Embedding health and wellbeing opportunities for people experiencing homelessness in a wider support system.
Introduction
A collaborative project by the Plymouth Soup Run, The Plymouth Alliance and the University of Plymouth created a novel context and effective partnership of providers from the academic, statutory and voluntary sector to support people experiencing homelessness. Through Saturday morning sessions managed by representatives of the Soup Run and the Plymouth Alliance partners Shekinah and Plymouth Access to Housing (Path), and hosted by Shekinah, rough sleepers and people in emergency accommodation were able to come into a safe and calm space, have a cooked breakfast, a shower and change of clothes, meet health practitioners, get advice on housing issues, and join in recreational activities, or simply relax. The sessions brought services to clients rather than the opposite, and offered support in a familiar and trusted setting at a time outside normal Monday-Friday ‘9-5’ service schedules.
The case study links to the following inclusion health draft principles:
1) Commit to action on inclusion health.
2) Understand the characteristics and needs of inclusion health groups locally.
4) Developing integrated and accessible services for inclusion health.
5) Demonstrate impact and improvement for inclusion health.
1-4. Permissions:
We have the necessary permission to share the study and have anonymised any individuals. We give permission for NHSE to share this case study and publish it as part of the framework, including use of logos as displayed here.
5. Organisations:
The case study involves the following lead organisations plus the University of Plymouth and a range of statutory and third sector service providers who joined the project on a voluntary basis:
The Plymouth Soup Run is a community voluntary service established some 25 years ago. Every night of the year, it provides free food, hot drinks, clothing, toiletries and sleeping bags to people experiencing homelessness, poverty and severe disadvantage. It lends a non-judgemental listening ear and also signposts people to appropriate services (e.g. housing support, healthcare). It offers a lifeline to Plymouth’s most vulnerable people.
The Plymouth Alliance was set to coordinate a complex needs system which will enable people to be supported flexibly, receiving the right help, at the right time, in the right place. Alliance partners provide housing advice and support, access to temporary and settled accommodation, treatment and support regarding substance use, including prescribing. The partners, Shekinah and Path, as below, plus 5 other support organisations commissioned by Plymouth City Council aim to improve the lives of people with complex needs, supporting the whole person to meet their aspirations and to participate in and contribute to all aspects of life.
Shekinah provides opportunities for people who are experiencing all forms of homelessness and other challenges they may be currently facing. Working with key strategic partners, Shekinah supports people to make meaningful changes in their lives and receive specialist support to address any health issues, find and support them in a home of their own and learn new skills.
Plymouth Access to Housing (Path) is an independent local charity based in Plymouth. It was set up in 1995 to support people who are vulnerable to homelessness by providing a range of services from work with rough sleepers through to support for people to maintain their tenancies.
6. The challenge
Homelessness impacts negatively on health, wellbeing and life expectancy. People experiencing homelessness suffer significant mental and physical health problems often in combination, and it is widely accepted that poor health can be both a cause and a consequence of homelessness. More than 7 out of 10 people experiencing homelessness suffer from one or more physical health problems, and an even higher proportion report a mental health issue. Both physical and mental health conditions are much more prevalent than in the general population. The most common physical health issues encountered by people experiencing homelessness include problems with bones and muscles and dental/teeth problems. Severe mental health conditions in the homeless population include major depression, schizophrenia and bipolar disorder, as well as extensive substance misuse. Data also show that they are three and a half times more likely to commit suicide than the general population. People experiencing homelessness are also heavy users of emergency services, exhibit frailty and die 30 years earlier than the general population, and often from treatable conditions. Their severe and multiple disadvantages raise personal and institutional barriers to using health, social and housing services.
People experiencing homelessness are not able to access universal services in an equitable way. Despite their greater needs, responses from health and social care organisations do not always accommodate complexity, clients’ conflicting priorities or multiple comorbidities. Often without a voice or advocacy, they can be deterred by settings where they feel excluded or stigmatised. This community is often described as ‘hard to reach’ but, in fact, it is the services that they need which may be hard to reach as a result of location, accessibility or scheduling constraints. Even when efforts are directed towards delivering a responsive service, capacity issues may mean that they are further disadvantaged.
7. Our approach:
The Plymouth Soup Run encounters clients every night and in all weathers. As the last service regularly out on the streets at night, volunteers are very familiar with the challenges that homeless clients experience, not least the bleakness, loneliness and lack of support that Monday-Friday service patterns impose, especially on rough sleepers and those in emergency accommodation.
A response to this need was piloted in late 2021 by the Plymouth Soup Run and Alliance partners who opened Shekinah’s Centre on a Saturday morning to offer support including breakfast, a shower, and accommodation advice. It quickly became clear that the service would be appreciated by clients, would be well attended and, importantly, that it created an opportunity for wider engagement and support, especially on health and wellbeing matters. This possibility was turned into a reality by the awarding of a 6-month grant from Plymouth University’s Higher Education Innovation Fund (HEIF). The grant enabled a team of partners from different relevant professional backgrounds/organisations and with extensive academic, healthcare and community experience to support a programme of activities with the following aims:
(i) Meeting basic human needs for nutrition, personal hygiene and connectedness.
(ii) Offering weekly engagement opportunities with activities supporting health/ wellbeing, recovery and personal development.
(iii) Providing data to evidence client needs and improve engagement with health/wellbeing opportunities.
8. 9. Impacts, insights and what people said:
Reach and engagement
Over the lifetime of the HEIF project (1st February 2022 and 30th July 2022), total of 174 people accessed the sessions: 25 (14%) women and 149 (86%) men. An average of 19 people attended per week; the vast majority were rough sleepers (59%) or in emergency or supported accommodation (37%). The average number of visits was 3 and the highest number by an individual was 20. There was considerable turnover and diversity in the levels of use. The most frequently attending clients appeared to have a high degree of entrenchment and/or impediments to their accessing accommodation and other support.
Comparison of attendance records with the number of rough sleepers evidenced in the city by Path shows that the reach of the project extended from 59% of rough sleepers initially to 82% by the end of the project. Current figures of attendance to June 2023 remain similar, with 20-25 people accessing the service each Saturday.
Engagement with healthcare providers during the project lifetime varied. Oral health educators interacted with the majority of clients present on any one day, whereas podiatry services or blood born virus testing reached 30-40% of those present. Engagement with mental health peer mentors took time for trust to build but produced some of the most effective interactions reaching around 20% of clients present. Numbers engaging in art activities ranged from two to seven (i.e. up to ca. 30% of those attending), some clients engaging briefly and/or sporadically and others immersing themselves in the activity for a whole session.
Impact
In pursuit of the project’s first aim, the Saturday morning sessions provided a well-staffed, safe, and quiet environment offering social interaction and support for physical needs. Rough sleepers and those in emergency accommodation were provided with a cooked breakfast, other refreshments, and a packed lunch. In addition, they were offered access to bathroom/shower facilities, clean clothing, sleeping bags and rucksacks as well as opportunities for companionship and enjoyable conversations. Through meeting basic needs, the service enhanced clients’ wellbeing and self-esteem through improved hygiene and connectedness.
Clients, staff and volunteers were enthusiastic about the sessions, feeling that they worked well with benefits to all. Time to get to know clients as individuals was appreciated, and clients valued the personalised service and the opportunity to have a “normal” conversation where they felt they could share their views and did not feel they were a “case” to be solved or “a number in a system”.
“It makes a lot of difference to people opening on the weekends. It’s changed my weekend, it’s changed my whole week. It’s left me on a positive note. If I hadn’t come today I wouldn’t have been able to sort out my appointments and I’d have been stuffed.” (Client)
“Yeah if it wasn’t for this place I probably wouldn’t have ate today and would be off doing something stupid.” (Client)
“The Saturday sessions offered clients the rare opportunity to make choices – about food offered, clothing and the possibility of joining in activities.” (Volunteer)
The sessions provided the opportunity for targeted, focused work, rather than reacting to crises. Clients could receive support and advice on accessing housing. Volunteers working in this field felt that it gave them a greater, more nuanced understanding of clients’ situations. The sessions also facilitated the building of links between organisations and supported collaborative working, with wider benefits for clients.
“So actually, quite a lot of situations have been resolved by my attending these sessions and giving them the information they need. I think through Shekinah I’ve been able to [help] quite a lot of people just by giving them the advice and the tools and the things they need to do… which has been good.” (Professional volunteer)
“Having the housing volunteer there on a Saturday means that, if a client is particularly vulnerable, they can be accommodated immediately and don’t have to wait until Monday.” (Staff)
The relaxed atmosphere created by the Saturday team, has clearly created health promotion opportunities as covered by the second aim. It made a great environment for working with people that would not normally engage, thereby promoting increased connection with health and community services by people who experience significant morbidity, mortality and social exclusion. It also promoted partnership working among health professionals.
“What it does identify is that interprofessional relationships are paramount in providing all-round healthcare.” (Visiting partner)
Health-related activities included: general wellbeing advice and treatment for medical issues including injuries by engagement with community outreach nurses; advice on smoking cessation/vaping; Awareness-raising on eyecare; blood-borne virus testing; oral health advice; mental health peer support; and podiatry treatment. As well as one or more of these activities each week there was always access to accommodation/ housing support, and the opportunity to participate in arts and crafts and table-top games.
“Mental health is a huge thing. Having the Heads Count [mental health peer support] people there is definitely good. To show [clients] that there are other things available and get them down to start meetings. I think that's a big, big thing.” (Professional volunteer)
“It’s amazing how you can come down here and have a shower and there’s the ladies with the toothbrushes and toothpaste. Little things that make you feel human again. You get treated as an equal as well which is brilliant.” (Client)
Health assessments and on-site treatment, as well as assistance with transport, promoted prevention and facilitated referral to other healthcare providers plus immediate treatment of conditions that would otherwise escalate and require access to A&E. Information, signposting and engagement with visiting partners increased awareness of health-related issues and available services, and increased client proactivity around health. Clients, professionals and volunteers all felt that the sessions filled an important gap in services.
Creative pursuits appeared to offer a valued activity and provided an opportunity to escape (even momentarily) from everyday concerns and reduce stress. The opportunity to express creativity often gets squeezed out in a life impacted by homelessness, therefore including art and craft activities was experienced as positive and appears to have been well received by the clients. Art sessions also stimulated rich conversations around life experiences and hopes, and opened up possibilities for discussing wider concerns including health. Client feedback revealed appreciation of the distraction from everyday worries and the opportunity to be expressive. It was felt that having an artist who is focussed on letting clients have some leisure time and to think about things creatively was not just a beneficial distraction, but it makes them feel that “they are a person again, that they are human” which is good for their mental health.
“Being able to have an in-depth conversation … and when you get people doing, say, drawing, painting, colouring, it's just amazing what conversations you can have and they talk about their earlier life. They'll talk about their current worries as well. It's just these happenstance conversations. They're just lovely and enable you to really get to know people.” (Lay volunteer)
“I was very, very touched this Saturday, where we had a woman who was very active in the art activity. She gained so much from it. Quite often people find it easier to open dialogue when they're not making that direct eye contact and they're doing something.” (Professional volunteer)
To address the third aim, data were collection by volunteers and professionals, experienced peer researchers and University staff. These, as well as field observations, provided insight and knowledge from diverse perspectives on evidenced needs, peer, practitioner and service provider experiences, and ways of improving client engagement with health/wellbeing opportunities. The project leads, functioning as embedded volunteer researchers, developed the evaluation framework and recorded personal reflective notes. Embedding evaluation into the workplan created learning opportunities and enabled flexibility in service provision to tailor it to clients’ needs and providers’ capabilities.
On-the-ground learning has led to:
- improvements in the delivery of Saturday provision and integration of insights from hands-on service providers, practitioners, peer researchers and service users into activities,
- building of and more effective utilisation of volunteer capacity,
- more effective cross-sector working among volunteers and professionals in different spheres (medical, social care, housing etc.).
The learning is being used to inform local strategies and practice for supporting patients with complex needs. Synthesis with existing research evidence has generated new knowledge and insights that feed into wider service improvements and capacity building, and out to service leaders/funders to advocate for strategic change.
Insights
By definition, all clients needed housing advice, but addressing health issues is an important aspect of supporting clients to come out of homelessness and transition to a healthier and more stable life; the reality that housing is indeed a health need is very clear when working with this community. So, embedding health interventions in a wider support context alongside accommodation advice made sense.
“We can learn about what each of the professionals do, how they work and the pressures they are up against. Can bring that into own daily work and provide a more joined up approach. So the service we deliver has more congruence.” (Staff)
“Building these links allows for the cross-fertilisation of ideas between different individuals and organisations in the city.” (Volunteer)
The needs of the client population are diverse, each individual is unique, calling for adaptation of engagement styles and flexibility to respond e.g. to the anxieties of a meeting a healthcare provider for the first time in many years. Trauma and shame surfaced as issues hanging over many clients. Hence, relationship building was important, as was offering help within a service that clients trusted and found familiar.
Each healthcare session brought learning: above all, the realisation that taking services to people – meeting them where they are, not only physically but also mentally and emotionally – works. The Saturday sessions provided an opportunity to explore and address the low health expectations of many clients, create opportunities for them to engage with healthcare providers, raise their health aspirations, and promote proactivity.
“They are prepared to engage with the voluntary [podiatry] service because it is immediately available to them at the point of their visit to the soup kitchen. I am not sure they would all go out of their way to seek or engage with other outreach services if it wasn’t so convenient for them or know where else to look.” (Visiting partner)
“The relaxed atmosphere created by the soup run team at Shekinah makes a great environment for [blood-borne virus] testing people that would not normally engage.” (Visiting partner)
Clients have a range of health care needs that often reach a critical point due to difficulties in accessing routine care. Embedding care in a service that targets this population group’s specific needs was identified as crucial in halting deterioration and averting preventable health conditions.
“I’ve seen the nurses and the podiatrist and [been referred to] the doctor, they are very good. Otherwise, it’s difficult to see the health professionals because have to go up to [the local hospital] and when you’re disabled it’s hard to get around … getting on and off the bus with crutches is difficult.” (Client)
Limitations
Not all healthcare needs could be met at the Saturday sessions, so the possibility for onward referral and signposting was an important aspect of the healthcare activities. Clients were successfully connecting with GP services, A&E and mental health peer support groups. However, participating dental professionals felt that whilst they were able to demonstrate self-screening for oral cancer and deliver oral healthcare messages, there remained a need for immediate acute intervention. In response, a mechanism has been set up to refer urgent cases to a specialist Community Dental Clinic for disadvantaged patients.
Findings have been published in an academic paper:
10. Tips and lessons:
A cost-effective approach: There is a minimum cost to providing the service described here but a small investment to cover essentials, combined with flexible working on the part of salaried professionals and significant leveraging of volunteer time and value, can enable an impactful and highly cost-effective service to be provided.
Supporting the workforce: Staff and volunteers, particularly those with lived experience, should be provided with appropriate support to ensure their wellbeing and a consistent service for clients, within a wider trauma informed approach.
A multidisciplinary integrated approach: We recommend that health issues, not least mental health, gain a higher profile in the range of support services provided to people affected by homelessness, through co-location of services, and increased collaborative and integrated working. A model of this approach can be seen in the recently established Health Inclusion Pathway, Plymouth (HIPP), which coordinates care across outreach, primary, secondary and emergency care, social care and housing services for people experiencing severe and multiple disadvantage.
Data collection and evaluation: Any service being started up could benefit from embedding evaluation into the workplan to create learning opportunities. Such an approach could use flexibility to enhance the service offer, tailoring it to meet clients’ needs and providers’ capabilities, and further promote positive relationships with partners. Effective evaluation and learning can also lead to practice improvement and capacity building.
11. What next:
On completion of the project funding in August 2022, the Saturday sessions have continued with a core of volunteers, flexible working by housing staff, and a year’s funding for essentials from Plymouth City Council. Health inputs continue to include fortnightly podiatry clinics, occasional GP and nurse sessions, regular mental health peer support, and dental clinic referrals. Clients are also supported to access wider primary and secondary care health services including through help with transport. Outside the framework of the sessions but stimulated by them, discussions are underway for collaborative activities on health issues including eyecare and smoking cessation. Regular art sessions continue to provide a significant means of engagement and a creative outlet for clients.
In the near future, the host organisation (Shekinah) will relocate to a new building with enhanced facilities for support activities and medical services. This will provide the opportunity to review health and wellbeing inputs to the Saturday service, including continued close collaboration with the HIPP programme.
A full evaluation report is available upon request.
For further information or to receive a copy of the report please contact:
Martha Paisi: martha.paisi@plymouth.ac.uk
Lyndsey Withers: lyndsey.withers@btinternet.com
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