QNI Homeless Health Initiative’s

Improving healthcare for homeless people - A LEARNING RESOURCE

Section B The Homeless Health learning pathway

Module 5: Planning, commissioning and delivering services for homeless people

Learning outcomes: • To understand the mechanisms for effective commissioning of healthcare services for homeless people and how to contribute to that process • To appreciate the importance of multiagency working in delivering healthcare services for homeless people • To understand the methods and tools that can be used to build multi-agency working and overcome any barriers and challenges • To appreciate the social enterprise model as an effective way of achieving multi-agency working

QNI HHI’s LEARNING RESOURCE Section B, Module 5: Planning, commissioning and delivering services for homeless people

Brief overview of the content

W

elcome to Module 5. In Module 4 you studied quality improvement in the context of health services for homeless people, looking in detail at service user involvement, benchmarking services, quality indicators, and finally examples of innovation, learning and good practice.

– and how to ensure their needs are best met. In Part 2 we will go on to examine how effective services for homeless people can best be delivered through a multi-agency approach. Finally, in Part 3 we will look in more detail at one specific and timely model for achieving excellence – the social enterprise.

Module 5 will focus on the delivery of those How to use this module services, looking in detail at: First read carefully through the learning outcomes below, and consider your starting point. You Part 1: Commissioning homeless health services may be relatively new to this field, or you may be more experienced, seeking to underpin your Part 2: Providing homeless health services practice with additional learning and the sharing through multi-agency working of innovation and good practice. Part 3: The social enterprise model

Whatever your starting point, think in advance about what you want to get from the module and In Part 1 we will look at the mechanisms for make a note of any additional learning outcomes. commissioning services for homeless people Then read through the material. It has various

learning points along the way. Some of them will simply ask you to think about your perceptions of a particular issue before going on to read the theory. Others will require you to go away and talk to colleagues or to reflect on your own practice or experience. The exercises are intended to strengthen and underpin the written material, making it relevant and meaningful to your practice and working circumstances.

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understand the mechanisms for effective commissioning of healthcare services for homeless people and how to contribute to that process.

Learning outcomes

Nurses have a key developmental role with commissioners to transform services so they are accessible, appropriate, flexible, equitable, of a high quality, inclusive, appropriate and will be effective in meeting the health needs of homeless people so as to improve health outcomes. This will have cost saving benefits to homeless people and to the local health economy.

Nurses have key leadership roles to play in the commissioning of health care for homeless people as they know their client group, know the health needs of their client group (both physical and mental and from a public health perspective), On completing the module, you will be invited know the gaps in service provision, know the to return to the learning outcomes, and consider partner organisations from both the voluntary whether they have been met and what it means and statutory sectors and know models of good for your practice as a result. practice.

By the time you have worked through this module and completed the self-assessment exercises, you should be able to: • • • •

understand the mechanisms for effective commissioning of healthcare services for homeless people and how to contribute to that process

Intended outcomes of effective appreciate the importance of multi- commissioning

agency working in delivering Commissioning is not an end in itself, but the healthcare services for homeless people means by which health service money is spent to achieve the aims of the service. In summary, the understand the methods and tools that intended outcomes of commissioning, for all local can be used to build multi-agency populations including homeless people, are: working and overcome any barriers and challenges • Provision of high quality care that is patient focused with informed patients appreciate the social enterprise model having choice and control as an effective way of achieving multi-agency working. • A focus on high quality health outcomes through integrated and equitable services

Part 1: Commissioning homeless health • services In Part 1 we aim to achieve the following learning outcome:

Development of supportive environments and strengthening of community action through partnership working

‘Nurses have key leadership roles to play in the commissioning of health care for homeless people’

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Reorienting health services in order for and ensuring continuity of care. Many homeless them to be effective people have poor expectations in terms of health care provision and low health aspirations. They Making it happen – leadership, often experience discrimination and successful accountability and capability with a engagement with homeless people is key to recognition of the need for change success in both health care provision and health improvement. This is often time consuming but and personal development worthwhile in the long term. Building healthy public policy that will Can you think of proactive approaches? tackle health inequalities and problems in Write a list of them now. access to services

Your list might have included some of these Homeless people can be defined as people approaches: who do not have a secure home – from rough sleepers to people in overcrowded or insecure • assertive outreach accommodation. Homeless people suffer from significant health inequalities compared to people • advocacy in more secure accommodation, both in terms of their health status and in their ability to access • sign posting services (see earlier sections in this learning • key working and case management (which are pack). key to success) Homelessness causes multiple risk factors which have both an immediate and long term • change management and recovery (are also key elements in long term and effective health detrimental impact on the health and wellbeing improvement.) of homeless people. Risks include poor nutrition, poor access to hygiene facilities, personal safety, privacy, warmth, space, access to warm clothing, Health needs of homeless people money, mobility, stability, supportive relationships Homeless people present with both physical and more. The basic needs, such as shelter, food and mental health problems which can severely and warmth, take priority ahead of health. affect their quality of life and block routes out of homelessness.They have poorer health outcomes Homeless people also face double disadvantages than the rest of the population. People sleeping of health inequality and difficulties in access rough have a rate of physical health problems that health care. Some of the barriers they encounter is two or three times greater than in the general are the complexities of the health system, population (Randall, 1999). The average age of lack of knowledge amongst staff of how to death for homeless people is 40.2 years (Health manage complexities, inflexible processes and inclusion Task Force, 2010). 47% of rough sleepers bureaucracy, difficulties with transport, and lack of have at least one physical health need at a point understanding of their rights and responsibilities. in time (Cabinet Office, 2010). Homeless people Homeless people may also face discrimination present with multiple health problems which and stigmatisation, communication and literacy relate to physical, mental health and substance problems; and have previous negative experiences misuse issues and are also at risk of long term of using health services. health conditions.

Understanding homeless people

Homeless people often lead chaotic lives Mental health problems were found to be eight and access, meaningful engagement and case times as high among hostel and B & B residents management are key to stabilising their care needs and 11 times as amongst rough sleepers compared

to the general population (Grenier, 1996) with 50 - 75% of rough sleepers have Axis 1 disorders (anxiety disorders, depression, dementia and psychosis disorders) and as many as 30% have schizophrenia (UCLH reference on mortality stats, 2009). People who sleep rough are 35 times more likely to commit suicide (Grenier, 1996). The multiple physical health problems that homeless people experience also limit their ability to access health care. Homeless people often find it easier to access services at the point of need where they are going to have other needs met or where they can access care without having to tackle barriers to care: for example, they will go to an accident and emergency department rather than trying to register with a GP and make an appointment. This can be very costly as it is estimated that homeless people each use an estimated 8 times more hospital inpatient services than an average person of a similar age (Leicester Homeless Primary health Care Service, 2007/08) and their secondary care costs around £85 million in total per year. Compared with the general public, they are 40 times more likely to be unregistered with a GP and use A&E five times more than the rest of the general public.

economy of provider organisations including NHS, third sector, social enterprise and others. It envisages closer working between health and local authorities, leading to more integrated services. ‘Transforming Community Services’ – this was a programme introduced by the previous Labour Government to improve care across six key areas of community practice, and to complete the separation of commissioning activities from the provision of community services. It has led to the movement of most community staff out of primary care trusts, and into employment by other NHS or third sector bodies. ‘Inclusion Health’ – a joint Cabinet Office and Department of Health report published in 2009, and being taken forward under the new Government, this programme aims to improve access to primary care services for a wide range of excluded groups of people. The common issues that have been identified as priorities for the future of the health service in Equity and Excellence: Liberating the NHS are: •

Putting patients and public at the heart of everything, with more choice and control

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Patient centred care and personalised care

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Shared decision making – ‘No decision about me without me’

• Equity and excellence: Liberating the NHS – published in 2010, this is the Coalition Government’s White Paper on the future of health services in England. It proposes that GPs, working in consortia of • practices, will be the future commissioners of health services; and it encourages a mixed

Strengthening the voice of the client by the creation of HealthWatch England and local HealthWatch bodies

National policy drivers

Embedded in many of the national policies and priorities are drivers that are key to improving the health of homeless people and in ensuring that local health services are inclusive and equitable. Important recent national health policies that will influence commissioners and commissioning include:

High quality, accessible care to all, particularly to those who are most vulnerable

‘Compared with the general public, they are 40 times more likely to be unregistered with a GP and use A&E five times more than the rest of the general public.’

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• Empowering professionals and providers giving them more autonomy • Joined up services- health and social care and health improvement Improved health outcomes

Cutting bureaucracy and improving • efficiency • Tackling health inequalities. • There will be a new public health service with a ring-fenced budget, and a ‘premium’ in the allocated budget for areas that need additional help to reduce health inequalities: both of which should help local commissioners to improve care • for homeless people. Now reflect on the implications of this for your own practice and the service • and the locality of where you work. Commissioning competencies For commissioning to be effective and achieve its desired outcomes, a set of ‘commissioning • competencies’ must be in place. These include the following actions and abilities: •

Engagement with users to shape appropriate, responsive and flexible services and to improve health Working collaboratively with partners to commission services that optimise health gains and reduce health inequalities Improved integrated pathways to prevent fragmented services and to provide services that are efficient and effective. Continuous and meaningful engagement with clinicians to inform strategy and drive quality, service design and resource utilisation Management of knowledge and robust and regular needs assessments that establish current and future local health needs Prioritising investment according to local needs, service requirements and the values of the NHS Effective stimulus to the market to meet demand and secure required clinical, and health and wellbeing outcomes

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Promoting and specifying continuous improvements in quality and outcomes through clinical and provider innovation and configuration

data is needed to create an effective database.

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• Procurement skills that ensure robust and viable contracts

Carry out a Comprehensive Needs Assessment on the health needs of homeless people, identifying existing service provision, barriers to care and gaps in service provision

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Effective management of systems and work with partners to ensure contract compliance and continuous improvements in quality and outcomes

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Have a multidisciplinary steering group to advise on health and homelessness with quarterly meetings and an annual review

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Engage with, and obtain evidence from, partner organisations - to discuss meeting multiple and complex needs, and pooling budgets, in order to meet needs, and to map existing pathways and funding streams

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Engage with service users regarding the design of service provision

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Identify relevant models of service provision.

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Making sound financial investments to ensure sustainable development and value for money (RSPH 2009)

Good practice for commissioners

Commissioners must have adequate data and analysis to incorporate the needs of homeless people in to the commissioning cycle. Homeless people are some of the most vulnerable people in society and must benefit from local health care provision. They must also be able to shape health care services in order for their needs to be met, and to see an improvement in their health and wellbeing. Preventing ill health and the promotion of health and wellbeing are key for both immediate and long term health improvement.

Skills for nurses involved in commissioning

Nurses hold a wealth of information and experience that contributes usefully to the commissioning process. Nurses already involved So commissioners should: in commissioning in primary care trusts in England use a unique set of skills and knowledge to inform • Know the local homeless population the commissioning process, and help to achieve – numbers and need - obtaining data the desired outcomes for local people. from local GP systems, hospital data sets (to identify high cost individuals), Can you think of what this unique set of locations used by homeless people, skills might be? Write a list of them. provider agencies working with homeless people, accommodation Your list might have included some of the data such as hostels and night shelters, following: and from local authority commissioned services. Both qualitative and quantities • Leadership skills

‘For commissioning to be effective and achieve its desired outcomes, a set of ‘commissioning competencies’ must be in place.’

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Negotiating skills

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Assertiveness skills

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Negotiation skills

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primary care

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housing, social services

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emergency services

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voluntary sectors agencies

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public health workers

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Creative and innovative thinking

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Strategic and objective thinking

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An understanding of the commissioning • cycle

Good practice for health care providers

Good commissioning needs to be matched by good practice in the organisations that provide health and well being services to local people. These organisations are as much part of the commissioning cycle as the commissioners, and have a profound influence on the quality of care experienced by local people. Provider organisations should identify the needs of the clients from a public health perspective – health needs assessment should be carried out to identify the client group, their health needs, morbidity for the client group, service provision, gaps in service provision, partners, good practice locally and nationally, care pathways. Health Equity Audits should be carried out as they are used to identify and address inequalities, focusing on how fairly resources are distributed in relation to the health needs of different groups. It enables a systematic review of inequities in ill-health and in access to effective services. Forming a multiagency board of providers working with homeless people locally could provide evidence of need for the commissioners, and drive forward the development of an integrated service. Key partner agencies should reflect the broad spectrum of needs of homeless people and the wide range of agencies involved in their care, Think about which agencies are involved. Write a list of them. Your list might have included some of the following:

service users themselves.

Consultation with service users is key to understanding their health problems, their experience of accessing health care, the barriers to care, gaps in service provision and the kind of services they would like. It is useful to employ a wide range of approaches to engage with homeless people, including the use of advocates and health trainers, and training ‘expert patients’ from within the client group. Providers should always consider using a case management approach to chronic disease management, as many homeless people have long term conditions.They should also work to develop referral and care pathways, policies, protocols so as to promote access to services and continuity of care.This should not however preclude a focus on prevention, health promotion and screening for homeless people, to allow early identification of problems and to maximise their health. Staff support and development in provider organisations is essential if they are to provide high quality, effective services. This includes training (professional, mandatory and skills development), leadership development, specialist supervision for what is complex and often stressful work, and mentoring. The practicalities of funding for office space, administrative support, clinical space, equipment, stationary and venues for meetings and training can be challenging to provider organisations, but will make the service more efficient and effective, and therefore costeffective for the commissioners. Finally, providers should carry out their own

equality impact assessments and social audits that include homeless people, rather than relying on those carried out by commissioners. This information can be fed back in to the commissioning cycle to ensure that high quality services are maintained, and service gaps filled, to improve homeless people’s health.

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rough sleeping/insecure housing status

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family breakdown

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substance misuse

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lack of social support

Part 2: Multi-agency working

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lack of work

Part 1 looked at good practice in commissioning access to benefits services for people who are homeless. Parts 2 and • 3 will go on to look at service provision, focusing vulnerable adult/child protection issues in particular on effective multi-agency working as • a vital ingredient. Part 2 will look at some of the crime. rationale, benefits and risks of the multi-agency • approach, aiming to help you to: Many of the most vulnerable people may face • appreciate the importance of multi- several of these issues at one time. Just looking at this list shows that it is impossible to meet these agency working needs without all services working together. • understand the methods and tools that Effective support for homeless people to break the cycle of disadvantage therefore requires a can be used to build multi-agency working and overcome any barriers and multi-agency approach. challenges. As we saw in previous modules, homelessness Rationale, benefits and risks: why the multi- can both create mental health problems and exacerbate those that already exist. In one agency approach is crucial third of cases, losing a home is associated with We have seen in previous modules that homeless mental health problems (Craig et al 1995). Many people are an extremely diverse group who suffer people have multiple needs – for example, mental severe and complex health problems - and are health and substance misuse issues. People thus one of the most vulnerable groups in our sleeping rough have a rate of physical health society. Despite the increasing knowledge of the problems two or three times greater than the extent of their difficulties, they still experience general population (Randall and Brown 1999). substantial barriers to accessing health care. The average life expectancy of rough sleepers These barriers compound their health problems, is only 42 (Crisis 1996). Homeless children and can present roadblocks to their routes out are up to four times more likely to experience of homelessness. mental health problems; have a history of low birth weight, anaemia, dental decay and delayed Homeless people present with multiple health immunisations; be of lower stature; and have a needs and multiple issues that also affect their greater degree of nutritional stress. They are also physical and mental health. These can include any more likely to suffer accidents, injuries and burns or all of the following: (Harker 2006).

‘In one third of cases, losing a home is associated with mental health problems.’

Yet homeless people frequently experience great difficulties in accessing health care. They are 40 times more likely to not be registered with a GP, yet four times more likely to use Accident and Emergency than the general population (Crisis 2002). Many mainstream healthcare providers lack knowledge of homeless health issues, impacting adversely on the continuity and quality of care and on the appropriateness of access and discharge arrangements. As a result, the people most in need of good quality, responsive health care are often the least likely to receive it, exacerbating their health problems and blocking routes out of homelessness.

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The needs of the whole person can be met – including health, housing, finances etc.

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A person-centred approach can be achieved, taking into account the needs, wishes and aspirations of the homeless person, not just the way the service wishes to work.

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Access to, use of and choice of services is maximised.

• Poor health for homeless people is not inevitable, however. Better health and life outcomes can be achieved. Multi-agency working can enable holistic • services that meet homeless people’s multiple • needs. Take a moment to think about some of the benefits that a multi-agency, holistic approach can bring – both to homeless people • and to healthcare practitioners. Note these down now.

Information can be shared, enabling services to support people more effectively.

Your list may include the following benefits for • homeless people:

The cycle of disadvantage can be broken at last. For example, if a person’s mental

Continuity of care is improved. Information is recorded only once, saving time, reducing frustration and preserving dignity. Dealing with people’s needs are more effectively leads to improved quality of life, health and emotional wellbeing.

health problems are treated in tandem with new housing provision, the person can be housed with less chance of losing the tenancy due to a • relapse. Your list may include the following benefits for healthcare practitioners:

authorities about local needs. Failure to safeguard children and vulnerable adults Now think about the risks if there is no effective partnership working.

Given the often extreme vulnerability of homeless adults and homeless children, there may be serious concerns for their safety if there is no effective multi-agency working. Guidance about safeguarding children and vulnerable adults must be taken into account and their needs must be assessed and planned for. (This will be discussed in more detail in Module 3.)

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Efficiency is improved and time is saved.

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The quality of information is better: all services involved can share more information and be better informed locally about the multiplicity of homeless people’s needs.

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Improved planning: services are in a far better position to plan how to Boxes 5.1 and 5.2 below give two examples of meet those needs – and to work what can happen when effective partnership working is not in place. together to meet them.

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Resources can be shared, building capacity into agencies - by working together each service can find ways to fill their own gaps.

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Risks can be assessed more accurately.

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One set of notes makes life simpler and enables easier access to information.

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The importance for homeless people of contacting health services at an early stage – and of the different contributions health practitioners can make – can be raised at early on.

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Data collected through multi-agency working can be used for Joint Strategic Needs Assessments, commissioning, monitoring, research, local evidence and discussion, and to make representations to regional and national

Box 5.1: A vulnerable mother and children A mother with mental health and drug problems flees her home with her children because of domestic violence, and stays with different friends. Her ex-partner discovers her locations, which puts the family at more risk, leads to more moves and makes it harder to monitor their needs. Without effective informationsharing and partnerships between housing, health, social care and police, vulnerability is increased. This could lead to neglect, abuse, serious harm or even death. Box 5.1: A vulnerable single homeless adult A man with mental health problems is housed but with no effective health and social care support, leading to a failed tenancy. He returns to rough sleeping, and is vulnerable to suicide and serious risks to his health and wellbeing.

‘Without effective information-sharing and partnerships ... vulnerability is increased. This could lead to neglect, abuse, serious harm or even death.’

Failure to meet homeless people’s needs

Without effective multi-agency working, services will simply not be able to meet homeless people’s needs effectively. Homeless people present with a variety of needs, many of which interact and contribute to each other, sometimes causing problems to spiral. Dealing with only one of these needs will not effectively resolve the problem.This can lead to deterioration in health and wellbeing, • and a lack of access to life chances.

Inappropriate use of services

Without effective liaison between health and other services, and in the absence of services that effectively meet the needs of homeless people, a revolving door can be created. This means that clients repeatedly attempt to use services, but the services never successfully meet their needs.This • is extremely costly financially, in terms of heavier use of Accident and Emergency and hospital beds. It is also costly in terms of the wellbeing of the person, who may be repeatedly frustrated, disappointed and disillusioned or feel devalued – and never have their needs met.

Methods and tools for multi-agency working

Forming long-term,mutually beneficial partnerships through building relationships and joint working arrangements is the way forward. Nurses and other professionals working with homeless people often already know about reaching out to people who are traditionally seen as hard to engage. Their excellent and often advanced skills in communication will be transferable and highly beneficial in partnership working.

make your interaction with them as tailored to their needs as possible. If possible, find out first how they work and their needs through discussion with colleagues, reading information, informal discussions with contacts, etc. Remember, this will benefit you and your aims in the long term. Find ways to communicate and demonstrate to potential partners how your work connects with theirs – this means showing how working with you will make a key contribution towards them meeting their objectives and priorities (CSIP 2006). Allow time for, and prioritise, the establishment of trust in forming new partnerships, as there may be initial issues to resolve. Be prepared to understand the other partner’s point of view and be prepared to give as much support as you can. For your part, be as proactive, clear, consistent, reliable and honest as you can. Be aware of your own boundaries and make these clear to the other partner - for example, when are they able to get hold of you what meetings you can attend, etc.

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Agree ways in which client information can be shared. This could be a key stumbling block, given the different rules of each agency.

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Ensure that the roles of staff are clear and understood.

You may already have some experience of partnership working. Think about how • you went about building the relationships. What worked well? What were the main challenges? What would you do differently if starting afresh?

If you are considering beginning a formal partnership to deliver a service (such as a social enterprise):

o If you are considering beginning both informal and formal partnerships, here is some good advice.

Involve key potential partners at the beginning of the planning process, so that there is joint ownership and involvement.

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Create a ‘win-win’ situation by developing a set of joint aims and objectives that

Just as you reach out to ‘hard to reach’ o client groups, reach out to services by going to them where they are, and

complement those of each partner agency.

with? More information on the models described is listed in the Resources section at the end of o Clarify the roles and responsibilities of the learning pack. each partner; governance arrangements; how the service will be evaluated; and The Leicester multidisciplinary team model what the outcomes and measurements There has been a homeless service in Leicester will be. Ensure you know who will since 1990. In 1998 a comprehensive needs be making decisions and how, and assessment, which was presented to the then secretary of state, identified the multidisciplinary who will be accountable. team (MDT) approach as undoubtedly the most o Set up a steering group to provide the appropriate to address multiple and complex service with access to appropriate needs, and as one of key ingredients. advice and support (see Section D: The MDT of representatives from health, social Learning Resources). care, homelessness providers and more, meets Take a moment to think about the skills weekly, funded by Leicester City Council. It you will use and develop in setting up employs a 0.5 Grade 2 administration worker and practising multi-agency working. Note them who takes minutes at meetings, writes them up down now. and circulates them, maintains the MDT meetings’ organisation and liaison, maintains the database You may have included the following: and submits an annual report. •

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advanced communication skills The team uses three forms specifically designed (developed through work with a highly for multidisciplinary use (all available on the vulnerable group) QNI/HHI website). These cover new cases, client reviews and closure of cases. This approach assessment skills (as above, developed to provides opportunities to discuss difficult issues, a high level) and ways to agree actions and follow-up.The case study below describes how the MDT approach management skills works in practice.

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project management skills

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case conferencing skills.

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Models of multi-agency working

This next section reviews some methods and tools practitioners have used to set up and maintain multi-agency working. Read them through and think about their applicability to your own area of practice. Which, if any, do you have experience of working

In Practice Case study: a single homeless adult The Manchester Homeless Families’ Team The Homeless Families’ Team is part JohnManchester had multiple needs, including: of a multi-agency team in Central Manchester and healthplace visitors, nursery nurses and • includes no settled to stay, sometimes a part-time nurse. It provides a city-wide service sleeping rough, sometimes on friends’ and takes referrals from Manchester Housing sofas Department. It works closely with housing and services health services • social mental healthteams, problems, including and midwives. Although not lone the team suicidal thoughts andworkers, anger problems

‘Nurses ... working with homeless people often already know about reaching out to people who are traditionally seen as hard to engage.’

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alcohol issues pain in his feet caused by his toenails not having been cut for a long time loss or theft of his cash – and it was two weeks until his next benefits payment poor nutrition generally suicidal thoughts,

John visits Norma, the nurse at his day centre. She treats his feet, refers him to another centre where they can give him a food bag that day, and gives him advice on nutrition. She asks him for consent to bring his case up at the weekly multidisciplinary meeting. He agrees. Norma also makes sure she knows how to find John, taking his mobile number and the number of his friend who is supporting him. At the MDT meeting later that day, Norma raises John’s case and achieves the following results: • referral to hostel for a room, and long-term housing assessment • referral to the Dual Diagnosis Team - with particular regard to suicidal thoughts • referral to special personal care service for foot care • an immediate crisis loan if Norma ensures he completes the form, and cash payments to be weekly in future • the homeless day centre agrees to encourage him regarding nutrition. The Manchester Homeless Families’ Team The Manchester Homeless Families’ Team is part of a multi-agency team in Central Manchester and includes health visitors, nursery nurses and a part-time nurse. It provides a city-wide service and takes referrals from Manchester Housing Department. It works closely with housing and social services teams, health services and midwives. Although not lone workers, the team

members face many challenges, with several hundred families in temporary accommodation in Manchester at any time, often with complex needs, constant changes of address, and many leaving temporary accommodation without a forwarding address.

‘Notify’ - London’s notification system to track homeless families Notify was developed following the recommendations of the Laming report into the death of Victoria Climbié. Police, education, health and housing are all notified when a family registers as homeless. Every relevant agency is notified when families move, even out of the borough. Particular concerns are flagged up, for example, disability, child protection or domestic violence. The worker receiving the notification contacts social services, who hold the information.

or even simply to attend meetings with other agencies. Some managers may have concerns about allowing staff to attend such meetings and liaise in this way, given staff workloads.Yet investing in the time to liaise with partners is frequently the key to resolving the very issues that confront homeless people and those who work with them, given the multiplicity of people’s needs.

Making a business case to support multi-agency working is one way forward, as is using multiagency working as a way to help you meet your targets and others’. Being aware of the benefits of The multi-agency risk conferencing model multi-agency working, and the risks of not doing (MARAC) it, is key. Pioneered in Cardiff in 2003, MARAC combines risk assessment with a multi-agency approach to Different organisational cultures help high-risk victims of domestic abuse. Bringing Different organisations have their own cultures, together 16 agencies, including police, probation styles of working and limitations. It can be hard services, the local authority, health, housing, refuge for partners to understand the points of view and the women’s safety unit, the conferences of other organisations. Within professions there provide a forum for sharing information and can be significant differences in cultures, such as taking action to reduce future harm. Conferences those between general and mental health nurses, were initially held monthly in Cardiff but are now and between sectors such as health and housing fortnightly, each covering about 20 people and services the gap can seem as wide as the ocean. families at high risk. People may not even realise what they need to explain to the other service, as they are so used Overcoming challenges to multi-agency to their own culture. Some ways of working may seem obvious – but not to an outsider. Meeting working The next section looks at some of the main face-to-face, regular contact via phone and email, challenges involved in multi-agency working and dialogue, discussion, being prepared to explain the how to overcome them. You will already have obvious, and willingness to listen are good ways identified some of them, either through past to resolve these issues, as well as an open-minded experience of your own or through anticipating and creative approach to problem solving. difficulties that could be involved. They include Different priorities the following: Different organisations have different aims and objectives and work towards different outcomes. Time Time, or lack of it, is a common barrier to multi- Again the solutions are dialogue and discussion. agency working. Practitioners can feel trapped by their workload and day-to-day issues, lacking If you are setting up a partnership, consider how the time, knowledge and confidence to do the your priorities are similar as well as different. necessary proactive work to set up partnerships How can you each contribute towards meeting

‘Notify was developed following the recommendations of the Laming report into the death of Victoria Climbié.’

each others’ priorities? You will often find that • by working together you make better progress • towards your own objectives than if you had worked alone. • Sharing information Different services often have different rules on • sharing information. Sharing information with the police and other services can often be challenging. • Again, dialogue, discussion, and using consulting guidance are ways to resolve this. Examples from other services where information is shared can • be helpful. •

Key partners and drivers in multi-agency • working Who are the key partners in multi-agency working? Ask yourself the following • questions: • • Which local agencies are essential for a • service to succeed and survive? • Which local agencies would have important experience or perspective to • bring to the service?

substance misuse teams dual diagnosis teams primary health care services – including GPs, practice nurses, dentists, pharmacists TB nurses generalist and homelessness health visitors school nurses environmental health departments district nursing teams tissue viability services safeguarding children boards benefits – e.g. job centres, disability benefits centres local advice centres such as citizens’ advice bureaux

Make a list of your potential and actual partners. • You may already be engaging with these agencies • daily.

national advice services, e.g. Connexions

Your list may have included many of the • following: • • housing department

public health services

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the police

third sector organizations, inlcuding faith organisations and community groups local businesses relevant to your area of work

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social services

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education (both child and adult, • depending on client group)

refugee and asylum seekers’ groups

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homeless day centres

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interpreting and advocacy services.

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homeless hostels

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This list is not exhaustive and there are many different agencies in different localities, including mental health services – including small community groups that could be vital to community mental health teams, crisis your work. teams, assertive outreach teams, CAMHS teams, counselling services

Key drivers of multi-agency working

better informed about policy developments in their area. Health may not be on the agenda: your attendance would be a chance to raise the health needs of homeless people as a crucial component of this work. Contact your local council or umbrella voluntary organisation to find out more.

Many policy initiatives and approaches introduced in recent years have contributed to multi-agency working, and can be used to strengthen and facilitate the multi-agency approach. It is important to understand why they are there, how they work and how you can get involved, while recognising that they may change, evolve or disappear as local Joint Strategic Needs Assessment and national policies and priorities change. The Joint Strategic Needs Assessment (JSNA) is seen as an essential, and now statutory, support Local Area Agreement (LAA) These are three-year agreements between central to effective commissioning. It is a key means government, the local authority and its partners by which commissioning bodies describe the in an area, e.g. health services, to improve public future health, care and wellbeing needs of local services. LAAs set out the priorities agreed populations, in preparation for LAAs and to between central government and a local area (the inform locality commissioning strategies. As such local authority and Local Strategic Partnership) it is a vital opportunity to find ways of ensuring and other key local partners.The aim is to simplify that homeless people are considered in local some central funding, help connect public services assessments of health need. Contact your local more effectively, and allow greater flexibility for commissioning body and ask how you can feed local solutions to local circumstances. Through into this process. these means, LAAs are intended to devolve decision-making and reduce bureaucracy. (See Common Assessment Framework (for children) The Common Assessment Framework (CAF) is a Section D for more information). key part of delivering frontline children’s services in England that are integrated and focused Local Strategic Partnership (LSP) To engage with the LAA for your own area, get around the needs of children and young people. involved in your Local Strategic Partnership. An It is a standardised approach to conducting an LSP is a ‘partnership of partnerships’ - a non- assessment of a child’s additional needs and statutory partnership which provides a single, deciding how they should be met. Ask your local overarching local coordination framework. It health trust, child and adolescent mental health develops and drives the implementation of service and council how they implement the CAF community strategies and LAAs, and agrees the and what is expected of you. allocation of neighbourhood renewal funding. Contact your local council, which is responsible Common Assessment Framework (for adults) for running the LSP, ask for more information and This was being planned in 2009-2010 election. See www.dh.gov.uk for details of how it will be attend its meetings. developed. Homelessness Forum The Homelessness Forum provides an opportunity That concludes Part 2. We examined the benefits for all agencies and individuals who work with and the challenges of multi-agency working and or have experience of homelessness to share looked at some models currently being used to information, develop best practice and become achieve it.Your objectives were to:

‘Sharing information with the police and other services can often be challenging.’

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appreciate the importance of multi- address them, or because those who see homeless agency working in delivering people in other healthcare environments do not healthcare services for homeless people have the knowledge and skills to care for them in a timely and appropriate way. • understand the methods and tools that can be used to build multi-agency Frontline health and social care professionals working and overcome any barriers and and can make a very real difference to improving challenges clients’ experiences and achieving positive outcomes, by influencing the quality of care that homeless people receive. This is best achieved by Part 3: The social enterprise model At the end of Part 2, we considered some of the maximising the influence of front line staff.A good models currently being used to achieve multi- way of achieving this is for a group of professionals agency working. The final part of this module to bid for the right to set up a service as a social will focus specifically on the role that social enterprise, as described below. enterprises can play in delivering health services for homeless people. You should aim to achieve According to the Social Enterprise Coalition, social enterprises are businesses driven by a the following learning outcome: social or environmental purpose. There are 62,000 of them in the UK; they contribute over • appreciate the social enterprise model £24bn to the economy and employ around as an effective way of achieving 800,000 people. Like all businesses, they compete multi-agency working. to deliver goods and services, with the difference that social purpose is at the very heart of what Business with a social purpose As we have seen, some homeless people are they do, and any profits they make are reinvested among society’s most vulnerable and excluded towards achieving that purpose. Social enterprises people and often present to healthcare services operate in almost every industry and sector, from with multiple and complex needs.These needs are health and social care to renewable energy, retail often ignored or missed, however, either because to recycling, employment to sport, housing to specialist services do not exist to identify and education.Whatever they do, they do it differently

from a typical business because they are driven and empowerment of staff and service users to by a social and/or environmental mission, and are devise new, effective ways of delivering services, focused on the community they serve. as seen in two organizations it visited - Central Surrey Health, and the third sector Goodwin Can you think of any well-known Development Trust in Hull. Both have strong examples of social enterprises outside nurses in leadership roles and link well with other the health and social care sectors? nursing and midwifery leaders. The Commission also noted the growing evidence of the many Examples you may have come up with include benefits of employee engagement, which in turn The Big Issue magazine; Jamie Oliver’s restaurant facilitates transformational leadership (Ellins and Fifteen; and the fair-trade chocolate company Ham 2009). The principles and lessons learned Divine Chocolate. are relevant to all organizations, not only those formally labelled as social enterprises. Social enterprises have been slow to take root in the NHS and many staff wrongly associated them Central Surrey Health, the first employee-owned with privatization. Previously, NHS staff wishing social enterprise in the NHS, is an award-winning to set up a social enterprise did so through the co-owned business that provides community ‘right to request’ initiative, which gave them the nursing and therapy services to a population of right to ask their primary care trust to start a 280 000. It combines the people-centred values health service delivering social enterprise. This and principles of the NHS with the drive of a scheme was abolished in 2010, however, as successful business. Its mission is to ‘revolutionize part of the planned abolition of PCTs, although healthcare in our community by bringing new solutions all applications currently in progress will be to old problems and working tirelessly to improve honoured. health standards for all.’ At the time of writing it was not known what scheme would replace this, but the Department of Health (England) has confirmed that its proposed localism bill will include greater rights and opportunities to set up social enterprises. The concept chimes well with the 2010 Coalition government’s ideas on ‘Big Society’.

To achieve this it stands by three core principles. First, it operates as a social enterprise. Second, it is co-owned by its employees. All its nurses and therapists own a 1p share in the business and have a real and equal say in how it is run. This is motivating and engaging, and has helped create an open, honest, can-do culture. Third, clinical leadership is at its heart. Its senior management What advantages do you think the and clinical team are all nurses or therapists, so social enterprise model might bring to people in touch with service users’ needs are in a homeless health service? Note these down charge of providing and developing services. before reading on. The box below describes how the Leicester The social enterprise philosophy was advocated Homeless Healthcare Service was established as by the Prime Minister’s Commission on the Future a social enterprise. of Nursing and Midwifery in England (2010), as ripe for nursing and midwifery leadership. It said social enterprises stimulate engagement

‘There are 62,000 social enterprises in the UK; they contribute over £24bn to the economy and employ around 800,000 people.’

In Practice: Case study: Setting up a social enterprise Jane Gray, director of nursing and development at Inclusion Healthcare Social Enterprise CIC, exercised the Right to Request to become a social enterprise on behalf of Leicester Homeless Healthcare Service (LHHS) in 2009.The catalyst was the potential threat to the specialist general practice for single homeless people where she worked. It was being subjected to market testing and options appraisal as part of the local PCT’s separation of commissioning and providing services. ‘We feared that we might be integrated in a larger organisation that wouldn’t understand the importance of our work and our patients’ needs, that our service would be dissolved and our patients sent to mainstream services, or possibly that our service would be put out to open tender, resulting in the team having little or no control over how care would be delivered in the future,’ says Jane. The decision to run the service themselves wasn’t made lightly, and was taken after the team organised its own options appraisal. ‘It became clear, says Jane, ‘that we could take control of our destiny and run the service ourselves by exercising our Right to Request to become a social enterprise.’ In a secret ballot, all staff voted for the service to become a social enterprise and for Jane and the lead GP to run the service. ‘We were particularly attracted to becoming a social enterprise because they are businesses with a social purpose. It meant we could reinvest any surplus funds back into the business to improve services and also invest in staff training and development,’ says Jane. They employed a project director and project administrator with funding secured from the Department of Health’s Social Enterprise Pathfinder programme, and submitted an expression of interest to the PCT board. Their integrated business plan was approved and after a four-month transition phase the social enterprise went live in 2010. It has Jane and the GP as executive directors and four longer-

serving team members as shareholders, and is supported by a non-executive board. The team comprises 12 members – nurses, doctors, healthcare assistant, specialist alcohol worker, business manager, administrative support and receptionist. ‘This journey has been one of the most challenging, intensive, exhausting yet empowering and rewarding experiences of my career to date,’ says Jane. ‘I am convinced it was the right decision and I encourage fellow nurses to consider this as an option when looking at ways of meeting the needs of homeless people and other marginalised and vulnerable groups. ‘Being part of a social enterprise enables nurses who have flair and passion to make a very real difference to the patients they serve. Working at the point of delivery in a social enterprise enhances our ability to make changes to services in real time, which relieves the frustration nurses often feel and addresses patients’ needs promptly. Nurses must recognise that they are not only skilled clinicians with varying degrees of management experience, but also successfully run their family homes and manage other aspects of their lives outside work with great skill. I reminded myself this many times as I responded to the challenge of learning new skills to develop the expression of interest document and the business plan.’ Jane urges entrepreneurial nurses to consider and recognise the value of setting up a social enterprise and its benefits for patients. ‘Do your homework, read as much about social enterprises as you can and talk to those who can provide practical, financial and mentoring support. It is no easy option, and requires the ability to continue business as usual while dedicating time and energy to making the dream into a reality.’ The prospect of running a company is both terrifying and exciting. If you asked me if I would choose the same path if I knew then what I know now, the answer would still be yes - and in some ways I wish we had done this sooner!’, she concludes.

This concludes Part 3, the final section of this module. We have seen how the social enterprise model can provide real benefits in allowing the establishment of service delivery that is specialist, targeted, flexible and independent, and enables and empowers front-line practitioners to lead change.

This may include increasing your level of service user involvement, starting to collect a particular kind of data, and recording some of your stories and case studies and using them to demonstrate the value of your service. •

What will I stop doing as a result of reading this module?

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Could a social enterprise model work for • your service?

What will I do differently as a result of reading this module?

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What risks or constraints are you You may decide to change the way you run currently operating under that might be consultation groups, or borrow an example of service user involvement from another agency helped by a social enterprise model? or area of practice. What would the particular risks and challenges be in your locality? Make a note of the action points you decide on, and set a target to review these in a few months’ time.

Take some time to reflect on what you have read. Consider the following For example, you may be collecting unnecessary points: data.

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Conclusion to Module 5

You have now completed Module 5. Go back to the learning outcomes and reflect on whether you feel you have met them. You may want to do some further reading to support the material here; resources for this are listed in Section D. Make a note of any points you feel you want to follow up.

This completes Module 5. We hope you found it valuable. The next module in this learning pack, Module 6, will look at your professional and personal development needs as a practitioner in the field of homeless health care.

Self-assessment exercise Take some time to reflect on what you have learned through working through this module, and how it relates to your practice. Try to answer the following questions, giving at least three points, as practical as possible, in response to each: •

What will I start doing as a result of reading this module?

‘If you asked me if I would choose the same path if I knew then what I know now, the answer would still be yes and in some ways I wish we had done this sooner!’