Call for evidence - inclusion health

Case Studies

• The Multi-disciplinary Team: START Homeless Outreach Services

  by Fran Busby, almost 3 years ago

  The START Homeless Outreach Services work across South London and are an integrated health and social care multi-disciplinary team for rough sleepers and people living in hostels, in 3 boroughs. They are funded by the 2 local ICBs as well as NHSE and OHID and provide both mental health and dual diagnosis care for people with co-occurring conditions. This is delivered by using a relationally focused outreach approach that works across transitions, to achieve recovery, stable housing and an eventual transfer back into mainstream care.

  The teams are made up of social workers, psychiatric nurses, OTs, psychology and psychiatry, peer... Continue reading

  The START Homeless Outreach Services work across South London and are an integrated health and social care multi-disciplinary team for rough sleepers and people living in hostels, in 3 boroughs. They are funded by the 2 local ICBs as well as NHSE and OHID and provide both mental health and dual diagnosis care for people with co-occurring conditions. This is delivered by using a relationally focused outreach approach that works across transitions, to achieve recovery, stable housing and an eventual transfer back into mainstream care.

  The teams are made up of social workers, psychiatric nurses, OTs, psychology and psychiatry, peer support, nurse prescribing and GP trainees and can offer medication, Care Act assessment, formal safeguarding, admission to hospital, application to Court of Protection, physical health care, referral to specialist residential care or rehabilitation as well as therapy and practical support. This is all available after a period of pre-treatment aimed at engagement and developing trust so that successful outcomes are more likely and is carried out by staff outreaching new clients in an intensive and engagement focused manner. The teams also act as a bridge between the third sector and statutory services, supporting and educating the former and advocating to and acting as inclusion health leads to the latter.

  The team is featured in the NICE Guidance for practitioners as an example of integrated health and social care made accessible for homeless people.

  Data is captured for the pilot teams funded by NHSE and OHID and demonstrates encouraging outcomes in improving accessibility of mental health and substance use care, reducing homelessness and increasing positive move on and a reduction in use of emergency health care and criminal justice contact. These findings and the approach of the team are being shared across partners in health and homelessness forums in London and the service model has been influential in several newly commissioned teams both in and outside the capital.

  The following case studies provide a flavour of the approach and work:

  Shelly is a 35 year old Somali woman with a history of early trauma. She lost her flat and son after an episode of post-natal illness, was not seen by mainstream services and ended up street homeless. She was evicted repeatedly from hostels and TA for assaulting staff in what appeared to be highly dysregulated states, but was seen as having substance misuse issues. She was unable to engage with any mental health care or assessment. The team care coordinator started working with Shelly when she moved into an Assessment Centre and built a positive, confiding relationship based on understanding her early experiences, tolerating resistance to contact and consistent care. This led to a more robust assessment and eventually an inpatient admission. She was diagnosed with Bipolar Affective illness, treated and moved into specialist hostel. She sees her START worker regularly, continues medication, is seeing her sister again and is soon to step down to low support housing.

  Key words: engagement, holistic assessment, relational care, assertive treatment

  Nicky is a 45 year old Spanish man who is a long term alcohol user and has EUPD. He has been street homeless for many years due to lack of benefits. He has repeated crisis presentations. He was referred by his hostel in a state of profound self-neglect: he was incontinent and his room full of hoarded rubbish. For weeks he just shouted at his social worker: eventually persistence paid off, he was supported to see the hostel GP and clean his room and see the addictions psychiatrist. His SW built a trusting relationship, worked around harm minimisation and after 6 months Nicky went to detox and rehab and was resettled out of London.

  Key words: hopefulness, persistence, motivational interviewing, outreach

  The teams are hoping to secure long term commissioning through demonstrating the outcomes achieved by this approach and to eventually merge the dual diagnosis and mental health sub teams into one overarching, statutory complex needs MDT for homeless clients in South London.

• Gypsy Roma Traveller Health Needs Assessment - Kent County Council

  by Megan Abbott , 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

  
  

  1) Permission: Do you give permission from the individual/group to share this case study? Please ensure submissions are anonymised.

  Yes

  2)Permission: Do you have permission from your organisation to share this case study? Do you have permission from any partner organisations also named to share this case... 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

  
  

  1) Permission: Do you give permission from the individual/group to share this case study? Please ensure submissions are anonymised.

  Yes

  2)Permission: Do you have permission from your organisation to share this case study? Do you have permission from any partner organisations also named to share this case study?

  Yes

  3) Permission: Do you give permission for NHSE to share this case study and publish it as part of the framework?

  Yes

  4) Logo: Would you like to share your logo for use? If yes, do you give permission for it to be published with your case study in the framework?

  5) Organisation/s: What organisation/s were involved?

  Kent County Council Public Health

  6) The challenge: What was the issue you were trying to solve? Include which Inclusion Health Group the initiative focused on and its level i.e. community/locality/system

  Gypsy Roma and Traveller inclusion health group.

  It is recognised nationally that Gypsy, Roma and Traveller communities have significantly poorer health outcomes than the general population of England and these inequalities in health are a result of interactions between adverse environments (living, working and social), lifestyle behaviours and poor access to health, care and wider support services. Kent has a higher percentage of Gypsy and Traveller people than the England average and many Roma communities. Nationally there is a lack of focus on Gypsy, Roma and Traveller communities in Joint Strategic Needs Assessments which results in these communities being overlooked when planning services.

  In response to these issues the council’s Public Health Team carried out a Gypsy, Roma, and Travellers Health Needs Assessment (HNA) to update the previous HNA of 2015.

  The aim of the Gypsy, Roma and Traveller Health Needs Assessment was to identify the health needs (including wider determinants) of the Gypsy, Roma and Traveller communities in Kent, to describe the current services and support in place to address these needs, and to identify the gaps in meeting these using evidence-based or best-practice approaches and make recommendations for future improvement.

  7) The approach/solution: What did you do? What help did you receive? How did you go about delivery?

  This HNA used an epidemiological and corporate approach described by Stevens and Rafferty to:

  • Describe, and where possible quantify, the scale of health needs faced by Gypsy Roma Traveller communities across the life-course (epidemiological).

  • Obtain stakeholder views on the needs for health and care services amongst Gypsy Roma Traveller communities and elicit views on the extent to which these needs are currently being met and barriers faced (corporate)

  • Map current community, health and care services available to Gypsy Roma Traveller communities against evidence-based/best practice standards in order to make an assessment of met and unmet need.

  The needs assessment has been carried out in two waves (wave 1 is now complete, wave 2 is planned to commence in summer 2023).

  Wave 1

  The aims of this wave was to:

  1. Identify those stakeholders (commissioners, service providers, Gypsy Roma Traveller community advocates) who were key informants for the needs assessment and who can also facilitate access to Gypsy Roma Traveller communities in Kent

  2. Build a picture of the Gypsy Roma Traveller communities within Kent from key stakeholders including an assessment of met and unmet health and care needs

  3. Co-design Wave 2 participatory research to uncover Gypsy Roma Traveller community members' perception on their collective needs, as well as their attitudes towards these needs.

  A mixed methods approach was used to describe the scale of health needs faced by Gypsy, Roma, and Traveller communities in Kent. A variety of stakeholders from health and social care, Kent County Council, Voluntary Community Sector Enterprise (VSCE) services, community advocates and other statutory services were interviewed to obtain views on the needs for health and social care services amongst Gypsy, Roma and Traveller communities and the extent to which these needs are currently being met and barriers faced.

  The groups in scope for this HNA were the Romany Gypsies, Irish Travellers and Roma groups. These are ethnically and culturally diverse groups although share the tradition of a nomadic lifestyle. When referred to collectively in this paper, it is with the understanding that there are differences between these communities which are recognised and acknowledged; equally, there are aspects of similar shared experiences which are also recognised.

  8) Insights and impacts: What evidence proves it worked? What difference it makes to the Inclusion Health Groups? How did this improve experiences, access and inclusion? How did this improve their health and help address health inequalities?

  The HNA report highlights the significant health inequalities faced by Gypsy, Roma, and Traveller groups across Kent which are in line with what is known about the health needs of these communities nationally. These health inequalities result from longstanding inequalities in the wider determinants of health as well as inequities in access to preventative, screening, and treatment services. These are exacerbated by experiences of stigma and discrimination faced by these communities. Additionally, levels of health literacy, cultural and health beliefs shape the way community members view the need for services.

  Findings suggest that action taken at individual, provider and system level will improve health outcomes for Gypsy, Roma, and Traveller people.

  Kent County Councils HNA makes several recommendations covering the following areas:

  • Instigating and monitoring Gypsy, Roma and Traveller ethnicity reporting in health, social care and Voluntary Community Social Enterprise (VCSE) services across Kent.

  • Using policy levers and system leadership to develop a system-wide approach to addressing health needs.

  • Increasing more joined up working between services and co-design with service users.

  • Investing in developing trust and culturally competent services.

  • Addressing health and mental health literacy through accessible information sources, peer support and adult education.

  • Training trusted individuals in Making Every Contact Count (MECC) to support healthy lifestyles and uptake of preventative services.

  • Identifying primary care champions, developing communities of practice and promoting inclusion health audits.

  • Developing innovative solutions to support those living nomadic lifestyles attend screening and routine appointments.

  • Investing in and training of community members to increase employment opportunities.

  • Developing granular understanding of community needs though furthered in-depth research with community members.

  The findings of the HNA have been shared with many groups across Kent and the Southeast Region. This has resulted in a raised awareness of the significant health inequalities faced by Gypsy Roma and Traveller groups and has led to the development of 'Provider Network Community of Practice' in which organisations across a range of statutory and voluntary sectors can share best practice. Other recommendations will be progressed through relevant KCC and Kent and Medway ICB workstreams.

  Other impact:

  We also plan to carry out the next iteration of this research:

  Wave 2

  The aims of this wave are to:

  Conduct qualitative research with Gypsy Roma Traveller communities to:

  a. Understand lived experience of this community

  b. Provide a deeper understanding of the issues faced in relation to health and social care services, barriers to access and gaps in services.

  c. In the absence of data to undertake a health and wellbeing survey to accurately capture the health needs of different subsets

  d. Findings to be triangulated with Wave 1 to determine priorities and generate a final set of recommendations.

  It is expected for Wave 2 (community engagement) to commence around Summer 2023. It was crucial for us to develop trusted relationships with stakeholders first and ensure we had gained knowledge and understanding regarding barriers and challenges with the community engagement before commencing with Wave 2.

  Clinical Research Network Kent Surrey and Sussex

  The CRN KSS underserved funding call has invited submissions of well developed plans from across the health and care system. The funding will support collaborative projects with strong potential to make a tangible difference in increasing access to health and care research for under served communities.

  Subject to being successful in this funding, we plan to develop research capacity in the community; allowing trust to be built, relationships to develop and maximise efforts of Wave 2 community engagement (above).

  Provider Network Community of Practice (Gypsy Roma Traveller)

  A quarterly meeting whereby key stakeholders in Kent will come together to discuss successful engagement, best practice, what’s working, as well as challenges and barriers; offering a forum of support and shared learning for professionals working to improve the health and wellbeing of these communities in Kent (first meeting planned for end of June).

  9) What people said: Any quotes or feedback from service users, staff, management or decision makers

  The HNA has been positively received by many stakeholders and the Head of the KCC Gypsy Roma Traveller Resident Service said that the work offers “more of a raised awareness of the importance of forming strong partnerships with health colleagues, and other trusted partners to make improvements for residents (…) it will bring additional benefit which will result in better outcomes for residents.”

  10) Tips for success: Approaches or links that make a difference or lessons learned.

  There are several pockets of best practice in Kent where individuals and services have recognised and responded to specific needs of the Gypsy, Roma, and Traveller communities. This had both fostered trust and engagement with communities and supported better health outcomes.

  ‘Best practice’ has been derived from the triangulated recommendations from stakeholder engagement and previous work undertaken in Kent to understand the health needs and barriers faced by the Gypsy Roma and Traveller communities. This includes:

  • Building trust with the communities in a sustainable and proactive way.

  • Offering relevant information and ensuring information is relayed in an appropriate format for the audience.

  • Using already established relationships and existing engagement.

  • Investing in workforce training to ensure there is understanding about cultural differences and experiences.

  • Offering a joined-up approach and exploring partnership working; utilising all contact with these communities where appropriate.

  We are planning future work with the Gypsy Roma and Traveller communities to explore and co-create approaches to achieve the above.

  However, ‘best practice’ services are often reliant upon the commitment of individuals and can be subject to short term funding. To succeed and be sustainable there is a need for system-wide recognition of inequalities faced and development of commissioned services and practices to address these.

  11) What next: What are you doing next?

  • Publish the HNA on the Kent Public Health Observatory website.

  • Socialise findings and recommendations in relevant fora and explore opportunities for collaborative work with existing engagement in the system (especially where recommendations can be maximised).

  • Subject to CRN KSS Underserved programme funding we plan to develop research capacity in the community; allowing trust to be built, relationships to develop and maximise efforts of Wave 2 community engagement.

  • Undertake Wave 2, which consists of qualitative interviews with Gypsy Roma and Traveller community members to understand the lived experience of these communities and in the absence of data to undertake a health and wellbeing survey in order to accurately capture the health needs of different subsets. Findings will then be triangulated with Wave 1 (stakeholder engagement findings) to determine priorities and generate a final set of recommendations.

  •Engagement work must be done sensitively and slowly in order to gain trust and ensure sustained work. Potential of health inequalities funding next financial year; this JSNA and CRN KSS funding (TBC) will be the groundwork to enable future sustained funding to support these communities.

  
  

  
  

• A partnership approach to tackling health inequalities in cancer screening

  by Kajal Lad, almost 3 years ago

  Leicestershire County Council (LCC) has been working in partnership with Primary Care, Charnwood GP Network and Charnwood community groups to reduce health inequalities in cancer screening (cervical, breast and bowel) and support future work in a partnership arena that uses a population health management approach to tackling health inequalities. As part of the Charnwood’s PCN tackling Health Inequalities plan, the project involved exploring the perceptions, experiences and influences to attending cancer screening in communities with poor uptake. The five communities of interest identified were a) Bangladeshi, b) Polish, c) Homeless, d) Carers and e) Gypsy Roma Travellers.

  To understand the... Continue reading

  Leicestershire County Council (LCC) has been working in partnership with Primary Care, Charnwood GP Network and Charnwood community groups to reduce health inequalities in cancer screening (cervical, breast and bowel) and support future work in a partnership arena that uses a population health management approach to tackling health inequalities. As part of the Charnwood’s PCN tackling Health Inequalities plan, the project involved exploring the perceptions, experiences and influences to attending cancer screening in communities with poor uptake. The five communities of interest identified were a) Bangladeshi, b) Polish, c) Homeless, d) Carers and e) Gypsy Roma Travellers.

  To understand the experiences and influences to cancer screening within the specified groups, a qualitative approach was deployed. Six Focus Groups were formed with the community groups of interest which allowed a deep dive into their understanding and experience of cancer screening as well as their barriers and their enablers. A quantitative approach was also employed to look at the variation in screening uptake by GP practice and PCNs using data published by Office for Health Improvement & Disparities (National Practice Profiles).

  There were similarities between the groups, as well as differences. The main themes that emerged from the focus group discussions included: Thirst for knowledge, Experience of healthcare, response to screening/experiences ad perceptions, cultural nuances, fear and fatalism and impact of being a carer. Key barriers and enablers are highlighted in the table below:

  Barriers	Enablers
  Lack of knowledge and misinformation	Influence of family history
  Language and Technology	Reminders
  Access to the GP and lack of transparency in care provided	Different access options
  Intimate nature of screening and fear of the unknown	Previous good experience of healthcare
  Cultural issues	Easy access to information
  Not taking into account wider issues e.g. mental health	Use of trusted messengers
  Fear
  Health literacy

  
  

  Arising from the research undertaken, the following recommendations have been made:

  • Building trust and rapport - implementing co-production. Co-production of health events and information for the local community.
  • Improving access to healthcare - exploring alternative times (weekends and evening) for appointments which could bring about more meaningful engagement from those who cannot access traditional appointments with primary care.
  • Improving knowledge and awareness - using trusted sources to share information within the community. GPs and local health champions were identified as the most trusted sources for health-related information.

  As a result of the recommendations made, two PCNs (Beacon and Carillon) within the Charnwood GP Network have started; Offering Saturday appointments via the extended access service to increase cervical screening uptake; Information has also been collected on patients that have declined bowel cancer screening to fully understand the reasons for the decline in offer and Making Every Contact Count approach has also been adopted, with staff undertaking the current training offer provided by Public Health.

  The LCC Public Health team, along with University Hospitals of Leicester (UHL) colleagues and Charnwood GP Network also worked in partnership on a multidisciplinary outreach pilot which involved hosting Respiratory Outreach clinics across two PCNS (Carillon and Beacon). The clinics were used as an opportunity to provide holistic care to patients in the community.

  In addition to the above, the Public Health team, along with ICB colleagues, provided an educational workshop session in September 2022 on how other members of the PCN can embed a population health management approach to tackling inequalities within the population. This was an opportunity to share any learning and resources with other PCN members.

  A bowel cancer screening audit was also conducted to explore the outcomes of the telephone call intervention by the healthcare provider and the interventions effectiveness. The audit showed that for those who did not complete a bowel screening test, the main themes identified for not completing the screening test were round having other priorities, not interested and kit not being received. The enablers were focussed around receiving more information on how to order a kit, bowel screening, method of collecting a sample and bowel cancer.

  The LCC Public Health team continues to work in partnership with the Charnwood GP Network to closely monitor the outcomes of the extended/enhanced access service and how this contributes to increasing cancer screening uptakes across Charnwood.

• Royal Berkshire NHS Foundation Trust's "Meet PEET" (Patient Experience Engagement Team)

  by Kirsten Rogers, almost 3 years ago

  The Royal Berkshire NHS Foundation Trust’s Meet PEET (Patient Experience Engagement Team) initiative focuses on engaging and listening to seldom heard groups in our community, for example, those in deprivation index 1 and 2 (the highest level of deprivation) or those who have challenges accessing our healthcare services or a disproportionately poorer patient experience. This might be because of language difficulties or other accessibility needs. We know, for example, that those in deprivation index 1 and 2, are more likely to come to the Emergency Department; more likely to be admitted as an inpatient; more likely to have longer waits... Continue reading

  The Royal Berkshire NHS Foundation Trust’s Meet PEET (Patient Experience Engagement Team) initiative focuses on engaging and listening to seldom heard groups in our community, for example, those in deprivation index 1 and 2 (the highest level of deprivation) or those who have challenges accessing our healthcare services or a disproportionately poorer patient experience. This might be because of language difficulties or other accessibility needs. We know, for example, that those in deprivation index 1 and 2, are more likely to come to the Emergency Department; more likely to be admitted as an inpatient; more likely to have longer waits for outpatient appointments and are more likely to not attend the appointments they do have.

  We are committed to improving access and patient experience for all and know that we need to listen to more diverse patient groups to fully understand their needs and how we can improve our services. We draw in specialities from across the Trust to give them opportunities to engage with our local community and our Meet PEET team is culturally sensitive, i.e. is comprised of nurses from diverse backgrounds, which helps build trust with community groups.

  We aim to:

  1) build relationships and trust

  2) understand and respond to different communities’ varying healthcare needs

  3) break down myths and barriers and improve equity in healthcare.

  Meet PEET includes the following flexible programme of activity:

  • Mini health checks in the local community, to start conversations about health.
  • Large engagement events with particular community groups, e.g. Gurkhas, Sikhs and Pakistani communities.
  • Junior Carers programme – engaging primary school children in our less affluent areas of Reading to become School Health Ambassadors and learn more about health topics and NHS careers.
  • Youth Forums – Engaging with 16-24 year olds, so that we can listen to, and involve, young people in Trust decisions that can improve services for current young patients and future generations.
  • Specialist groups/focused work – working with diverse groups of the community with particular needs (e.g. carers, deaf and hearing impaired, etc.), or, for example, working with particular faith groups.

  So far our various engagement activities have resulted in numerous benefits for different community groups. For example, our large scale events working with the Gurkha community have included sessions on cancer red flags, benefits of exercise, palliative care services etc. We have also worked with them to develop interventions to improve their experience, like creating a National best practice guide on ‘visiting hospital’ written in Nepalese.

  Our mini health checks are recognised locally as a shining example of how to engage the local community in health care. Over 22-23 we conducted over 700 mini checks which identified over 35% of those individuals had high blood pressure, 20% had high blood sugar and nearly 50% had high BMI. All those were signposted to further support for those issues. However, more importantly, often those individuals used it as an opportunity to share concerns they had about other health problems or the challenges they had faced accessing, for example, GP services or attending hospital appointments. Our nurses were able to help individuals with specific challenges, for example, calling the GP and requesting translators to be available for appointments, or connecting individuals with pharmacists who could check medications. However, the Trust was also able to make other interventions, for example, developing a social media campaign to highlight to those on benefits that they can claim travel expenses to their appointments – this was one of the key reasons those on low incomes were not attending appointments.

  Our young people initiatives have given children of all ages opportunities to engage with our health services. Our Junior Carers programme provides primary school children in the lower deprivation indexes with opportunities which they wouldn’t normally be able to access. We have shared health information with them that they can pass on to family and friends, as well as inspiring careers in the health sector. They have also undertaken a 15 steps observational assessment in our Children’s wards to provide a valuable alternative perspective, on improvements which could be made. For older children, we have provided Health4youth tours around the hospital to help influence their career choices and show the diversity of opportunities available in healthcare, and our Youth Forum gives young people a voice to influence our strategy and service designs for the benefit of all young people now and in the future.

  Engaging with the community has provided huge benefits for us as a Trust but also for the individuals and groups we work with in the community. Our Gurkha community leader said: “It was so important and very helpful to the communities and as an individual to give awareness, advice and very basic knowledge, to prevent from all possible health problems. We are so honoured and privileged to be part of the programme.”

  Our Community partner in Whitley, one of the areas we do regular mini health checks at, said: “It’s a real inspiration seeing partnership really working to the benefit of the community”.

  Our voluntary sector community partner (Reading Voluntary Action) said following one of our events: “Another successful day, where visitors, staff and volunteers spoke about how important it was to have someone who listened, took care and was so approachable and friendly. Some people who visited the team shared their negative experiences with healthcare professionals in the past”.

  One of the individuals we supported at an asylum hotel said: he was extremely grateful for the time, dedication and interest we took in his health. He also felt empowered when given the blood glucose monitor. He felt in control and understood what he needed to do.

  The key to making this approach successful is working with community leaders who know their community well. These individuals can help shape our engagement activities from best times and locations, types of engagement which would work best, promotion and encouragement to attend and topics they would like to focus on. We are very flexible in our approach, listen carefully to what people tell us and then make changes depending on their needs. Being out in the community rather than expecting people to come to us and attending places regularly really helps build trust.

  Moving forward we are looking to grow our engagement activities and work with more areas of our community. We are working closely with our Integrated Care Board to build a sustainable programme of events and to enable us to link the work we do with individuals into primary health care, i.e. ensure information from our mini health checks is added to patient records and triggers further interventions if needed. We are also focusing on key topics which will have the biggest health improvement outcomes in our area, for example Cardiovascular Disease, as well as still encouraging specialities across the Trust to use our engagement events as an opportunity to learn from their community.

• LGBTQ+ Migrant Health Inclusion

  by Ibtisam Ahmed (he/him), almost 3 years ago
  

  LGBT Foundation is a charity dedicated to empowering and uplifting LGBTQ+ communities, with a focus on health and wellbeing initiatives. As part of our membership in the National LGBT Partnership, we work regularly with the VCSE Health and Wellbeing Alliance. Our 2022/23 work programme included a project dedicated to finding out more information about the barriers to accessing healthcare for LGBTQ+ migrants. We interviewed several participants with the aim of best understanding how inclusion health practice can approach complex lived experiences holistically instead of segregating identities into disparate, constituent parts.

  Participant 6 shared an instance of when they first registered... Continue reading

  LGBT Foundation is a charity dedicated to empowering and uplifting LGBTQ+ communities, with a focus on health and wellbeing initiatives. As part of our membership in the National LGBT Partnership, we work regularly with the VCSE Health and Wellbeing Alliance. Our 2022/23 work programme included a project dedicated to finding out more information about the barriers to accessing healthcare for LGBTQ+ migrants. We interviewed several participants with the aim of best understanding how inclusion health practice can approach complex lived experiences holistically instead of segregating identities into disparate, constituent parts.

  Participant 6 shared an instance of when they first registered with a GP in the UK. They had never lived here before, meaning they were learning to navigate an entirely new healthcare system and culture. They were not fluent in English at the time and shared a concern around translation: “I did not know the translator and was not told how they were given to my case. Because I have some specific local terms that describe my sexuality, I was constantly worried that my answers were not being properly recorded and there was no way for me to find out.”

  Translation is a basic access issue for anyone requiring linguistic support, but that support also needs to be culturally competent. It is not just a case of translating broad terms, but specific and nuanced terminology. Participant 6 was not sure they were able to fully advocate for themselves in what should be a routine healthcare process. Moreover, they had no way of evaluating the situation and offering feedback to their provider.

  In this specific instance, it is vital for healthcare professionals and services to check with LGBTQ+ and migrant groups and communities to ensure the quality of translation. As a broader recommendation, this case study underlines the importance of coproducing service delivery, and accommodating nuance. LGBT Foundation is aiming to publish a report on our findings on LGBTQ+ migrant health inclusion, including a series of best practice recommendations, similar to our previous and ongoing work with other community groups. We hope this creates more conversations about complex needs, ultimately empowering communities and individuals like Participant 6.

  
  

• RESPOND: an integrated asylum-seeker and refugee health service

  by Sarah Eisen, RESPOND, almost 3 years ago

  RESPOND is an integrated, co-designed health system providing services for asylum seekers and refugees (ASR). Our Outreach Assessment Service has seen more than 1400 asylum-seekers in initial accommodation centres in North-Central London (NCL), exploring physical, mental, sexual, dental and social health needs (aligned to CORE20PLUS5), using a holistic care-planning framework to promote service access. A specialist multidisciplinary team (MDT) facilitates partnership-working, and a comprehensive patient-held health plan is created for service-users. RESPOND addresses health inequality in a vulnerable population, and has demonstrated improved access to health services, identification of health needs and patient / stakeholder experience.

  
  

  The Challenge

  RESPOND was... Continue reading

  RESPOND is an integrated, co-designed health system providing services for asylum seekers and refugees (ASR). Our Outreach Assessment Service has seen more than 1400 asylum-seekers in initial accommodation centres in North-Central London (NCL), exploring physical, mental, sexual, dental and social health needs (aligned to CORE20PLUS5), using a holistic care-planning framework to promote service access. A specialist multidisciplinary team (MDT) facilitates partnership-working, and a comprehensive patient-held health plan is created for service-users. RESPOND addresses health inequality in a vulnerable population, and has demonstrated improved access to health services, identification of health needs and patient / stakeholder experience.

  
  

  The Challenge

  RESPOND was established in response to large numbers of asylum-seeking children, families and lone adults placed in our sector during the COVID-19 pandemic. Existing healthcare systems neither had capacity nor could easily respond to the needs of the population, who are known to face significant barriers to accessing healthcare, and to have extensive and complex health needs, affecting physical, mental, sexual, dental and developmental health.

  The Approach

  RESPOND sought to develop, operationalise and evaluate a novel co-designed model to tackle health inequality and improve patient outcomes and experience. Using a fixed budget from sectoral funding and, later, per capita commissioned funds, RESPOND recruited and trained a team to deliver holistic community-based health assessments and care planning to asylum-seekers across the sector.

  RESPOND aimed to provide a flexible service, responding to changes to accommodation sites, proactively identifying eligible people and achieving effective engagement, including GP registration. A framework was developed to cover all key CORE20-PLUS5 priorities for both adults and children and to identify and address unmet physical, mental, dental and social health needs. A network was established to facilitate onward referral through partnership working across primary, secondary and tertiary health care services as well as local authority, social care and third sector organisations.

  By developing and validating a comprehensive electronic screening tool we developed live dashboards for continuous real-time review of relevant metrics. We established a programme of continuous improvement based on service-user /stakeholder feedback, health encounter data and longer term evaluation to assess impact on wider health systems and cost implications.

  Impacts

  Patient access

  Through proactive liaison with accommodation sites by specialist nurses, community outreach clinics were established for 12 sites across 4 boroughs and more than 1400 patients have been seen to date. None had previously received health screening. Development of bespoke administrative processes in response to service-user and stakeholder feedback increased attendance rate. Service-users were supported to register with a GP.

  Patient Outcomes

  A bespoke electronic screening tool identified extensive unmet health needs across CORE20PLUS5 domains. Of those assessed, 94% underwent infection screening; 100% with infections completed treatment. 100% received an Integrated Healthcare Plan. Approximately 3-5 referrals/patient were made supporting service users to access appropriate healthcare at the right time in the right place for them. More than 150 patients have been supported by our Complex Case MDT. We are securing academic funding to evaluate long-term outcomes. Service-user feedback reflected perception of health outcome improvement.

  Public health

  RESPOND identifies those in need of immunisation and identifies significant asymptomatic infection (45% of patients had at least one infection, including latent tuberculosis infection, hepatitis B and sexually transmitted infections). RESPOND was able to detect outbreaks of infection early and liaise with UKHSA and Health Protection Teams.

  Advocacy and research

  RESPOND has consistently advocated for appropriate service provision for ASR populations in NCL and nationally, with publications and contributions to national guidance and policy. RESPOND has a large dataset regarding ASR health needs, including the voice of the population themselves.

  Value for money

  Systematic, continuous data collection and detailed evaluation has achieved significant efficiencies. By proactively identifying and addressing health needs, RESPOND impacts positively on wider services in terms of capacity and cost, helping prevent acute, unplanned, complex presentations. Direct referrals save approximately £3.60/min (approximately £72/patient, or £77k of GP time for the patients seen to date). Our data suggests significant cost-saving potential by RESPOND by identifying infections alone.

  
  Sharing of learning:

  Learning has been shared locally, regionally and nationally, with organisations such as UK Refugee Council and Helen Bamber Foundation and with people with lived experience. Our work has been presented in national and international academic fora and is in preparation for publication in peer reviewed journals. We have developed a freely available online training series. Our work has contributed to workstreams of UK-HSA and RCPCH.

  What did people say?

  Stakeholders, service-users and people with lived experience (PLE) have been crucial to design, development, implementation and evaluation. A formal panel of PLE will imminently be convened to inform development of both clinical and research agenda.

  Response to feedback has improved administrative, clinical, referral and communication processes.

  Stakeholders:

  I was very impressed by how (RESPOND) brings expertise together for coordinated care planning - Health Visitor

  Great for improving communications between different agencies, formulating bespoke individual care pathways for children and families - Safeguarding Lead

  Immensely efficient – rapid decision making between large number of key people. Brings together expertise and experience. ble – GP

  There is a real gap in...provision and knowledge in healthcare professionals - it's what the NHS needs...that structure and training... and an evidence-based approach to deal with a whole lot of complex needs - 3rd Sector GP

  There's a real opportunity to work with RESPOND to get a richer picture of the asylum seeker experience and how all different agencies can come together to meet those needs – Commissioner

  RESPOND will take huge pressures off local services - 3rd Sector GP

  RESPOND is absolutely how I would want to see every asylum seeker who arrives in this country receiving healthcare – GP

  Their innovative and proactive approach to providing outreach support to this vulnerable and socially excluded group has resulted in increased access, streamlining of service use and a significant improvement in partnership working across the health, social care and charitable sectors – Chair of ICB

  RESPOND has played a pivotal role in addressing the health needs of one of our most underserved and vulnerable communities. Commissioner

  RESPOND prioritises early detection and effective system working so that people receive the appropriate intervention in a timely way, and this in turn helps to protection wider population health and reduce the burden on both primary and secondary healthcare services - UKHSA

  I have been struck by the passion and motivation of the UCLH team to drive research to improve patient care and health outcomes in these marginalised communities – Academic collaborator

  
  RESPOND is one of the leading innovation and multiagency services in the refugee sector in reducing healthcare inequalities and promoting wellbeing – Refugee Council

  
  Service Users:

  
  

  Information about services was very useful

  It can be difficult as we don’t understand the language. In (RESPOND) they get interpreters – that's good

  (Registering with a GP) is very important, I needed that support

  Because we are refugees... (people) don't respond...in a good way. But they treated us like normal people and I think that's the most important thing for me

  You are doing everything you can. You are doing the best job to help us. I want to thank you for everything you are doing

  It is designed well and it covered everything. Today’s appointment with the RESPOND team was wonderful

  For the first time, I talk about all the things (to) the same person, like healthcare...about problems, about background, all the issues I have. Sharing even part of the story... you just (feel) lighter

  I like having an appointment with my family. We are completely satisfied with the service and I hope it continues. I am grateful

  Has the appointment today addressed all the health needs of my family? 100%

  Tips for Success

  • proactive engagement (eg outreach into accommodation to identify individuals and bespoke administrative processes by trained staff) overcome barriers to healthcare access, addressing health inequalities
  • novel approach (eg holistic one stop assessment) addresses complex needs efficiently and effectively and delivers cross-sectoral care
  • there is a significant saving of time and money in wider NHS services as a result of a proactive approach
  • staff trained in trauma informed care delivery ensures compassionate inclusive healthcare
  • a holistic approach is essential to optimise efficiency, and identify health issues which, if not addressed, are likely to lead to unplanned presentations
  • A family multidisciplinary approach ensures equity of access to screening and treatment for family groups
  • provision of a written integrated health plan prevents omission and duplication and allows empowerment of service user to advocate for themselves if relocated
  • cross sector work is key; partnerships with eg social care, health visiting, primary and secondary care are cost effective and efficient
  • there is a significant impact on staff due to vicarious trauma; peer review and reflective practice are vital
  • innovative approaches to funding is necessary for these services which need to work across traditional sector boundaries to deliver appropriate care. Equity of access for all asylum-seeker and refugee populations is essential.

  Next steps

  RESPOND is currently working to secure sustainable commissioning for our outreach holistic assessment service. Our other services continue, with high numbers of service users. We are developing a programme of patient and public involvement to inform next steps of our service development and evaluation, and to inform our research priorities. We are analysing our initial evaluation for publication and look forward to sharing data which will inform future service development.

  Permissions

  Links to all 5 Inclusion Health principles.

  Permissions in place for all individuals, groups, organisations, and permission is given for NHSE to share this case study and publish it as part of the framework.

  Logo can be shared for us and permission granted to publish it.

  Host Organisation: University College London Hospitals NHS Foundation Trust.

  
  

• Salford Partnership Out of Hospital Care Model

  by Lydia Duncan, almost 3 years ago

  Inclusion Health Case Study

  • Permission- Sadly, this case study submitted is for a deceased person, but permission has been obtained from their next of kin. When asked Lucy’s sister said: “Anything to get that support back in place and help others as you all worked wonders for Lucy and I can't fault any of you”.
  • Permission- Greater Manchester Mental Health (GMMH) Foundation Trust has provided permission for this case study. Partner agencies, Salford City Council and Inclusion Health GP have also provided their consent for this to be shared.
  • Permission- We give NHSE permission to share and publish this case... Continue reading

  Inclusion Health Case Study

  • Permission- Sadly, this case study submitted is for a deceased person, but permission has been obtained from their next of kin. When asked Lucy’s sister said: “Anything to get that support back in place and help others as you all worked wonders for Lucy and I can't fault any of you”.
  • Permission- Greater Manchester Mental Health (GMMH) Foundation Trust has provided permission for this case study. Partner agencies, Salford City Council and Inclusion Health GP have also provided their consent for this to be shared.
  • Permission- We give NHSE permission to share and publish this case study in the framework.
  • Logo- We give permission for the GMMH logo to be used with the case study in the framework.
  • Organisations- GMMH, Salford City Council, ForHousing and Salford Primary Together (SPCT) inclusion Health GP were involved (via the Out of Hospital Care Model pilot)
  • The challenge:

  Lucy was a 50-year-old woman who was identified as homeless during her general hospital admission in 2021. Lucy had a housing assessment with a Salford City Council housing officer whilst she was on the hospital ward. Lucy was allocated to a 1-bedroom bungalow in Salford on discharge through the Out of Hospital Care Model, which was a pilot partnership between Salford City Council, GMMH and SPCT.

  Lucy had complex physical health problems; she had a diagnosis of advanced liver disease and hepatic encephalopathy. She had been referred for consideration of a liver transplant. She was successfully treated for hepatitis C in 2015, the liver disease, was thought to be secondary to the Hep C infection. She had an extended admission to hospital from August to November 2021 and she moved into the new accommodation after this admission.

  The GMMH dual diagnosis practitioner discussed with Lucy her mental health and substance misuse history. Lucy had been using heroin and crack cocaine for over 20 years. Lucy reported that using substances was behind her; she had been injecting heroin and crack cocaine for many years and was supported by services who had recently discharged her. She told us that she had no desire to use since her physical health was so poor and she physically couldn’t go and source any drugs.

  One of Lucy’s brothers and her mother had died in recent years. She was still grieving the premature loss of them both and would often talk about her past, traumatic experiences. Lucy would express a lot of fear around her hospital admissions. Lucy would sometimes communicate her distress and fear through agitation and anger, particularly when she was treated in hospital against her wishes. Around six years previously Lucy had been diagnosed with psychosis and was prescribed an anti-psychotic, although this had not been reviewed for some time.

  Unfortunately, Lucy had several re-admissions to hospital with features of decompensated liver disease, including bleeding from her gut due to liver cirrhosis, hepatic encephalopathy (confusion due to liver cirrhosis) and severe liver and subsequent kidney failure. During some of these admissions, Lucy presented as aggressive due to her confusion, however due to previous mental health diagnoses this was not always recognised.

  Her admissions to hospital were distressing experiences for Lucy. It was difficult to gain intravenous access for Lucy so she would need a central line put in place which caused her distress, and this became infected. She would often vomit blood and experienced incontinence.

  Lucy was admitted in March 2021, again following an episode of confusion. During this admission she showed signs of further deterioration, her kidneys as well as an admission to critical care. She was in considerable pain, but prescribing was limited to non-opiate based analgesia due to the risk of further exacerbation of her hepatic encephalopathy.

  Towards the end of April 2021, while still an inpatient, Lucy expressed to the consultant who was looking after her that she no longer wished to have care in hospital and wanted to return home (which was the out of hospital model provided accommodation).

  The challenges were around Lucy’s needs to be fully understood by universal services in the context of mental health, substance misuse, physical health, and homelessness. Lucy’s family were very important to her, but she was unable to sofa surf any longer due to her deterioration in physical health. The challenges for the services were balancing her wishes with her needs. Lucy’s distress and capacity required to be reviewed regularly and services required good joint working to reduce readmissions to hospital and to provide a dignified end of life support. Being homeless was a huge potential barrier for onward referrals between hospital and community teams. Having a historical mental health diagnosis, chronic substance misuse and declining physical health was challenging in terms of the level of knowledge, skills and understanding required for the universal services involved.

  • The approach/solution

  The Out of Hospital Care Model pilot partners worked together to ensure:

  • The GMMH dual diagnosis practitioner, the Salford City Council hospital-embedded Housing Options worker, housing support worker and relevant staff from SPCT discussed Lucy, her needs, joint care planning and actions at least weekly. A weekly MDT was created virtually.
  • Lucy’s family, specifically her twin sister who acted as her carer, were supported throughout. The GMMH dual diagnosis practitioner acted as advocate, offering referral for a carer’s assessment and liaising with adult social care to promote Lucy and her family’s experience and wishes.
  • A collaborative care plan was shared with the ward, which included a trauma informed way of working with Lucy to reduce her distress and increase her confidence in wanting to stay on the ward. This included a psychological formulation and details of other agencies involved to promote joint working.
  • The GMMH dual diagnosis practitioner regularly visited Lucy in hospital and liaised with the ward to share key information, promote Lucy and her family’s wishes, and increase communication to reduce the risk of preventable discharge and readmission.
  • SPCT provided an enhanced primary care response through a home visit on discharge from hospital and weekly telephone calls.
  • The GMMH dual diagnosis practitioner liaised with community teams to ensure the package of care provided was sustainable and was able to promote end of life services when required. The weekly MDT allowed this information to be shared with SPCT.
  • The partners attended “Complex Needs Training” facilitated by St Anne’s hospice which provided opportunities to build links and connect communities to support for people experiencing homelessness with advanced ill and terminal health.
  • Lucy’s temporary accommodation was furnished ground floor, accessible accommodation provided by ForHousing housing association, as part of a small portfolio of properties for this pilot. Salford City Council provided floating housing related support with the worker having a small caseload. This was not closed during her repeated admissions to hospital. This allowed her to be discharged to an appropriate property and all onward referrals would remain in place, such as district nurses and adult social care packages of care.
  • Lucy’s wishes were upheld. When Lucy asked to be discharged to the flat for end-of-life care this happened with the wrap around support of the partners. When this was no longer sustainable Lucy was involved in the decision to be admitted to a hospice and have her family around her in her last weeks.
  • The Out of Hospital Care Model was supported by Pathways Partnership Program, which allowed the partnership to receive monthly supportive calls and attend relevant training offered by Pathways. This consultation supported the interventions offered to be evidence based and allowed the model to be best practice in line with similar national models.
  • Insights and Impacts
  • Sadly, Lucy is not unique in being a homeless person with various needs struggling to access all required universal services due to their situation.
  • Evidence has shown that homeless people have trimorbidity (physical health, mental health, substance misuse), are 50 times more likely to have Hepatitis C than the general population (Beijer, U, et al, 2012) and are more at risk of early onset frailty (Pathways, 2020). The DOH (2010) found homeless people are 3 times more likely to be admitted to hospital and stay in 3 times as long as those who are not homeless.

  Homeless Link Homeless Health Needs Audit (2022) found that homeless people are almost 3 times more likely to report having a longstanding illness, disability, or infirmity than the general population and most of those with a diagnosed physical health condition are managing multiple comorbidities. Groundswell (2020) survey showed that 59% of women reported their health had contributed to them becoming homeless.

  In 2013 it was reported that 70% of patients who were homeless were discharged from hospital to the streets without having their care and support needs addressed (Cornes, M. et al, 2021) and in 2022 it was found that for those who had been admitted to hospital nearly a quarter (24%) had been discharged to the streets (Homeless Link, 2022).

  Having the partnership working together via the Out of Hospital Care Model meant that Lucy did not have to navigate the complicated homelessness and health and social care system alone. She had mental health, physical health, housing, and substance misuse professionals to assess, support, advocate and promote her needs through her end-of-life pathway.

  Lucy did not have to risk being ill on the streets, nor having to be brought back into hospital without a suitable discharge option or having a delayed discharge due to lack of accommodation. Lucy did want to self-discharge due to a trauma response to being in hospital, but this was explored and reduced at times by multi-agency working and shared formulation and communication.

  Unfortunately, due to the chronic nature of Lucy’s health the intervention did not improve her physical health, but it did allow Lucy (and her family) to have a dignified end of life, without the risk of street homelessness, with her wishes upheld and all services working in a joined-up response.

  The partnership accessed specific training to support their practice and was able to provide specialist advice to the other services involved to support knowledge and decrease any discrimination born out of a lack of knowledge and understanding of co- occurring conditions.

  • Revolving Doors (2019) published a capability framework for working with people who have co-occurring mental health and alcohol and/or drug use conditions (COMHAD). The out of Hospital Care Model demonstrated it met all aspects of the framework:
  • Values - showing compassion and empathy.
  • Effective management - flexible, person centred, assertive outreach.
  • Right care, right time - no wrong door.
  • Working effectively and collaboratively with multiple agencies - effective local pathways, information sharing processes and partnership working.
  • Working with families, carers, and significant others - recognising their own challenges and support needs.
  • Physical health and health promotion - preventing further poor physical health and treating current issues.

  Cornes, M et al (2017) looked at how to improve outcomes for people, including homeless people in intermediate care. The study concluded the following principles, which have been evident in the out of hospital care model in Lucy’s case:

  • Engagement work - working in consultation with Lucy around care planning, including decisions about the place of care and transitions to it.
  • Lucy’s physical reablement and broader health and well-being objectives were promoted by health, housing, and social care professionals as best they could.
  • Health, housing, and social care professionals worked together making sure local advocacy support was available.
  • During the critical transitional periods of Lucy’s care there remained a continuity of care.
  • What people said

  Lucy had told SPCT that she just wanted to get out of hospital and was happy with the accommodation offered via ForHousing and Salford City Council, commenting that she “loved it”.

  Lucy’s sister asked GMMH dual diagnosis practitioner and Salford City Council housing support worker to come to Lucy’s funeral and thanked them for all the support, saying how much it meant to Lucy and the family.

  SPCT said that this case study is a powerful example of the importance of teamwork, not only between the enhanced Pathway team that the Out of Hospital Care Model allowed for but also with the larger MDT community that helped to develop training.

  The GMMH dual diagnosis practitioner said that they felt proud and privileged to be able to develop such a strong and trusting relationship with Lucy, who lacked such relationships particularly towards the end of her life. They were proud to be able to advocate for her at the end of her life and ensure that her care was as dignified and as aligned with her wishes as it could possibly be.

  Salford City Council said that this way of working provided accommodation with a level of security, certainty, safety, and stability to a vulnerable person in an upsetting situation that wouldn’t have been immediately offered by other temporary accommodation routes.

  • Tips for success
  • Working in a homeless partnership model supported by 2021 NICE Guidance: NG214.
  • Weekly MDT.
  • Carer/family involvement.
  • Seeking consultation and advice from specialist organisations.
  • Making advocacy essential.
  • Seeking to build relationships, challenging working cultures and any discriminatory practices.
  • Making training mandatory and promote training to outside agencies.
  • Looking after staff through a trauma informed way of working - offering reflective practice and debriefs due to the emotional aspect of working with someone at the end of life. The partners facilitated a session on grief and loss with the homeless community after Lucy’s death.

  Lessons learned were around how to seek buy-in to multiagency working from larger organisations, understanding the stressors on the wider system and how this can be a barrier to achieving the desired outcomes.

  • What next?
  • Funding for this pilot has now ended but the partners continue to provide specialist support for homeless people in Salford, including those who are discharged from hospital.
  • The partners attend a weekly wider MDT facilitated by SPCT.
  • Salford City Council can refer any homeless person experiencing barriers in accessing universal services for support with their mental health and drug and alcohol needs to GMMH for assessment, support, and treatment. This has funding until March 2025 from the Rough Sleeper Initiative.

  We believe this case study meets all the following 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

  
  

  References:

  Beijer, U et al (2012) Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis. The Lancet Infectious Diseases; 12:11, 859–870

  Cornes M, Aldridge RW, Biswell E, Byng R, Clark M, Foster G, Fuller J, Hayward A, Hewett N, Kilmister A, Manthorpe J, Neale J, Tinelli M & Whiteford M (2021) Improving care transfers for homeless patients after hospital discharge: a realist evaluation. Health Services and Delivery Research Volume: 9, Issue: 17.

  Cornes, M, Whiteford, M, Manthorpe, J, Neale , J, Byng, R, Hewett, N, Clark, M, Kilmister, Fuller, J, A, Aldridge, A, Tinelli, M. (2017) Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care. Health and Social Care in the Community, vol. 26, Issue 3.

  Department of Health [Office of the Chief Analyst] (2010). Healthcare for single homeless people. London: Department of Health.

  Groundswell, (2020), Women, Homelessness and Health: A Peer Research Project. Available at: https://groundswell.org.uk/wp-content/ uploads/2020/02/Womens-Health-Research-Report.pdf

  Homeless Link (2022) Unhealthy State of Homelessness 2022: Findings from the Homeless Needs Audit. Available at: Homeless_Health_Needs_Audit_Report.pdf (kxcdn.com)

  NICE (2021) Guideline: Integrated health and care for people experiencing homelessness. Available at: https://www.nice.org.uk/guidance/ng214/documents/draft-guideline

  Pathways, (2020), Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Available at: https://www.pathway.org.uk/wp-content/uploads/Fraility-research-paper.pdf

  Revolving Doors (2019) Capability Framework: Working effectively with people with co-occurring mental health and alcohol/drugs conditions. Clinks. Available at: Capability-Framework-FINAL-3.pdf (revolving-doors.org.uk)

• North West London integrated approach to homeless health

  by Claire Wilson, almost 3 years ago

  NWL has the largest homeless population in London, and the borough with the largest homeless population, Westminster. There are stark health inequalities for those who are homeless; a combination of multiple, long term, often under-treated health needs, experiences of trauma and discrimination mean that this sub-set of our population often do not get the care they need.

  
  

  In 2021, NHS North West London was awarded funds from DHSC’s Shared Outcomes Fund to develop an Out of Hospital Care Model (OOHCM) for people experiencing, or at risk of, homelessness. This formed part of a nationwide programme of 18 sites, aiming to... Continue reading

  NWL has the largest homeless population in London, and the borough with the largest homeless population, Westminster. There are stark health inequalities for those who are homeless; a combination of multiple, long term, often under-treated health needs, experiences of trauma and discrimination mean that this sub-set of our population often do not get the care they need.

  
  

  In 2021, NHS North West London was awarded funds from DHSC’s Shared Outcomes Fund to develop an Out of Hospital Care Model (OOHCM) for people experiencing, or at risk of, homelessness. This formed part of a nationwide programme of 18 sites, aiming to:
  • Prevent discharges to street and associated readmissions;
  • Avoid hospital attendance and admissions (where health, care and support needs can be better met in the community);
  • Support an improvement in an individual’s health and wellbeing; and
  • Prevent rough sleeping and homelessness.

  
  

  Following the success of the first year of operation, NWL ICB has recognised the significant impact this model of care can have and approved a business case for a further 3 years of funding to deliver an integrated, multidisciplinary model of care for people experiencing homelessness, both when they are inpatients in acute trusts, and in the community.

  
  

  The ‘inclusion health teams’ are multi-disciplinary teams who work with homeless patients in hospital to maximise the benefit of their time there, providing specific health interventions, social care, housing, advocacy and practical input so that patients are discharged in an improved situation, reducing hospital re-admittance and homelessness. Part of the model includes specialist community homeless health nursing teams, and all parts of the model work in close collaboration with mental health and primary care for ongoing case management. The NWL model as a whole will consist of GPs, nurses, AHP and housing workers, and see approximately 1200 patients per year.

  
  

  The scheme has already proved successful and in its initial months of operation has delivered a 54% decrease in rough sleeping and a 200% increase in people moving in to temporary accommodation. The team have supported patients with their wider health needs, registering with a GP and making significant progress in meeting their housing and social care needs. A recent study with the London School of Economics has also demonstrated that the scheme costs the system a whole (including health, housing, social care, mental health, criminal justice, etc) 64% less, and care is more community based, preventative and recovery focused, improving patients wellbeing.

  
  

  In order to make sustained, positive change for a person experiencing homelessness it requires extensive and flexible input by trained and dedicated resources, however, it is also our aspiration that this model of care becomes part of 'business as usual' and sets the standard for how we treat people experiencing homelesness.

  
  

  The model of care is part of a wider, coordinated and integrated approach across NW London for people experiencing homelessness in the Integrated Care System, which includes other programme workstreams (e.g. primary care, vaccinations) as well as support for local place based plans for homeless health. Integrated governance is provided via a pan NWL Homeless Health Steering Group including NHS acute, community and mental health providers, ICB, voluntary sector, local authority, public health and more.

  
  

  
  

• Innovative model for screening adults and children for infectious diseases fleeing from conflict in Afghanistan

  by Suzanne Dixon, almost 3 years ago
  

  Links to all 5 aspects of the framework

  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

  Permission: has been granted and we give permission for NHS England to utilise these are case examples. Two logos are attached.

  Organisation/s: These were Manchester University NHS Foundation Trust, gtd healthcare and Manchester Integrated Care Partnership.

  The challenge: In 2021, a large-scale evacuation of people from... Continue reading

  Links to all 5 aspects of the framework

  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

  Permission: has been granted and we give permission for NHS England to utilise these are case examples. Two logos are attached.

  Organisation/s: These were Manchester University NHS Foundation Trust, gtd healthcare and Manchester Integrated Care Partnership.

  The challenge: In 2021, a large-scale evacuation of people from Afghanistan took place. 8000 Afghans were relocated to the UK and temporarily housed in hotels as part of the Afghan Relocations and Assistance Policy and Specification. A quarter of these were expected to be housed in bridging hotels in Manchester.

  Tuberculosis (TB) is a contagious bacterial infection which causes disease primarily in the lungs but can affect many other areas within the body. It is the second leading infectious killer globally behind COVID -19. Latent TB infection (LTBI) occurs when TB lies dormant within the body. 25% of the world’s population is thought to be infected with latent TB (1.7billion) and 10 % will go on to develop active TB. Within the UK 80% of all new cases of active TB cases are from those born in countries of high incidence. Hence, to reduce the burden of TB within the UK, those at risk of Latent TB must be identified early and treated effectively (appendices 3&4).

  Afghanistan has a high incidence of TB (193/100,000) population. The current TB rate in the UK is 15/100,000 population. Usually, migrants arriving from Afghanistan would have been screened for active TB prior to obtaining a visa necessary for travel to the UK, screening for latent TB being completed within 2 years of entry

  Our ambition was to develop and deliver an innovative model which delivered this screening in three months rather than the 2 years of entry to the UK. This would have, high participation rates, reducing the burden of TB within this group and to the UK population through spread of TB. The model that we would develop would take services to this group and be responsive to the cohorts needs, in addition, give high levels of satisfaction to staff.

  Public Health outcomes:

  -Safest consistent approach of care through agreed clinical pathways and clear organizational responsibilities

  -Completion of TB screening within 2 months

  -Adults and children with active TB disease were identified and treatment initiated within 5 working days (thereby preventing ongoing transmission of TB)

  -Adults and children with latent TB infection were identified and referred to TB Clinic and treatment was offered within 6-8 weeks of detection (thereby preventing TB disease in the future)

  -Systematic hand-over of patient care when patients move from Manchester by both TB and primary care teams.

  In 2021 people fleeing from conflict in Afghanistan, Manchester expected 25% of the UK cohort. Tuberculosis is a contagious infectious disease that can be fatal. Afghanistan has a high burden of TB; usual screening was not possible. An innovative model was delivered within 3 months, the full process usually takes 2 years to complete.

  The approach/solution: We identified key stakeholders within all the organisation involved and brought together a task and finish group to explore and agree on a clinical model and a shared understanding of roles, responsibilities and risks of all the organizations involved. Funding was requested and agreed upon. The task group developing the implementation plan and operationalising this. Outcomes were fed into the nationally which informed the policy as it developed and other programs.

  Insights and impacts: 561 Afghans were screened for both active disease and latent TB infection within 3 months of entry to the UK. 38 persons with LTBI were identified. In addition, we have signposted individuals and families to other support services, thereby facilitating access to good quality primary and secondary care services (for example, 4 adults found to have Hepatitis B have been referred to Infectious Disease Team).

  • Safest consistent approach of care through agreed clinical pathways and clear organizational responsibilities

  Multi-professional and multi-organizational teams developed pathways and documentation with clear lines of clinical and administrative responsibility. All supporting materials were available in all the languages spoken by the group. Our primary healthcare provider is on-site and supports patients at all stages and has mechanisms set up to communicate in various methods (written, face to face, WhatsApp groups).

  • Completion of initial screening within 2 months

  started in December 2021 following GP registration. Screening of 344 children was undertaken prior to Christmas and required 4 days of Mantoux testing and reading undertaken over a 2-week period. This was facilitated by 5 interpreters (Dari, Farsi, and Pashto). 217 adults were offered blood testing and chest Xray in January 2022 organized and facilitated by clinical and administration staff again supported by interpreters. Results were collated by the TB Collaborative Project Manager and the Screening TB multi-disciplinary meeting was staffed by senior member of the Adult and Paediatric TB Clinical Team.

  • Adults and children with active TB disease were identified and treatment was initiated within 5 working days (thereby preventing ongoing transmission of TB)

  No persons with active TB were identified.

  • Adults and children with latent TB infection were identified and referred to TB Clinic and treatment was offered within 6-8 weeks of detection (thereby preventing TB disease in the future)

  30 (14%) adults and 8 (2%) children were identified with latent TB infection and have been referred for and treatment commenced.

  We screened all the population for HIV, Hepatitis B and C. 4 cases of hepatitis B and received appropriate therapy.

  • Systematic hand-over of patient care when patients move from Manchester by both TB and primary care teams

  If there has been relocation from the hotel to alternative accommodation, both primary and secondary care providers have liaised with the next services to ensure continuity of care.

  The results and lessons from screening are now being utilized for screening at other hotels. The model has been discussed at a national level and the impact of the approach to hard-to-reach groups has been shared and accepted for abstract publication.

  The results of our chest X-rays in children have been shared with the National TB team and have been instrumental in a change in National policy. New entrant children from Afghanistan will now only have a chest x-ray if they have symptoms or a positive Mantoux (TB) test, thus reducing the radiological burden to this group of children.

  The success of our TB screening has enabled us to utilize the existing paradigm in other locations. Adjustments made the population cultures and values, numbers to be screened, clinical and administrative teams as well as hotel infrastructure.

  The success of our TB screening has enabled the existing model for New Migrant TB Screening which had essentially halted over the COVID Pandemic. Previously, this was a secondary care hospital-based driven service delivered by TB Teams and had been very poorly attended (75% DNA rate) with low completion rates amongst those identified with latent TB. Managing migrants, refugees, and asylum seekers has proved challenging, and our recent experiences working collaboratively with our primary care partners have demonstrated that difficult-to-access patients may benefit from a more personalized and locally delivered service. The UK is also during bringing people fleeing from conflict in Ukraine, the learning from this programme is being developed to support this group. Thus, it is likely that future development of the New Migrant Screening will be community-based with an embedded primary care structure to facilitate general well-being and health screening with the ability to screen for infectious diseases and other long term health conditions.

  What people said:

  Feedback from families: "…We have experienced many blighted and unfavourable conditions in 2021. All this time you tried to support Afghan refugees and their families. We will never forget your spiritual and practical support to save our lives and make us happy, as you have been working day and night- and spending-time helping refugees and coordinating with other teams for better facilities. For this, we thank you."

  " I wanted to take this opportunity to say how we appreciate your dedication.

  We will never forget your assistance, generosity and sympathies for our people during a very Critical Situation."

  This project was also recognised locally and nationally by the 2022 HSJ patient Safety awards as a finalist in three categories: Best use of Integrated Care and Partnership working in Patient Safety Award, Improving Health outcomes for ethnic minority communities and early-stage patient safety innovation of the year

  Tips for success: The results and lessons from screening are now being utilized for screening at other hotels. The model has been discussed at a national level and the impact of the approach to hard-to-reach groups has been shared and accepted for abstract publication. This was a challenging time; the cross organisational working will facilitate further transformation at a quicker pace. So many people contributed to this programme and recognising this has been important and a key driver.

  What next: There has been a great deal of learning from this which is being spread across all areas of the organizations involved and those that are networked in across the Northwest and Nationally.

  
  

• A new approach to an old disease: delivering specialist care to children with Tuberculosis close to home

  by Suzanne Dixon, almost 3 years ago
  

  This links to all 5 aspects of the framework

  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

  Permissions: I give permission for this to be shared and for the networks logo to be used. I have permission from our networks host organization to submit this

  Organisation: This work was developed by the Northwest Paediatric TB managed clinical network, which draws its membership from all organisations... Continue reading

  This links to all 5 aspects of the framework

  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

  Permissions: I give permission for this to be shared and for the networks logo to be used. I have permission from our networks host organization to submit this

  Organisation: This work was developed by the Northwest Paediatric TB managed clinical network, which draws its membership from all organisations that deliver paediatric TB care and the UK Health Security Agency. Our network is hosted by Manchester University Foundation NHS Trust.

  The challenge: Tuberculosis is a serious communicable disease which can spread through communities. Significant health inequalities exist in the incidence and outcome from TB in the UK; the most deprived 10% population has an incidence seven times higher than the least deprived 10%. Untreated it can cause debilitating multi-organ disease and death. Fortunately, if the diagnosis is made promptly, a complete cure with no long-term sequelae can be achieved in the majority of cases. Delays in diagnosis, incomplete treatment, drug resistance, underlying comorbidities and extremes of age are associated with poor outcomes. Compared with adults, children have a less effective immune response to TB so, when exposed to an infectious case they are more likely to become infected, more likely to develop TB disease and more likely to develop severe and life-threatening forms of TB e.g., meningitis. Local coroner feedback identified that a number of local deaths from TB could have been prevented.

  As we started this process there was clinical concern with 27% of children referred to the tertiary centres had long term sequelae and 3 deaths were seen in a 12-month period- to which the coroner gave feedback on. Children and young people were travelling long distances to receive their care and engagement levels were low. There was a concern at the start that such an approach would centralise patient care in tertiary centres and through delivering this model this has been proven not to be the case.

  Our approach involves North Wests Trusts including TB nurses, adult and paediatric medical staff the UK Health Security Agency, commissioners and charity partners.

  • National Strategy for TB was driven by the NHS England/PHE Collaborative Strategy for TB and now the TB Action plan 2021-2026. The Northwest has relatively low rates of TB disease (6.2 per 100,000 population) but very large and increasing numbers of new entrants from countries with high TB incidence.
  • The diagnosis of TB is also more difficult in children due to low bacteriological yields and difficulties obtaining samples for culture. Lack of standardised paediatric drug preparations also makes children more difficult to treat than adults.
  • In order to achieve good outcomes in children, it is essential that effective mechanisms are in place to identify, investigate and treat children at risk of TB promptly. This requires a level of expertise which can be difficult to maintain when numbers are small; hence clinical consensus was gained to develop a network approach which ensures good outcomes, as local as possible to home, supported by audit (cohort review) and education.

  The approach/solution: This work was identified and overseen by the Northwest TB control Board and Northwest paediatric partnership board and delivered by the Northwest Paediatric Allergy and infection network to deliver a Northwest paediatric TB network. A task and finish group was set up, which represented all areas involved and this group took a step wise approach to delivery, setting up and delivering a weekly virtual MDT clinic. This allowed the service to be set up quickly and establish a working system by determined and focused individuals. Outcomes were agreed.

  Network members have together worked through what is needed and how this can be delivered which leads to excellent care. From day 1 there has been clear medical, nursing and managerial leadership both from the NHS and UKHSA. Any challenge or barrier has been worked through in a collaborative approach. The team has learnt from what has not worked to establishing a solution which is effective.

  This pioneering approach is delivered by empowered healthcare professionals through a clinically agreed pathway, audit, education and a virtual clinic (between healthcare professionals).

  Insights and Impacts: This has been commissioned by Greater Manchester TB collaborative, (now Greater Manchester Integrated care partnership) and has run since 1^st November 2017. The virtual clinic runs as a weekly teleconference, underpinned by clinical documentation.

  Our patient data from 2021 showed that:

  • 118 discussions for 57 patients were held
  • 21 children had TB disease
  • 19 had Latent TB infection
  • 17 had a final non-TB diagnosis.

  Referrals were received from 12 district general hospitals and their associated TB specialist nurses. Advice was sought for a variety of reasons, there could be more when one source of advice requested:

  • 20 investigation
  • 10 treatment
  • 14 radiology interpretation
  • 9 screening

  This resulted in 61% change in management and a reduction in delays when staff were away on planned or unplanned leave. Transfer from tertiary centres to district general hospitals was able to take place earlier and more rapidly.

  87% of families discussed in this service come from the top 20% most deprived postcodes as described by the index of multiple deprivations with a number of challenges to accessing services, ensuring that care is kept locally increases local clinical knowledge and reduces lack of compliance or attendance with treatment.

  Our model has been picked up in whole or part in other areas of the UK, and now the audit approach is being delivered other areas for TB and is now being explored to deliver drug and alcohol services in other areas. The British Association of TB shared such an approach, and it is great to see other areas such as the Northeast work from our clinical guidelines and enhance them for local adaptation and we have utilised this development for the Northwest. This approach was selected by the 2019 HSJ value awards as a finalist, and the impact of the approach was commented on as excellent by the Care quality commission.

  The model being developed is being utilised to advocate a similar approach for the assessment and management of adult TB as professional exposure reduces alongside the number of adult affected.

  The concepts utilised here are outlined in the NHS long term plan and NHS Inclusion Health Framework and it has been great to see clinical agreement in developing services being the first and only driver for the development of services.

  When variation of approaches has been identified these have been resolved with local teams include children whose assessment and treatment did not involve a paediatrician, dividing families to be assessed into different streams for children and adults. A robust governance process is in place with clear escalation routes depending on the variance of care e.g., patients diagnosed with respiratory TB not started on treatment will have UKHSA are notified.

  One of the most important parts of innovation and working across organisational boundaries is taking time to pause and note progress and celebrate success. Thank you to everybody who has been part of the journey to date.

  Tips and Success:

  Having both management and clinical leadership from all areas is important from the outset. Creating a culture which is open and honest is central to this. This model did not stop at any point during the Covid-19 pandemic and has created a culture of development and support of each other.

  We actively welcome anyone wishing to explore this model to get in touch and see this model in action.

  What next:

  We continue to deliver all aspects of our programme with a continued focused on improving quality and clinical outcomes for our children and young people through our audit process. Increasing numbers are coming through the northwest through changes to migratory patterns and population movement through world events including the fall of Afghanistan and war in Ukraine. Securing funds to maintain this stability is underway.

  What people said

  TB Specialist Nurses	“From my experience, the virtual clinic has been invaluable in the management of paediatrics with TB or contacts of TB I am very grateful for all of the help and support the team have offered to me which in turn has increased my confidence with paediatrics” I feel the suggestions and support from all of the specialists was invaluable to us TB Nurses and I am sure we will call on you again “Building on last year’s Paediatric Cohort audit day, this year saw a very positive response to continuing to improving outcomes for children with active and latent TB”
  Stephen Dickson Chief Executive, Royal Manchester Children’s Hospital	“The drive from our clinicians working collaboratively across the Northwest has ensured that this vulnerable group of children receive their care as locally as possible giving them the best outcomes. It is an excellent example of the adoption of technology to improve care, which has already come to be invaluable in providing immediate resilience within the Northwest during the COVID-19 Pandemic”
  Dr Sarah Anderson When she was National Lead for TB Strategy Chair of National TB Delivery Board	This is a truly innovative way of delivering child centred care. This virtual MDT for clinicians remote from a specialist centre has improved patient care, revolutionised travelling times and increased local knowledge of TB. The National TB Programme are now sharing it as an exemplar of best practise”