Health and housing feature

It is a huge sector, struggling to cope with increasing demand, but traditionally averse to outside help so when it comes to joint working housing providers have often found themselves left out in the cold. As Gill Moy, director of housing and customer services at Nottingham City Homes (NCH), puts it: “we have loads of toys that we want to share with people to play with, but we never get invited to the party”.

But against the odds some housing providers have persevered. Inside Housing caught up with a couple to find out how they were faring.

Our search takes us first to Greater Manchester, where First Choice Homes Oldham is pushing ahead with not one but four health projects in partnership with local NHS organisations.

The housing association runs four projects that involve joint working with health services in the area. The Hospital to Home discharge service has been set up in partnership with the Royal Oldham Hospital, Pennine Care NHS Foundation Trust and Oldham Council. A housing officer from FCHO is based at Royal Oldham Hospital and provides support to medical staff to prevent delayed patient discharges where there is a housing-related problem. For example, an older person may not be able to return home because they fall regularly and there are no support bars in their homes. The housing officer can arrange for their home to be adapted so they can return home and free up the hospital bed for another patient.

A pilot began in April 2016 and helped 92 patients to move home quickly – 26 of these patients were rehoused into accommodation that was more suitable for their needs, preventing repeat hospital visits. The local Clinical Commissioning Group was impressed by the pilot and agreed to provide half the funding for the service, with FCHO providing the remaining half.

Kelly Webb, assistant director for health and housing needs at First Choice Homes Oldham, says the service is now “really well established” within the discharge team at the hospital “and it’s an absolutely essential service”.

But she adds: “If we’re honest, initially when we established the hospital discharge service it was brand new and we had a lot to overcome - there was a lot to do around networking, understanding what we could bring to the table, how we could make a difference…and that wasn’t a quick win.”

The biggest barrier for FCHO has been persuading NHS organisations to share medical information on patients. “When you’re in a health environment its medical information and we absolutely understand the need to maintain data protection around that but it’s trying to find ways that we can access some of the data for the benefit of all. There has been barriers around the sharing that we’re only just overcoming,” Ms Webb says.

But the success of Hospital to Home has made it easier for the association to start other health projects because it had built a solid working relationship with the local hospital’s discharge service.

The landlord also now runs an A&E to Home service at the same hospital which started in October last year and deals with people who are regularly turning up at A&E with non-clinical issues, such as drug abuse or homelessness. Around 10 of the referrals every month have been directed to further community services such as an immigration advisory service, urgent care social workers or the local homelessness team.

Two other projects – Housing Options for Older People and Healthy Homes – are focused out in the community rather than in hospital and help to find older people suitable housing and care so they can live independently for as long as possible or to adapt their homes.

Getting that initial foot in the door was the tough bit, Ms Webb says, partly because of a lack of awareness on health workers’ part about what housing can offer.

“There is maybe a lack of awareness of what we actually do and how we can benefit them. There’s maybe not an understanding of how we could help deal with some of their acute pressures because you don’t necessarily see housing as having a role to play in managing the pressures of A&E. You wouldn’t expect a nurse or a doctor in an A&E to understand the ins and outs of a housing association,” Ms Webb points out.

Lorraine Black, support and wellbeing manager at FCHO, says it been “a big learning curve for both us and the NHS”.

The pooling of health and social care budgets in Greater Manchester, a major part of the region’s devolution deal which resulted in a £6bn pot, has been a game changer, Ms Webb says.

“There’s been a change in thinking. I think we’re working much more collaboratively with the 10 authorities within Greater Manchester and working much more collaboratively with our local social care services. Where we are now compared to where we were three years ago - we’re streets ahead. Two years ago we didn’t have a health service and now we’ve got four – it’s really kicked up a gear.”

Nottingham City Homes, which has been valiantly trying to get joint working off the ground with Nottingham City Council’s adult social care team and local NHS organisations.

As Ms Moy puts it: “We passionately believe that housing has so much to offer health and social care but we knew we needed to be the ones to lead this piece of work by picking up our toys and crashing the party.”

For NCH the pitch to its NHS and social care colleagues revolved around the daily contact housing staff have with local people. Frontline staff see their residents on a regular basis so NCH argued they could identify early signs of illness and help connect people with services to stop them from deteriorating. Housing staff can also spot if a home needs to be adapted to suit the resident’s needs, making it more likely they can stay in their own home for longer.

All this could be of great use to the NHS and social care, housing leaders argue, because it could stop people from visiting their local accident and emergency department needlessly or ensure they can be discharged from hospital as soon as possible because they will have a home to go back to that has been adapted for them. One of the biggest reasons for delayed patient discharge in the NHS is older people stuck in a hospital bed because their home is not adapted to suit their needs.

NCH recognised the role they could play in speeding up these discharges and sought a place at the table when it came to seeking solutions for some of the financial challenges health and social care face. The three sectors locally signed off on a memorandum of understanding (MOU) in June 2016 pledging that health, social care and housing and support sectors will work together to achieve better health outcomes for the community.

First off, the group came up with five priority areas for the MOU –

• Providing evidence for the need for integrated health, social care and housing work
• Developing efficient and innovative working practices where information is shared, joint working is carried out and funding opportunities are “maximised”
• Making sure homes in the private sector are safe, well managed and help to protect the health and wellbeing of residents
• Developing the financial resilience of Nottingham citizens
• Helping local partners to identify and carry out their role in homelessness prevention as well as meeting the health needs of homeless people

This joint working fed neatly into a high priority NHS project that was underway nationally during 2016 – the creation of Sustainability and Transformation Plans (STPs). These are plans required by NHS England that set out a five year vision for an area to improve care and the efficiency of health services.

As a result of NCH’s place at the table the Nottingham and Nottinghamshire STP is now one of the only areas in the country that includes the housing sector in its plans for the future. Specifically, it states that housing providers will provide “better support” to help people to be discharged from hospital “safely and at the right time” by making sure their accommodation is safe and appropriate to return to.

But despite this high profile role for housing the joint work has hardly been plain sailing. The main setback has been the pressure on budgets in the health sector, which has led to delays in getting things moving.

Ms Moy says: “Largely the frustrations are due to some of the financial pressures that we find colleagues in adult social care and health are facing. We’re starting to see some pressures build up on that for the next financial year. I know our colleagues in the NHS and in adult social care are under a lot of financial pressure. Budgets are reducing drastically but you’ve got more people living longer, more people who need services at a time when budgets are dropping.”

This pressure on the health service’s time is also apparent when Inside Housing tries to find someone from the local NHS to interview about the joint working with housing. After several attempts it becomes clear we won’t be able to hear from the health service’s side.

This constant firefighting by health and social care leaders means their focus has not been on longer-term solutions that could result in savings. “From the housing point of view we’ve got so much to offer the health and social care agenda and being part of that wider integrated workforce but they’ve got so many budgetary pressures that they’re having to make decisions based on short term savings - probably to the detriment of some of the longer term savings that working with housing can actually bring”, Ms Moy says.

It’s also been difficult to communicate to some health workers the value of housing in a setting where the focus is on acute medical need. “If you think about what housing has to offer – a lot of it is early intervention and prevention things. It’s hard for them sometimes to think in a holistic way and say if we cut these things at the front end it’s going to cost us in the long run. Some of them do understand it but I think they’re faced with some terrible pressures really,” Ms Moy explains.

NCH is running a Hospital at Home project which aims to keep vulnerable residents out of hospital and is now seeking to work with local hospitals to help them discharge patients, funded by the local Clinical Commissioning Group.

Housing providers have often said it is difficult to penetrate the NHS bubble, where workers use specific language that can seem unfamiliar to housing professionals. So how did NCH persuade its local CCG to commission services from them? Ms Moy says it’s all about having good evidence.

“They like to see evidence but it’s not always necessarily evidence on health terms. In housing we tend to do a project and look at where you started the journey and where you ended it. With the Hospital at Home project we did some evaluation of that and it shows you the savings it makes, the impact you’re having in terms of speeding up hospital discharges, but it also talks about quality of life stuff for tenants which I think is something health don’t do particularly well. They tend to get focused on medical outcomes, but the person-centred outcomes are equally important so what does it mean for the individual in terms of their quality of life.”

“We’ve done case studies and one of the first cases we helped was a chap who was living in a flat above a pub but he couldn’t get up and down the flight of stairs. He got admitted to hospital because he had a fall and he was really lonely and had no reason to get up in the morning. We rehoused him and put him into one of our independent living schemes where he’s now got social connections and he’s not socially isolated and lonely anymore and has a reason to get up in the morning. Those things are really difficult to measure - if you improve peoples’ mental health it has an impact on the physical health as well. Instead of being a frequent flyer at the health services like his GP.”

NCH has also carried out a stock condition survey of the city’s housing which showed that some of the worst housing is in the private rented sector and owner-occupied. Ms Moy says this has focused peoples’ attention “on where the biggest health inequalities are actually occurring”.

Ms Moy is pleased with the relationships NCH has developed with healthcare professionals but she says the bit that is exercising everybody is how the work can be financed. She is determined to keep going though. “I very much do believe that housing has a heck of a lot to offer the health and wellbeing world and adult social care so it’s really important we persevere despite all the financial pressures that are on us.”