Outreach Inclusion Health Provision for those who are homeless or vulnerably housed in Somerset.

Outreach Inclusion Health Provision for those who are homeless or vulnerably housed in Somerset.

In Somerset we recognise that people who are homeless or vulnerably housed experience some of the most severe health inequalities and report much poorer health than the general population. Many have co-occurring mental ill-health, drug and alcohol dependence and physical health needs, and are likely to have experienced significant trauma throughout their lives. We know that people who experience homelessness are also likely to sit within other inclusion health groups definitions including drug and alcohol dependence, being vulnerable migrants, Gypsy, Roma and Traveller communities, sex workers, people in contact with the justice system and victims of modern slavery.

Supporting the needs of this cohort is complex and we know that this complexity often proves too challenging for both the client and the systems in place to deliver good Health, Wellbeing and Housing.

Since 2019 Somerset has fundamentally reframed homelessness from a housing issue to one of health and wellbeing. This has been achieved as a consequence of developing long term, trusting, professional relationships with colleagues in Somerset from the NHS, Public Health, VCFSE sector and local government who together as part of a wider piece of work (Better Futures), have successfully developed an approach to meeting the health needs of some of the most vulnerable adults in our communities.

We have:

• Reframed ‘Homelessness’ from a ‘housing’ issue to one of a health and wellbeing concern for Somerset – a cultural shift supported by the Somerset Health and Wellbeing Board
• Worked with the LGA to develop the Somerset ‘Better Futures’ programme.
• Authored and adopted ‘Improving Health and Care Through the Home in Somerset’ - A Memorandum of Understanding’ (MoU)
• Galvanised system wide commitment to implement our Homelessness Reduction Board (HRB) approach for Somerset – which now owns and drives the Better Futures Plan.
• Capitalised on ‘Everyone In’ to pursue the WHO aim for the eradication of the hepatitis C virus (HCV) by offering dried blood spot tests to hostel residents, screening for HCV and subsequent treatment where required.
• Supported innovation and secured NHS HEPP funding with which to pilot a needs-assessed Homeless Nursing Team which has now been adopted as BAU for Somerset (see below)
• Pursued a comprehensive Covid-19 protect and vaccinate offer using a range of approaches including:
  • GP in-reach
  • GP out-reach
  • Bespoke NHS Vaccine team sessions at community and accommodation settings and surgeries in all districts.
  • Vaccine Centre extended opening

Our vaccine and monitoring approach was cited by OHID as an example of good practice to other areas within the SW.

• Delivered bespoke Health Protection training to accommodation and support providers.
• Commenced Oral Health Prevention and Treatment development activity.

This activity demonstrates a system wide commitment to ALL five inclusion health draft principles:

1) Commit to action on inclusion health

2) Understanding the characteristics and needs of inclusion health groups locally

3) Developing the workforce for inclusion health

4) Developing integrated and accessible services for inclusion health

5) Demonstrating impact and improvement for inclusion health

Since 2021, as part of this incremental system wide response we have embedded or established:

• Specialist Outreach Health Inclusion GP provision (Core NHS funded GP in Taunton (1 day per week) and Yeovil (1 day per week) with an additional short term funded GP offer in the Mendip area (1.5 days per week).
• The introduction of a countywide specialist Homeless and Rough Sleeper Nursing Service (HRSNS) following a successful NHS Heath Equalities Partnership Programme pilot. ( Homeless and Rough Sleeper Nursing Service for Somerset - Homeless and Rough Sleeper Nursing Service for Somerset (somersetft.nhs.uk) ) comprising a Clinical Lead, 4 x Band 7 Nurses, 4 x Health Link workers and 1 x Administrator
• Additional specialist MH Nursing and Peer Support provision utilising NHSE Long Term Plan funding (the new posts sit within the HRSNS). 2 x Mental Health Nurse and 2 x Peer Support workers
• Somerset Inclusion Health Practitioner’s forum where professionals working in this arena can meet and discuss current issues, challenges and learning with a view to embedding a wider team ethos.

Working together, the Nursing Service and specialist GP’s, are now very much the vanguard of health provision for the homeless inclusion health cohort – a group of adults whom we know experience significant difficulty accessing health care which is further exacerbated by the rural nature of the county.

We are confident we are now meeting previously unmet need and can evidence significant increases in case finding and supporting clients to successful health outcomes or improved health care.

Initial analysis of local data conducted as part of the Better Futures programme and Somerset Homeless Health Needs Assessment (2023)* including SomersetFT NHS data is showing us that:

• Specialist Outreach GP caseload; Taunton – 100, Yeovil - 116, Mendip – 71 = (+/-) 287
• Homeless and Rough Sleeper Nursing Service - Since Sept 2021 the nursing team have worked with approx. 700 individual people and have approx. 300 contacts per month (many of these will be with the same people – weekly for example) (Their Data shows a total increase in referrals from 2021 (153) to 2022 (590) of 285%)
• The population of the Better Futures analysis (those accessing supported or temporary accommodation) identified over 300 adults with combined Health and Care needs.
• Somerset FT/NHS are telling us that the known population of homeless/NFA patients they are seeing = approximately 300 individual adults at any given point in time.

This assertive approach to patient finding and care has produced many case studies where; through preventative action and safeguarding activity, lives have been saved or dignity provided at the end of life.

Homelessness has now been identified as a key area for enhanced service provision through the NHS Core 20 Plus programme in Somerset.

Together we continue to secure funding and invest time into further enhancing the homeless health offer in Somerset – such as:

• NHS England Dental activity – South Somerset; Commissioned by Healthcare Public Health Directorate, NHS England South-West. This is funded activity where a dental provider, working together with VCSE, Specialist Outreach GP and the Homeless and Rough Sleeper Nursing Service will pilot a specialist offer for the homeless community. A Clinical Psychologist from Second Step (who provide support for adults with significant complexity – which is funded by Adults Social Care) has delivered Trauma Informed training for the dental staff.
• Innovation for Healthcare Inequalities Programme (InHIP) - Cardiovascular case finding and treatment optimisation in primary care to improve uptake of innovative technologies with an emphasis on support for those homeless or rough sleeping. This is an NHS Innovation funded piece of work being undertaken by NHS and Public Health. In addition to case finding and treatment activity there is a data element which should benefit the wider inclusion Health workforce (looking at patient record EMIS and RIO).
• The Rough Sleeping Drugs Alcohol Treatment Grant (RSDATG) which is funded by DLUHC and is managed by the Office for Health Improvement and Disparities. Originally targeted at the Mendip area of Somerset this has been extended because of local government reorganisation to become countywide.

The main aims of the RSDATG being:

• to help support people who sleep rough, or who are at risk of sleeping rough, to access and engage in drug and alcohol treatment and to sustain engagement as they move into longer term accommodation.
• to build resilience and capacity in the local drug and alcohol treatment system to continue to meet the needs of this population.

MEAM Somerset has also been accepted as part of the national MEAM Network helping focus our commissioning and support activity for this cohort still further.

The work being undertaken in Somerset was recognised by the Royal Society for Public Health as an example of Best Practice and the team was shortlisted in the 2021 RSPH Awards. RSPH | Health & Wellbeing Awards 2022 | The Royal Society for Public Health UK

What next?

• Working with partners the ICB are reviewing the existing Specialist Outreach Health Inclusion GP offer with an aspiration to deliver an equitable offer for this cohort across the whole of Somerset.
• We are currently finalising our Homeless Health Needs Assessment for Somerset to understand our population, inform future commissioning and service development activity – including both health and specialist housing provision. This is due to be published in Summer 2023 and we have a plan to refresh key data sets annually.
• We are working with the two main hospital settings to improve both; the approach to this cohort on admission and also the planning around their leaving hospital to avoid people being discharged to the streets.
• We intend developing a Somerset Homeless Health strategy to underpin the Somerset ICB NHS Core 20 Plus commitment where Homeless and Coastal Communities have been identified as priorities.

This submission is endorsed by colleagues from; Public Health (Somerset Council), Somerset NHS FT and Somerset ICB (including salaried GP’s as referred to above).