care is patient-centred.
Clinicians are also embedded within the housing needs assessment process, where they can highlight the health and wider needs of individuals, for example, by ensuring patients with paranoia aren’t placed in shared accommodation or those with social isolation aren’t placed alone.
Hampshire and Isle of Wight Healthcare currently employs five clinicians across six local authority areas. In the first 18 months of the project, clinicians helped to prevent ten accommodation breakdowns and evictions. The team enabled patients to access the care and support they needed, including registering for the GP. The clinicians were also able to support nine homeless individuals to come in off the streets, where local authority colleagues had previously been unable to engage with them. This initiative highlights the importance of providing multi-disciplinary and holistic support to individuals.
Partnership with Citizens Advice in inpatient settings
Feedback from staff at the trust revealed social stress had contributed to a high proportion of patients on inpatient wards reaching crisis point and subsequently being admitted. Staff on wards were not equipped or trained to deal with the wider problems patients were facing including family breakdowns, legal issues and financial insecurity. In response, the trust launched an innovative project to embed Citizens Advice case workers on hospital wards.
The trust piloted the project in one hospital in July 2022, but it is now live across four adult acute mental health hospitals. Each hospital has one Citizens Advice case worker located on inpatient wards for two days a week, dedicated to providing face-to-face support for service users, with a third day spent supporting patients within the community. The case worker can build relationships with patients while in hospital and follow up with outreach support after discharge, such as meeting people at libraries to provide advice on benefits support. The trust recognised this was more effective in ensuring uptake of follow-up services, especially for those who had encountered barriers in accessing support.
In the first 24 months of delivery, the Citizens Advice case workers had supported a total of 286 patients in inpatient settings, addressing over 1,500 distinct advice needs. The project has revealed the complexity of patient need, with the average patient registering between five and seven distinct advice needs (compared to the average Citizens Advice user having between two and three at a traditional Citizens Advice setting). The most common concerns related to finance, housing, and family mediation.
Analysis from Citizens Advice has estimated the financial benefit for the 286 people supported as a total in excess of £556,000, particularly in helping patients to access benefit payments they were not previously aware of. In addition, feedback from trust staff has been hugely positive, with reports of reduced stress levels and higher job satisfaction. The trust is conducting a formal research evaluation in order to consolidate the impact and share learnings more widely. It was recently announced as a finalist in the NHS Parliamentary Awards 2024 within the Excellence in Mental Health Care category for this initiative.
[1] Hampshire and Isle of Wight Healthcare formed on 1 October 2024 following a merger between Solent NHS Trust, Southern Health NHS Foundation Trust, community, mental health and learning disability services from Isle of Wight NHS Trust, and child and adolescent mental health services delivered in Hampshire by Sussex Partnership Trust. The initiatives described in this case study originated in Southern Health NHS Foundation Trust and are now being taken forwards in the new organisation.