Call for evidence - inclusion health

Case Studies

• Enhancing inclusion and health outcomes for criminal justice-experienced people through lived experience engagement: the example of RECONNECT

  by Revolving Doors, almost 3 years ago

  Revolving Doors is a national charity working to break the cycle of crisis and crime. We advocate for a system that addresses the drivers of contact with the criminal justice system, including trauma, poverty, and discrimination. We bring independent research, policy expertise and lived experience together to champion long-term solutions for justice reform. In this case study, we outline the work of our Lived Experience Team (LET) with RECONNECT, from the perspective of two of our RECONNECT lived experience representatives, David and Emily.

  
  

  The issue

  
  

  Disengagement and mistrust are major obstacles to achieving health inclusion for individuals with criminal justice... Continue reading

  Revolving Doors is a national charity working to break the cycle of crisis and crime. We advocate for a system that addresses the drivers of contact with the criminal justice system, including trauma, poverty, and discrimination. We bring independent research, policy expertise and lived experience together to champion long-term solutions for justice reform. In this case study, we outline the work of our Lived Experience Team (LET) with RECONNECT, from the perspective of two of our RECONNECT lived experience representatives, David and Emily.

  
  

  The issue

  
  

  Disengagement and mistrust are major obstacles to achieving health inclusion for individuals with criminal justice experience. Past experiences of being let down and unheard have led to a lack of trust and disengagement from health services. This issue is particularly prevalent among those serving short-term prison sentences, who may question the importance of seeking support. Once released from prison, individuals are often left to navigate their health needs on their own, leading many to fall through the cracks, especially those caught in the revolving door of crisis and crime. This is characterised by repeat, low-level crime driven by unmet health and social needs, such as problems with drugs and alcohol, poverty, homelessness, or mental-ill health. Inadequate healthcare within prisons, long waiting lists, and limited awareness of available support further contribute to the challenges. Trust also plays a significant role, as individuals may be hesitant to admit their struggles or disclose sensitive issues – particularly women, who fear the consequences for their children – and tailored services that address their specific needs are often lacking. The transition back into the community brings additional hurdles for those lacking digital literacy, or guidance on the support available. While probation services may offer some support through signposting, there is a noticeable gap in their ability to provide the in-depth, comprehensive support that is most needed for people leaving prison, leading to health needs being overlooked.

  
  

  Our approach and how it made a difference

  
  

  In 2019, NHS England approached Revolving Doors with a vision for a care after-custody service aimed at improving continuity of care for individuals transitioning from prison to the community, which formed the basis of the RECONNECT service. This collaboration involved the Lived Experience Team (LET) working closely with the NHS England Health & Justice team to shape a service that truly met the needs of people leaving prison

  Lived experience engagement has been central to the service's shaping, from initial discussions and specification development to board-level meetings and implementation. The LET played a pivotal role in developing some of RECONNECT’s key features, such as the inclusion of peer mentors. Recognising the barriers of mistrust faced by criminal justice-experienced people when interacting with professionals, our lived experience members consistently point to peer mentoring as a solution to bridge that gap and foster engagement.

  “People with lived experience have been there. If you want to find solutions, you need to go to those who are most impacted by the solutions you’re trying to develop.”

  – LET representative for RECONNECT

  “I prefer to speak about my problems with someone who has been through the same and has come out on the other side... especially around sensitive things like mental health, because they get it, and they can understand how you feel at a given time. If you have someone who’s just there as a tick box exercise, you’re not going to get the same level of engagement and interest from people using the service.”

  – LET representative for RECONNECT

  The importance of extended support and personalised care was also emphasised. The LET voiced the need for support to begin well before release and be available for an extended period, allowing sufficient time to build trust.

  “I’ve received therapy before and was only given 8 sessions. It made me feel really pressured to be ‘fine’ and wasn’t helpful to my recovery. Everyone gets through things at different times, and that’s what we wanted RECONNECT to reflect.”

  – LET representative for RECONNECT

  The LET's first-hand knowledge brought attention to important aspects that others without lived experience may have overlooked. For instance, they successfully made the case for RECONNECT not to be included as part of a licence condition and provided valuable insights on the language and strategies used to promote the service.

  “Involving people with lived experience is cost-effective: as a service, it avoids you wasting money on solutions that don’t work.”

  – LET representative for RECONNECT

  “Meeting health needs should never be part of a licence condition.”

  – LET representative for RECONNECT

  Our lived experience members were also able to assess the impact of RECONNECT while conducting a visit to one of the service’s operational sites. One memorable feedback they report was that of an individual using RECONNECT in Surrey who went from being homeless on release to now being on a positive trajectory towards becoming a peer mentor. They described the support they received as “life-changing”, highlighting the transformative role of having a peer mentor who was readily available, offering continuous support, and facilitating faster referrals. Their success story exemplifies the vital role of lived experience engagement enabling positive life transformations that may not have been possible otherwise.

  “When I did the site visits, I was pleased to see that people were really engaging with the service – this was one of our key concerns from the start. People engage better when it’s voluntary.”

  – LET representative for RECONNECT

  
  

  
  

  Key learnings from RECONNECT

  
  

  • To maximise the involvement of individuals with lived experience, it is most effective to adopt a "blank page" approach that allows them to contribute valuable input right from the beginning of service development.
  • Individuals with lived experience should be involved at both a strategic and delivery level, including by actively participating in the service specification and board meetings, acting as peer mentors, and evaluating impact.
  • Equally important is the provision of accessible information that caters to individuals with diverse educational backgrounds, enabling their full engagement in the process, from induction packs for those using the service to internal reports for those in lived experience roles.
  • Through-the-gate support, consistency, and continuity of staff are essential in providing effective support to those who are traditionally disengaged from health services.
  • Specialised pathways providing tailored support for women, neurodivergent people, and other groups experiencing distinct needs, were identified as a crucial factor contributing to the success of RECONNECT.
  • Enabling people to self-refer into RECONNECT empowers individuals, eliminates unnecessary bureaucracy, and increases engagement.
  • Accountability measures such as site visits and audits carried out by people with lived experience help identify areas for improvement and promote transparency.
  • Providing individuals with the flexibility to engage with the service at their own pace and allowing ample time to establish trust is crucial.
  • Simplifying vetting processes and reducing waiting times for peer mentors’ applications can enhance the effectiveness of the service.

• Arch Health CIC Workforce development: Case Study

  by Arch Health CIC, almost 3 years ago

  Arch Health CIC Workforce development: Case Study

  
  

  Arch offers a number of training opportunities for medical students, clinicians and support workers and services working with people experiencing homelessness in Brighton and Hove and nationally. By sharing our expertise it is hoped that there will be a better understanding of inclusion health amongst clinicians, more clinicians wanting to work in inclusion health and a more holistically trained workforce within the homeless sector across Brighton and Hove and further afield.

  
  

  Arch’s offer for workforce development includes:

  
  

  • 4th year medical student elective

  Arch offers one elective student placement in our team each academic... Continue reading

  Arch Health CIC Workforce development: Case Study

  
  

  Arch offers a number of training opportunities for medical students, clinicians and support workers and services working with people experiencing homelessness in Brighton and Hove and nationally. By sharing our expertise it is hoped that there will be a better understanding of inclusion health amongst clinicians, more clinicians wanting to work in inclusion health and a more holistically trained workforce within the homeless sector across Brighton and Hove and further afield.

  
  

  Arch’s offer for workforce development includes:

  
  

  • 4th year medical student elective

  Arch offers one elective student placement in our team each academic year. This includes experience of all areas of Arch’s work and provides students with an insight into the health inclusion specialism. Participants also gain a deeper understanding of the issues faced by people experiencing homelessness by working with our outreach team in different accommodation settings and on the streets.

  
  

  • Student Selected Component for second year medical students

  Arch GP, Dr Kate Pitt, delivers a co-designed student select component Brighton and Sussex Medical School (BSMS) in homeless health, this is an eight-week course delivered several times throughout the academic year. This module has been co-designed, with the Brighton and Hove Common Ambition steering group, made up of people with lived experience of homelessness. This has been very successful in proving the importance of including people with lived experience in student training and the collaboration is now advocating for mandatory training to be included in this area for all medical students at BSMS

  
  

  • GP Registrar training

  Arch and local partners Justlife have delivered teaching on inclusion healthcare, homelessness and drug use and dependence.

  
  

  • Shadowing opportunities

  Students in training at the Royal Sussex County Hospital (e.g. Nursing students, occupational therapists) can arrange a day shadowing the multi-organisational hospital inreach team.

  
  

  • Health Inclusion talks

  The multi-organisational Pathway team (from across Arch, SCFT and Justlife) give a talk every month to junior doctors and nurses to build knowledge around health inclusion.

  Arch and local partners SCFT deliver talks to the New to Practice primary care scheme locally on inclusion healthcare, homelessness and drug dependence.

  
  

  • Online Homeless Health tutorials

  Tutorials led by Arch ANP, are aimed at frontline workers (including clinicians), working in homelessness in Brighton and Hove. They offer an expert insight into commonly-faced conditions seen at Arch, and offer guidance on early diagnosis, engagement and support, and signposting to local services, to help prevent complications and deterioration. Topics covered have included diabetes, alcoholic liver disease, wound care, respiratory illness and frailty.

  
  

  • Arch annual conference (Brighton)

  Arch works alongside local partners Justlife and the Frontline Network to hold an annual conference that offers expert training in a host of homeless health topics, as well as the chance to network with those in the city and in the sector.

  
  

  Key impacts and insights include:

  Students on placement with Arch have reported that they appreciate being part of a small team, seeing how we assess and manage complex patients with tri-morbidity (mental, physical, and dependence issues), and being able to understand the complexities faced by someone experiencing homelessness and a more broad understanding of homelessness.

  The initial co-designed student select component was oversubscribed and is due to be delivered multiple times throughout the year. All feedback from students was very positive, with some calling for the training to be mandatory.

  The initial online homeless health tutorial was attended by 20 people working within the homeless sector, they are now drawing in 50 attendees.

  Over 40 different organisations were represented at the last annual conference. Organisers received the following feedback:

  • “Great speakers, fantastic knowledge/experience”

  • “Incredible conference. Thank you :)”

  • “Always feel very inspired by such a large number of very passionate people”

  • “I feel truly enthused by the whole day. Thank you!”

  
  

  Key learning for Arch in this area includes:

  Co-designing medical student training offers students a unique insight into this area of health inclusion and benefits clinicians and people with lived experience who are working together.

  The increase in popularity of the online tutorials demonstrates the interest in understanding more about health inclusion issues within the wider sector and that there is perhaps a gap in knowledge in training for Support Workers.

  Sending out surveys after the event enables Arch and partners to improve the conference each year. Survey responses enable Arch to understand where gaps in knowledge across the system might be and to plan accordingly.

  
  

  What’s next:

  Arch will continue to provide all of the training opportunities laid out above. Arch will be developing a strategy for training over the next five years. It is hoped that there will be further opportunities for Arch to feed into training and development including more co-design opportunities and reaching clinicians in other cities. In the near future Arch will be looking to develop teaching for nurses and allied health professionals in inclusion health across the Sussex ICS Primary Care Workforce.

  
  

• Brighton and Hove Common Ambition: Case Study

  by Arch Health CIC, almost 3 years ago

  Brighton and Hove Common Ambition: Case Study

  Patient voice for those experiencing homelessness in Brighton and Hove has never been fully established. The experiences and insights of these patients have been difficult to gather and health inclusion services have very little co-production woven into their delivery model.

  
  

  Brighton and Hove Common Ambition brings together people with lived experience of homelessness, frontline providers and commissioners through co-production within homeless health services. This is in order to improve systems, services and outcomes for people experiencing homelessness in Brighton & Hove. It is a three year project and it is in its final... Continue reading

  Brighton and Hove Common Ambition: Case Study

  Patient voice for those experiencing homelessness in Brighton and Hove has never been fully established. The experiences and insights of these patients have been difficult to gather and health inclusion services have very little co-production woven into their delivery model.

  
  

  Brighton and Hove Common Ambition brings together people with lived experience of homelessness, frontline providers and commissioners through co-production within homeless health services. This is in order to improve systems, services and outcomes for people experiencing homelessness in Brighton & Hove. It is a three year project and it is in its final year.

  
  

  This is a partnership project that is funded by the Health Foundation, the project partners are Arch Healthcare (NHS), Justlife (third sector), the University of Brighton (academic and evaluation partner), The Brighton and Hove City Council Health Department and NHS Sussex.

  
  

  The Common Ambition Steering Group design and deliver the project. This group is made up of people with lived experience of homelessness and members from Arch Healthcare, Justlife and University of Brighton. The Steering group first came together in June 2021 and the work it has carried out covers the following areas: developing effective co-production practices; system review; service design; training; advocacy and campaigning. The co-production sub projects carried out by this group include:

  
  

  Developing effective co-production practices

  • Developing a group approach to trauma informed working

  
  

  System review

  • Mapping Brighton and Hove’s homeless healthcare system and identifying the challenges and barriers within the system.

  
  

  • Mapping the Brighton and Hove housing pathway, identifying challenges and co-designing solutions

  
  

  Service Design

  • An initial service design sprint focussing on finding solutions to difficulties accessing services and co-designed a prototype called ‘Route to Roof’

  
  

  • Inputted into the development of Arch Health CIC move-on and outreach services

  
  

  Training

  
  

  • Co-designed a training course for medical students

  • Co-produced events to share learnings

  • We are currently working to co-produce a co-production training workshop

  
  

  Advocacy and campaigning

  • Forming Media and Communications group to co-produce project communications

  • Co-producing a social media campaign for World Homeless Day 2022

  • Co-produced a project website: Home - Brighton & Hove Common Ambition (bhcommonambition.org)

  • Developed manifesto points for local MPs before the May local elections

  
  

  There have been serval key impacts noted by group members participating in the project including:

  • Growing in confidence and skills building

  • Developing a voice for this community and feeling heard

  • Moving on to college or volunteering roles

  
  

  There have also been key impacts on Arch Health CIC, project partners and wider city stakeholders including:

  • Lived experience involvement in designing healthcare services

  • System maps that can be used by the whole city

  • Effective co-production practices that can be shared and adopted by services in the city

  • Effective design of process to ensure lived experience participation in medical student training

  
  

  Testimonies, learning, experience and co-produced processes from people with lived experience of homelessness can be found in blogs written by group members on the project’s website: Latest News - Brighton & Hove Common Ambition (bhcommonambition.org)

  
  

  Key learning from the project so far includes:

  
  

  • An important learning to share is that co-production in homeless healthcare takes time and resources to build trust and a safe environment to ensure effective co-production.

  • Co-designing and delivering the project plan and specific deliverables and outputs has meant that detailed goals, outputs and timelines could not be predetermined. There was a level of uncertainty in methods and processes, these had to be co-designed as the project evolved.

  • In order to effectively co-produce it is important to ensure there is a level of understanding of the system and services, this was developed by mapping the system collaboratively.

  • It is impossible to take up the challenge to work with people with lived experience to improve health services and outcomes, without addressing the system as a whole. Feedback from across the system, featuring in almost every conversation, states that the system is inaccessible, confusing, disjointed and there is a distinct lack of good communication and housing.
    
    

    What’s next?:

  The project is funded via the Health Foundation until March 2024. The project team is exploring opportunities to enable this project to continue past this time. The project is looking to revisit medical student training in order to establish a mandatory element. It will also explore mental health services in the city and how co-production can support improvement here. The big hope for the project is that it will be able to advocate and co-design a homeless health hub where all services can sit under one roof and people experiencing homelessness have a central place to access care and support.

  
  

  
  

• Arch Health CIC GP Surgery: Case study

  by Arch Health CIC, almost 3 years ago

  Arch Health CIC GP Surgery: Case study

  Arch Health CIC exists to explore every opportunity to improve the health and well-being of people without a secure home in Brighton and Hove. We are committed to this because periods of homelessness can have a devastating impact on a person’s life and we believe that excellent, caring, primary health care can prevent long term suffering and save lives.

  Many people who are experiencing homelessness face complex health challenges, often further exacerbated by a lack of trust in healthcare systems and services. In order to provide an effective healthcare service for people facing... Continue reading

  Arch Health CIC GP Surgery: Case study

  Arch Health CIC exists to explore every opportunity to improve the health and well-being of people without a secure home in Brighton and Hove. We are committed to this because periods of homelessness can have a devastating impact on a person’s life and we believe that excellent, caring, primary health care can prevent long term suffering and save lives.

  Many people who are experiencing homelessness face complex health challenges, often further exacerbated by a lack of trust in healthcare systems and services. In order to provide an effective healthcare service for people facing homelessness, Arch runs a unique GP surgery, Arch Healthcare, which provides a specialist service that acknowledges the whole person and provides care with kindness, respect and humanity.

  To register as a patient at Arch Healthcare, people need to be either sleeping on the streets, living in emergency accommodation, living in a hostel, a traveller, living in a van or ‘sofa surfing’ with friends or acquaintances. Many of the patients at Arch Healthcare have multiple and compound needs which require highly specialised care and attention which we endeavour to provide with every interaction.

  • The surgery environment is warm and welcoming; Our reception team are often praised by patients for their kind and understanding manner; everyone is very aware that the way we make people feel in the waiting room has a direct impact on what happens in the consulting room and beyond, and in itself provides an opportunity for meaningful interactions.

  • Our reception team, as well as clinicians, are well-trained and knowledgeable about non-clinical matters which can have a profound bearing upon our patients’ lives, for example support networks, foodbanks, housing rights, and local organisations to call to make the next step a little easier.

  • Support and time is given to clinicians in order to develop their skills and knowledge, so they can provide expert healthcare tailored to the needs of patients.

  • We have a relatively small number of registered patients (1400), many of whom are known to staff by their first name.

  • In addition to a schedule of pre-bookable appointments we have lots of same-day appointments available every day to ensure those with urgent needs can see a clinician quickly. This is also in acknowledgement of the fact that periods of homelessness mean it can be harder to plan one’s time in advance.

  • Longer appointment times (15 mins) help to give time to build up a relationship of trust between doctor and patient.

  • All of the above go towards providing restorative, person-centred care, and place an emphasis on a strong therapeutic alliance. This helps to build a relationship of trust and encourages patients to engage with their care, moving towards long term health improvements.

  • In recognition of all of these factors, Arch obtained a rare CQC rating of Outstanding across all areas, at last inspection (2019)

  Key learnings

  • Much of the care Arch offers is vastly strengthened by partnerships with key organisations in the city. For example Arch commissions health engagement workers from the specialist charity Justlife in order to support patients with complex health challenges to manage their care. This has made a huge difference to patients’ health and wellbeing.

  • Accessibility: in order to keep improving Arch’s accessibility, an expanded outreach service was established (see our case study on our outreach service, also submitted) - this was in response to the fact that not everyone is physically able to travel to the surgery, and also in response to the fact that Arch is not universally known about, amongst people who could benefit from our service

  • Patient voice: Arch is a lead partner in the Common Ambition project (see our case study on this, also submitted) - which puts patient voice at the heart of driving improvements to the homeless healthcare system. Having people with lived experience of homelessness is essential to targeting the issues that matter to Arch’s patients, and what works, and what does not, in supporting them to access healthcare and move towards long term wellbeing.

  Impact: here are some quotes from our 2022 patient survey, the results of which showed an overwhelmingly positive impact:

  • Great listening - felt respected - fit me in for a face to face promptly

  • You're all amazing and caring. I felt taken seriously for the first time in my life.

  • Perfect code of conduct. All inclusive and equality for all patientsVery friendly

  • Empathetic - Patient led care - Respectful of Trans identity

  • Keep being awesome

  • I think I'm very lucky to have Doctors and Nurses that really care about my wellbeing with a drop in surgery on call twice a day/five days a week

• Arch Health CIC Step Down Beds: Case Study

  by Arch Health CIC, almost 3 years ago

  Arch Healthcare - Step Down Beds Service - Case study:

  
  

  To ensure people who have been admitted to hospital and are at risk of homelessness at the time of discharge have a safe place to recover with regular clinical input Arch has collaborated with local services to provide seven step down beds in the Brighton and Hove. This service has been in place from February 2021. The first year (pilot year) was funded through the Covid Recovery Fund this was then continued through the Out of Hospital Care fund. Currently, for the year 2023/24 the service is funded by Sussex... Continue reading

  Arch Healthcare - Step Down Beds Service - Case study:

  
  

  To ensure people who have been admitted to hospital and are at risk of homelessness at the time of discharge have a safe place to recover with regular clinical input Arch has collaborated with local services to provide seven step down beds in the Brighton and Hove. This service has been in place from February 2021. The first year (pilot year) was funded through the Covid Recovery Fund this was then continued through the Out of Hospital Care fund. Currently, for the year 2023/24 the service is funded by Sussex ICB and the Rough Sleepers Initiative (RSI) (BHCC)

  
  

  The Step Down Beds service is a link between community and hospital services - providing patients experiencing homelessness who are discharged from hospital with accommodation in a supportive hostel, daily clinical visits, and dedicated support workers to ensure they can recover fully after a hospital admission. It can also support patients to stay within the community and receive care and treatment, in order to prevent a hospital admission.

  
  

  The service is a partnership project and brings together the different skills and expertise of homelessness and inclusion health in the city to provide an integrated and accessible service for those facing homelessness before, during or after a hospital stay. This joined up working enables a holistic approach to inclusion health. The expertise and roles of the partnership are laid out below:

  
  

  Arch Healthcare (Specialist primary care and GP surgery)

  • Provide clinical inreach team, this is a nurse led team with support from GP’s.

  • Clinical team visit every day Mon-Fri to monitor existing conditions, change dressings, manage and prescribe medication and refer into other support services (such as substance misuse and mental health)

  • Ensure Step-Down resident is registered with Arch GP surgery

  • Able to support patients to link in with other primary and secondary care services.

  
  

  St Patrick's YMCA DownsLink Group and New Steine Mews Hostel (Brighton and Hove City Council) (hostel accommodation provider)

  • Manage the accommodation where the beds are located

  • Provide Personal Assistants who are responsible for supporting patients while they are in stepdown beds, for example supporting to attend appointments, providing companionship, helping with benefits, advocating.

  • Support patients to access food, cleaning and laundry services.

  • Manage move on plans

  
  

  Pathway hospital inreach team

  • Identify people within the hospital, carry out initial assessment and start housing process

  • Refer into step-down beds

  • Ensure safe travel to step down beds

  
  

  Homeless Prevention Officer (BHCC)

  • Works with clients in step down beds to find suitable move on accommodation.

  
  

  Brighton and Hove City Council

  • Project commissioning and reporting

  • Identifies move on accommodation

  
  

  There have been many positive outcomes for those accessing this service including:

  
  

  • Lower rates of unplanned hospital admissions and lower rates of unscheduled care (e.g. going to A&E, and getting admitted to hospital).

  • Enabling access to detox and rehab and accessing substance misuse services

  • Stabilising physical and mental health

  • Residents have stabilised with the input from clinical and non-clinical staff

  • Improved health engagement, including GP registration, accessing dentists, sexual health clinics, specialist services for diabetes and secondary care teams.

  • Supporting patients to better manage medications.

  • Moving on to permanent accommodation

  • Moving on to employment

  
  

  Key learning for this partnership service includes:

  
  

  • Ensuring daily clinical input has not only improved the health of residents but helped to build engagement with health services.

  • Personal Assistants for all step-down residents has been key in building relationships and enabling residents to stabilise.

  • Links between the hospital and community teams strengthen through regular meetings and communication.

  • Finding suitable accommodation to move on to has been a challenge, it has improved by building better relationships with the city council, creating more than one pathway for residents and having a dedicated Move On Coordinator for residents but it is still taking a long time to find accommodation.

  • Taking the time to build good relationships between services, including regular team meetings and sharing knowledge has been key to the success of this service.

  
  
  

  What’s Next:

  
  

  The Step-Down Beds service has secured funding for another year in Brighton and Hove, it is hoped that it will continue beyond this.

  
  

  During the year ahead we are looking at:

  • Continuing to develop pathways into suitable move on accommodation.

  • Developing initial assessments for health and looking at the patients wider health needs during their stay in step down.

  • Building stronger links with other services

  • Developing plans to maintain the service beyond 2024.

• Arch Health CIC hospital inreach service, “Pathway”: case study

  by Arch Health CIC, almost 3 years ago

  Arch Health CIC hospital inreach service, “Pathway”: case study

  Homelessness is a healthcare problem: a period of homelessness can be devastating for a person’s health. Conversely, good healthcare can empower people, and give them a base of stability and strength, to address challenges they may be facing in their lives.

  
  

  Pathway is a national model that uses the opportunity of hospital admittance, to identify people experiencing homelessness, and by providing extra, tailored care, coupled with housing support, help these patients to benefit from their hospital treatment and recover properly, during and beyond their hospital stay.

  
  

  Enabling people to stick with... Continue reading

  Arch Health CIC hospital inreach service, “Pathway”: case study

  Homelessness is a healthcare problem: a period of homelessness can be devastating for a person’s health. Conversely, good healthcare can empower people, and give them a base of stability and strength, to address challenges they may be facing in their lives.

  
  

  Pathway is a national model that uses the opportunity of hospital admittance, to identify people experiencing homelessness, and by providing extra, tailored care, coupled with housing support, help these patients to benefit from their hospital treatment and recover properly, during and beyond their hospital stay.

  
  

  Enabling people to stick with their treatment and stay in hospital as long as they need, will ensure they’re not leaving whilst still ill, and thus at risk for readmittance within a short time.

  
  

  Supporting people to move on to somewhere appropriate after their hospital stay, will ensure that people have the chance to recover properly, regroup, and have a better chance of moving onto a more stable life, and can take control of their health and wellbeing in the future.

  
  

  Brighton has the longest running Pathway hospital in-reach programme outside of London. Since 2012, this small collaborative team set up shop in the Royal Sussex County Hospital, now part of Sussex University Hospitals, and started to identify and support patients in hospital at that time who didn’t have a home to go to upon discharge.

  
  

  This multidisciplinary team consists of:

  
  

  • Clinical lead Dr Chris Sargeant and Pathway Housing and Team Coordinator, Katie Carter, both from Arch Healthcare, Brighton’s specialist homeless healthcare service.

  • In-reach nurse practitioner Emily Greer, from Sussex Community Foundation Trust’s Homeless Health Inclusion Team, a specialist community physical health team made up of Nurses, Nurse Prescribers, Occupational Therapists, Physiotherapists and Assistants.

  • A&E Support Worker Patti Kydd from specialist charity Justlife, a charity that provides health engagement and support to people living in emergency accommodation. All patients discharged to emergency accommodation are offered referral to the Justlife team.

  
  

  The Pathway in-reach team works with the hospital’s clinical teams to ensure appropriate treatment, full understanding of the patients’ circumstances, and awareness of other health issues. The team also try to meet possible needs such as for toiletries and clothes, tv access and books, to ensure a dignified hospital stay, and understand the importance of building up trust with patients who may have lost faith in the system, to ensure that all treatments are fully effective. The team then work with the patients and Housing Needs colleagues to ensure that they come out to a stable environment upon discharge, including support with housing and benefits, so that patients would be able to get out of hospital and recover properly and safely.

  
  

  Any patients who are not registered with a GP are registered at Arch Healthcare while they are still in hospital, to remove the need for them to do this after discharge.

  
  

  The Pathway in-reach team introduced a weekly multidisciplinary team meeting to bring together services from the community and the hospital to plan discharges, and monitor progress after discharge. This developed into the Multi-agency Homeless Health Meeting (MAHHM) which has since expanded its remit to include patients who are at risk of hospital admission. MAHHM enables the journeys of patients to be traced, looking at the whole person and their story so far, in order to provide considered, effective, human treatment.

  
  

  Impact of the programme:

  
  

  In the 10 years that Pathway has been up and running in Brighton, figures show that for people facing homelessness, despite rising rates of homelessness in the country, A&E attendances, unplanned hospital admissions and readmissions have fallen.

  
  

  Dr Chris Sargeant says:

  
  

  “There have been many memorable patients in 10 years. The first months were spent letting people know that we were here and looking out for our patients.

  One of the first was a man who had been admitted after being stabbed. He had had a place in a supported accommodation but was told he was not welcome to come back. He was very distressed by this, as he had been the victim of a violent attack, so it did not seem right that he should lose his accommodation.

  The supported accommodation were somewhat surprised when asked if he had been evicted and proper procedures followed. The manager agreed that the decision had not been taken properly, so he was allowed to return.

  
  

  Another patient had been a very regular attender at the hospital, sleeping rough and presenting sometimes several times a week. After one longer admission he was given emergency accommodation after an application had been made by our team and Adult Social Care colleagues put in for regular carers. His rate of attending dropped. Further assessments took place at his accommodation which had not been able to happen previously as he often could not be found. Following these a specialist nursing home was found and he agreed to go there, settled well and now rarely comes to hospital.”

  
  

• Arch Health CIC expanded outreach service: case study

  by Arch Health CIC, almost 3 years ago

  Arch Health CIC expanded outreach service: case study

  Arch Healthcare provides specialist primary care services for people facing homelessness in Brighton and Hove. ARCH stands for Accessible, Restorative, Community Healthcare, so we are always looking for ways to make our service more accessible to people who may not be able to reach our surgery, in the heart of the city, or who may not be aware of our service. Our newly expanded outreach service was established in order to address this.

  The team is made up of GP Tal, Advanced Nurse Practitioner Ruth, who is the Outreach Coordinator, and Jess... Continue reading

  Arch Health CIC expanded outreach service: case study

  Arch Healthcare provides specialist primary care services for people facing homelessness in Brighton and Hove. ARCH stands for Accessible, Restorative, Community Healthcare, so we are always looking for ways to make our service more accessible to people who may not be able to reach our surgery, in the heart of the city, or who may not be aware of our service. Our newly expanded outreach service was established in order to address this.

  The team is made up of GP Tal, Advanced Nurse Practitioner Ruth, who is the Outreach Coordinator, and Jess, the Outreach Health Engagement Worker. They see patients in a variety of settings, including hostels, outreach clinics or at their sleep sites (doorways, sheds, stairwells, car parks and tents). They also run regular clinics at day centres and other locations and services, and partner with outreach organisations on a regular basis to reach people in different locations, over evenings and weekends. To navigate the topography and street layout of Brighton speedily and easily, the team uses e-bikes to travel around, maintaining the ability to see and find patients opportunistically.

  The outreach service has been involved in a wide variety of consultation types including the management of acute illness and injuries, and monitoring of long-term conditions. It has also been useful in helping to raise awareness of Arch, and what the surgery can offer to people facing homelessness.

  Impact: example of establishing a relationship and building up trust

  Outreach Coordinator Ruth arranged a visit to a local Travellers site with the organisation Friends Family & Travellers (FFT) with a view to setting up a monthly outreach clinic. During this visit, numerous residents expressed concerns about a new locked barrier that had been introduced at the site entrance, reporting that on 2 occasions, ambulances had experienced delays accessing unwell patients because of the barrier.

  Arch’s outreach team liaised with FFT, the Ambulance service, Fire brigade and Brighton & Hove council. As a result, the barrier was unlocked, reducing risks associated with delayed emergency vehicle access. This success was also important in establishing trust with the local Gypsy and Traveller community.

  “You will be happy as well as me to hear that they have removed the barrier from the site entrance which was an issue for site residents when we visited site last year. Thank you very much for your help on this and residents have also thanked us.”

  “This is an excellent outcome and thanks for your hard work on this! This change will make a huge difference to residents’ lives.” (Project co-ordinator, Friends, Family and Travellers).

  Key learning so far:

  • Establishing relationships with partner organisations (e.g. day centres, hostels, specialist services), in order to run regular clinics and reach people where they are, has been key in reaching people who might have been unaware of Arch, or physically unable to get to the surgery. The team continue to work in an agile and flexible manner, so as to continue to reach people and offer support in the most effective and accessible way.

  • Using e-bikes instead of a vehicle, enables spontaneous and opportunistic contact with people, and also contributes to brand recognition, raising awareness of Arch’s specialist service among those who weren’t aware of it previously.

  What’s next:

  • As the team builds up relationships with key partners, and demand for regular clinics grows, the team continues to put careful thought into the balance between regular consultations and one-off, opportunistic contacts, reaching new patients in need of healthcare.

• Pathway Progression case study

  by Loretta Cox @OxleasNHS, almost 3 years ago

  The London Offender Personality Disorder (OPD) Partnership is consortium of London NHS trusts that work with the Probation Service and other third sector organisations to deliver psychological treatment to complex high-risk offenders in the community and prisons.

  This case study describes the benefits of psychologically informed partnership working to provide safe, understanding and effective interventions to support this man with complex needs.

  Richard was referred to the Integrated Community Pathway Service (ICPS) Case Prioritisation Meeting (CPM) November 2021. He is a white-British Male, convicted in 1992 for murder within the context of an armed robbery. Richard was allocated to an... Continue reading

  The London Offender Personality Disorder (OPD) Partnership is consortium of London NHS trusts that work with the Probation Service and other third sector organisations to deliver psychological treatment to complex high-risk offenders in the community and prisons.

  This case study describes the benefits of psychologically informed partnership working to provide safe, understanding and effective interventions to support this man with complex needs.

  Richard was referred to the Integrated Community Pathway Service (ICPS) Case Prioritisation Meeting (CPM) November 2021. He is a white-British Male, convicted in 1992 for murder within the context of an armed robbery. Richard was allocated to an ICPS psychologist for an assessment upon release in February 2022, into the Housing and Accommodation Support Service (HASS) project. It was noted in the referral that previous substance use concerns had been raised during release on temporary licence (RoTLs), and that a supported living arrangement in the first instance might provide a more stabilising environment in which an assessment of Richard’s support needs could be completed.

  Shared understanding/formulation:

  Richard and his psychologist thought together about how he developed a sense of self-worth and identity - from his lifestyle of acquisitive offending and developing a reputation for violence, which was endorsed and encouraged by his family and friends. Given the early sense of shame at his personal circumstances (growing up in poverty and facing rejection by his peers), the self-worth gained from this lifestyle likely served to protect from feelings of judgement, rejection or powerlessness. Being placed in care at a young age, due to his parents own mental health difficulties and addiction to alcohol, was considered with Richard to perhaps further his need to feel a sense of belonging, avoiding judgement and rejection, and develop an identity which enabled both safety and respect from others. Throughout adolescence and early adulthood, at which time the index offence occurred, the influence of others seems to have been important, whether this was using substances as part of a social environment and lifestyle, offending to obtain the money/possessions to fund and maintain this desired identity, or boosting self-worth and shielding against physical threats of others and the threat of shame through behaviour that garnered the respect of others (e.g. threats of violence, reputation). It is within the context of armed robbery, carried out whilst under the influence of drugs and alcohol, to fund his lifestyle and identity, that the index offence occurred.

  Upon release, Richard was motivated to address and abstain from drug use, recognising that peer influence, significant boredom, and a lack of alternative coping strategies for emotions, were factors which could place him in a vulnerable position to relapse. At the time of assessment key presenting difficulties were: low mood and anxiety, relating to a sense of overwhelm at the journey ahead in the community and struggling to establish a new identity outside of previous lifestyle, feelings of low self-worth and worry about judgement and rejection from others who were perceived to have ‘matured’ whilst he felt he had work to do to prove himself to others. This related to financial instability, awaiting benefits approval, which was at odds with previous identity and lack of reliance on others and ability to present desired image of self to others. We considered the role that self-criticism plays, with Richard ruminating that he should ‘know better’ or should be doing better. As a means of coping, he would withdraw and avoid others, which in the short term might help by avoiding the situations which trigger feelings of anxiety. In the long term, we thought about how this keeps Richard away from his goals, and from developing a new sense of identity and self-worth.

  Summary of support offered, and work completed to date:

  Key worker support from HASS:

  • Contained and supported living environment to accommodate needs relating to adjusting to life in the community following a long time in custody and previous difficulties in open conditions with drug use.

  Weekly support from ICPS clinical practitioner:

  • With practical matters; filing in forms and paperwork to ensure access to benefits, universal credit, to support financial stability (supporting letters provided by ICPS psychologist)
  • Exploring and developing an understanding of any volunteering, training or employment opportunities Richard would like to pursue (Inclusion & Involvement (I&I) Hub referral completed – see below)
  • Support with budgeting and managing finances, where financial instability and resulting impact on mood and sense of identity and self-worth relating to both wellbeing and risk of return to aspects of previous lifestyle
  • As time progressed, the work with his clinical practitioner focused on exploring his values and meaningful activity [building sense of identity], working closely with the I&I hub to access opportunities which Richard has been proactive in engaging with. These sessions are also focused on noticing, naming and managing difficult emotions.

  Drug and alcohol support:

  • Change Grow Live (CGL): Richard has been engaging with the local drug and alcohol service, engaging with groups and reporting these spaces to have been helpful, though at times difficult due to exposure to others who are using drugs more (in terms of frequency, and breadth of substances including significant opioid use). He has struggled to remain abstinent from drugs, however has not returned to use of heroin and regularly collects his script to manage symptoms of withdrawal and support abstinence from heroin. Richard has however struggled to abstain from use of cocaine and cannabis.
  • Testing from probation: The initiation of drug testing from probation, as recommended in his ICPS report, revealed positive tests for cocaine, and less frequently cannabis.
  • Richard has been open to discussing this with his ICPS clinical practitioner and psychologist, developing an ongoing formulation, understanding of motivations and functions. An escalation in use was responded to by multiple professional network meetings, working across agencies (probation, NHS, HASS and the various ICPS staff members involved) to collaboratively agree a plan forward, including review meetings with Richard to jointly agree this plan.
  • Sessions with ICPS psychologist: As per the above described meetings, increased contact with his ICPS psychologist was initiated, to revisit the formulation and the role of drugs in providing an escape and avoidance of difficult emotions. His sense of overwhelm and fear of failure and worthlessness, were explored.

  Inclusion & Involvement hub engagement:

  • Richard has been engaging well with the Maintain the Difference employment project, which is due to come to an end in March/April.
  • Redemption Roasters barista training has begun, as an opportunity to further his employment skills, and offer the opportunity for employment and financial stability following the end of the MtD project.

  Therapeutic intervention:

  • Richard began to engage early on with Mentalisation Based Therapy (MBT) as per the recommendations of his ICPS assessment – this was to support Richard to develop an understanding of his patterns of thinking and feeling about himself and others. He described feeling overwhelmed by the volume of appointments and areas he was working on following completion of MBTi, and so the professional network were responsive and MBT was paused to prioritise i.e. employment, financial stability, relationship to drugs.
  • Richard has been engaging with a series of 1:1 sessions with his ICPS psychologist following escalating lack of stability, drug use and stress and overwhelm. This has focused on an evolving formulation following disclosure of certain previously undisclosed childhood trauma as trust and rapport with his psychologist developed.
  • Current therapeutic planning includes work to address the origins and impact of self-criticism, compassion focused psychoeducation relating to trauma and its impact, with plans to consider with Richard EMDR (eye movement desensitisation and reprocessing) sessions to support reprocessing of key memories underpinning sense of shame and worthlessness, formulated to underpin both the function of his drug use and past offending lifestyle.

  It has been important throughout the work with Richard to ongoingly consider and revisit sequencing, meeting Richard where he is at and considering the impact of feeling overwhelmed in order to take a paced approach within his window of tolerance, being mindful of tendencies towards self-criticism, sensitively to feelings of failure, and resulting withdrawal, avoidance or drug use. Building trust, rapport and relational safety has been essential; providing reassurance, containment, and clarity around who is doing what, why, and when, rooted in a shared formulation and responsively moving towards his needs and goals. Richard has notable strengths and has worked hard and been receptive to support, and developed good working relationships with his professional network. Despite ongoing road bumps relating to a longstanding history of addiction to drugs, he is engaging well with the ICPS and his pathway plan.

• Integrated Outreach Working with Street Based Sex Workers in London, Find&Treat, UCLH & SHOC team, Mortimer Market Centre

  by Binta Sultan, almost 3 years ago
  

  Our case study links to all five inclusion health draft principles:

  1) Commit to action on inclusion health

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

  3) Develop the workforce for inclusion health

  4) Developing integrated and accessible services for inclusion health

  5) Demonstrate impact and improvement for inclusion health

  Background:

  This programme of work began in response to the progressive defunding of sexual health outreach services, rising health inequalities and the halting of delivery of outreach services during the pandemic. Homelessness and problematic drug use are key factors that initiate engagement in street-based sex work They... Continue reading

  Our case study links to all five inclusion health draft principles:

  1) Commit to action on inclusion health

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

  3) Develop the workforce for inclusion health

  4) Developing integrated and accessible services for inclusion health

  5) Demonstrate impact and improvement for inclusion health

  Background:

  This programme of work began in response to the progressive defunding of sexual health outreach services, rising health inequalities and the halting of delivery of outreach services during the pandemic. Homelessness and problematic drug use are key factors that initiate engagement in street-based sex work They often overlap and lead to multiple social exclusion, destabilising an individual and increasing their vulnerability. During the COVID-19 pandemic, the numbers of people engaging in sex work has increased due to increased poverty levels. an increasing number of women have fallen into homelessness, sexual exploitation and street-based work due to financial instability. In parallel, there was reduced activity of sexual health outreach services and clinic based sexual health. This was on a background of already significant cuts to sexual health services due to budget cuts, that occurred in the years prior to the pandemic.
  The Find&Treat, UCLH team, a pan-London, peer-centred inclusion health outreach team partnered with the SHOC sex worker health promotion team from Mortimer Market Centre, CNWL to deliver night outreach services for street based sex workers in North London. This team has grown to include joint working with drug services and the development of a rapid access housing pathway for vulnerable women.

  
  

  Methods:

  The Find&Treat outreach van was used to deliver monthly night outreach services.This programme provides integrated point of care HIV/HepC/HepB/Syphilis/Gonorrhoea. Chlamydia testing and treatment alongside addressing safeguarding, housing and social care needs. Vaccines including COVID vaccination have been delivered through this programme. Needle exchange and naloxone provision on the outreach van.

  The locations where the Find&Treat van setup are known for street-based sex work. The sessions run from 9pm to 3am. The outreach teams engage with clients beforehand to inform of the presence of the outreach van and testing. Warm drinks and food were provided along with a convenience pack containing sanitary products, socks, masks, toiletries and condoms.

  Health offer:

  Mobile chest radiography was offered to all clients with immediate reporting. All patients are offered pregnancy testing, point of care testing for HIV, hepatitis C antibody and RNA, syphilis and follow up bloods as necessary and point of care STI screening for Neisseria gonorrhoea (NG) and Chlamydia trachomatis (CT) using Cepheid NAAT triple site testing. Treatments for STIs are provided, in line with local clinic policy. Emergency contraception and referral for HIV PrEP is offered to all who needed it. Supported referrals into local contraception services and sexual assault services are also made.

  Vulnerability assessment:

  Safeguarding referrals are made to local teams and all are offered support from an independent sexual violence advocate.

  Housing:

  Women who experience homelessness are able to access immediate housing assessment and accommodation in the night through a pathway set up with the rough sleeping team at the Greater London Authority and St Mungo's teams.

  Drug services:

  Patients are able to access rapid access pathways to Opiate Substitution Therapy via local drug services.

  Outcomes

  98 street based sex workers screened. High levels of sexually transmitted infections, experience of violence and mortality.

  Outcomes included cross-organisational learning, training of sexual health promotion team to be able to deliver point of care testing in outreach setting, development of rapid access to drug and housing support pathways.

  Health:

  STI results and treatment below, majority of those with an STI have been treated. 2 new HIV diagnoses one started treatment, one awaited, 4 Hep B diagnoses, referred to clinic, 1 new HCV diagnosis, treated and cured.

  2 pregnant women; re-engaged with maternity services and drug services

  Housing & Drug Services:

  23 rough sleeping: 12 now in temporary accommodation

  57 reported crack/heroin use: 22 now engaged with drug service, 4 now in detox programme

  Experience of violence:

  7 deaths (2 murders, 3 likely overdose, 2 unknown), 2 experienced attempted murder (reported), 4 kidnapping (2 reported), 5 missing, 37 people victim of recent sexual assault, 63 victims of domestic violence

  
  

  Conclusion:

  This is an organic programme of work, brought together by dedicated outreach teams and peer support workers in response to high levels of need. It continues but remains unfunded and not formally commissioned due to fragmented commissioning of sexual health, HIV, hepatitis C, housing and drug services, and is at high risk of stopping due to precarious funding for the teams that lead this service.

• Groundswell's Homeless Health Peer Advocacy Service

  by Rachel Brennan, almost 3 years ago

  Groundswell’s Homeless Health Peer Advocacy (HHPA) service supports people experiencing homelessness to address physical and mental health issues. Staff and Volunteers who have direct experience of homelessness support people to overcome practical and personal barriers to accessing the healthcare they need and supporting them to develop the confidence and skills to increase their ability to access healthcare independently. Here is a case study that outlines some of the work we do to support our clients.

  Client H: Referred by Homeless Nursing team.

  Male, 46 years old, foreign national, no recourse to public funds, needs translation support.

  Diabetes Type 2

  Colorectal... Continue reading

  Groundswell’s Homeless Health Peer Advocacy (HHPA) service supports people experiencing homelessness to address physical and mental health issues. Staff and Volunteers who have direct experience of homelessness support people to overcome practical and personal barriers to accessing the healthcare they need and supporting them to develop the confidence and skills to increase their ability to access healthcare independently. Here is a case study that outlines some of the work we do to support our clients.

  Client H: Referred by Homeless Nursing team.

  Male, 46 years old, foreign national, no recourse to public funds, needs translation support.

  Diabetes Type 2

  Colorectal health

  Mental health issues and history of daily drinking

  Groundswell Case Worker engaged with H the day before temporary Christmas accommodation was ending at a London hotel and he would be returning to rough sleeping, completed initial engagement including outlining the Homeless Health Peer Advocacy service, understanding his health priorities and current situation. Supported to attend investigative appointment at a London hospital. Supported to make HC1 application and attend GP appointment to ensure up to date with annual diabetes health check. Supported to attend diabetic health check and diabetic eye screening. Once HC2 certificate was issued booked optician and dental and supported to attend. H was issued with glasses that were later stolen while he was rough sleeping. Case Worker supported H to attend a therapy assessment where concerns were raised around mental health and risk highlighted which resulted in H being offered a telephone assessment a few months later and was offered 3 sessions with a mental health agency for emotional support. H was being supported to make a asylum claim by another London homelessness organisation, Case Worker was informed that H would be moving into home office accommodation so arranged medication supply however accommodation fell through and returned to the street. Arranged GP appointment to discuss management of diabetes while H was rough sleeping, coached on insulin use and storage. Partner organisations and GP had raised safeguarding concerns and were chasing Social Services for needs assessment and accommodation. Supported to attend and engage with course of dental treatment.