- To drive forward plans for mental health and wellbeing in local communities, a more integrated and strategic approach between health, housing and social care is needed.
- For people living with serious mental illness, housing can be a critical factor in helping people to live as independently as possible, while also accessing the support they need to live and thrive in local communities.
- This report explores what more can be done at the policy and practice levels to achieve a more integrated and strategic approach between health, housing and social care. It brings together the key outcomes and recommendations from a series of engagement events, culminating in a Mental Health and Housing Summit. The summit focused on strengthening the link between housing, health and social care and explored the impact that supported housing can have on people with mental health problems.
- With large, sector-wide transformation and investment taking place across the health and care landscape, now is an opportune time to invest in and make explicit the relationship between mental health and housing.
- National bodies have a role to play in setting out a clear vision and national strategy, supported and underpinned by long-term investment. This can be implemented at scale across the country, adapting to local populations needs, through the newly formed integrated care systems.
- There is a need to develop more consistent and explicit models of supported housing services that are built on good practice, quality and collaboration between people with lived experience and their clinical, supported housing, and social care teams. This can and should be built on pockets of excellence already available across the country so that there is consistent, guaranteed access to supported housing services, regardless of where someone might live.
- This publication will be useful to all those with an interest in improving the care of people with severe mental health issues, including clinicians, managers, commissioners, policymakers and politicians.
This report was commissioned by the NHS Confederation’s Mental Health Network, delivered and written by HACT and supported by our event partner, Home Group.
The COVID-19 pandemic has brought the importance of housing into sharp focus. Homes are a critical foundation in people’s lives and a primary location of care and support. Safe, secure and affordable housing is crucial in supporting people to live well, work and take part in community life – it is a key determinant of positive physical and mental wellbeing.
For some, home can be a place of nurture and security that provides stability and solid foundations when they are experiencing poor health. For others, home can be challenging and contribute to poor physical and mental health. Some may find themselves experiencing homelessness or living in insecure and poor-quality housing. And others may become stranded in hospital and other institutions, because a more suitable place to live has not yet been found. It is therefore appropriate that housing is recognised as an even more critical factor that enables people to live well.
As organisations that represent and work with NHS-funded mental health and learning disability service providers and commissioners, and the social housing sector, the NHS Confederation’s Mental Health Network and HACT have always recognised the need for a more integrated approach between mental health and housing. Together, we want to ensure that as the country emerges from the pandemic, we drive forward greater integration as a core part of recovery.
This report reflects on the barriers and enablers to integrating supported housing and housing expertise into mental health pathways. It has been informed by extensive engagement with senior leaders and people with lived and professional experience, who have generously given their time to help us develop solutions to this pressing issue. This includes sharing their perspectives and agreeing common actions at our seminal Mental Health and Housing Summit.
There is much good practice to draw on across the country, but we recognise that more is needed to deliver a strategic and operational environment where integration, collaboration and co-production happen everywhere. This report sets out a set of recommendations for national bodies and local health and care systems and partnerships that we believe will enable a more integrated and strategic approach between health, housing and social care.
Sean Duggan, Chief Executive, Mental Health Network
Andrew van Doorn, Chief Executive, HACT
There is little argument that good quality housing and positive mental health are inextricably linked. To enable people to live well, work and take part in community life, there is a critical need for safe, secure and affordable housing. 
Housing expertise is rarely found within NHS multidisciplinary teams
Settled housing is known to have a positive impact on mental health.  It is well evidenced that poor quality housing, poverty, worklessness and crime are linked to poorer physical and mental health outcomes.  Mental ill health is frequently cited as a reason for tenancy breakdown,  with housing problems frequently referenced as a reason for someone being admitted or re-admitted to inpatient care. 
Accessing housing and being able to move through a pathway of care requires service users to negotiate a range of obstacles. Housing expertise is rarely found within NHS multidisciplinary teams. Without it, specialist mental health services and teams struggle to help service users navigate and negotiate complex systems. A lack of suitable housing – in mainstream or supported housing – and placements cause difficulties with timely discharge from hospital.  This can prevent service users from achieving their recovery goals and limit their ability to receive support and help in the least restrictive environment possible.
NHS mental health services are currently facing significant pressure. The proportion of beds occupied across mental health trusts remains high. For the third quarter in a row, bed occupancy remains at over 85 per cent, above the Royal College of Psychiatrists’ recommended safe maximum bed occupancy, with quarter three of 2021/22 at 87.3 per cent. 
There are also significant delays in discharging patients who are medically well, with one of the key reasons being a lack of appropriate housing or accommodation post discharge. The total number of days of delays to discharge from mental health services linked to housing was 4,286 in April 2021 and has continued to increase over the year. In January 2022, the number stood at an increase of 59 per cent. [8,9]
Reports and analysis over many years have demonstrated the cost-effectiveness to the NHS of supported housing as an alternative to inpatient care. [10,11,12] However, even though the economic case has been made, there have been significant cuts in local commissioning in the past ten years of all forms of supported housing. Barriers to collaboration, integration and investment therefore exist that result in people with mental ill health remaining in more restrictive environments and result in severe challenges in pathway flow.
A crucial time for integration
The Health and Care Act 2022, the first major piece of primary legislation on health and care in England in a decade,  emphasises that the future of health and care must be based on collaboration and partnership working at a local level. As a resngaging the local housing system will be mission critical. Integrated care strategies, to be developed by integrated care partnerships, will need to involve people who live in the partnership’s area. Gaining a greater understanding and involvement of the local housing system will be essential if parity of esteem and equity of outcome are to be achieved.
The social care white paper published in December 2021  identifies the importance of integrating housing into local health and care strategies, with at least £300 million in investment to build the right partnership and boost the availability of specialised housing. This comes at a time when the NHS and its partners are driving forward a major programme of transformation in community and primary care, with greater integration of mental health support. The Community Mental Health Framework is clear that additional investment in community mental health teams needs to involve housing as part of ensuring access to a broader range of expertise and mental health support. 
The current situation therefore provides an opportune moment to integrate supported housing and housing expertise into mental health pathways that lead to better reported outcomes for people living with mental health problems, while making best use of resources across all sectors. This report explores what is needed to enable this to happen.
The issues and solutions for integration between health, housing and social care are multiple and operate at service, trust, place, system and national levels. Different stakeholders hold the solutions to achieving greater integration and consideration is needed across a range of issues, operationally and strategically, and in the commissioning, funding and policy environments.
What is supported housing?
Supported housing is any housing scheme where accommodation, support and sometimes care services are provided as an integrated package.  The aim is to help people to live as independently as possible. Supported housing includes adult placement schemes, sheltered housing, group homes and crisis houses. According to the Supported Housing Alliance, at any one time, over 600,000 people rely on supported housing to provide a secure place to live and to offer appropriate care and support.
Find out more in Supported housing: improving outcomes in mental health patient pathways.
Recommendations at a glance
Homes England should develop a National Supported Housing Strategy, endorsed by NHS England and NHS Improvement, underpinned by long-term investment. This would inspire greater confidence from housing providers and developers to better meet the NHS’s appetite and demand for supported housing.
NHS England and NHS Improvement should develop a clear vision and national strategy for mental health and housing. It should demonstrate the importance of housing within mental health pathways and current transformation priorities, which can be translated locally through integrated care systems and their integrated care boards.
The cross-government mental health plan currently in development must recognise and propose action on housing, recognising how important it is for good mental health and wellbeing for the whole population.
Development of expertise and workforce programmes that deliver a higher consistency of specialist skills in multidisciplinary teams across health, housing and social care settings. A focus on workforce should encourage collaboration between clinical and non-clinical teams, with a
shared understanding of quality and risk.
Development of more consistent and explicit models of supported housing services are needed that are built on good practice, quality and collaboration between people with lived experience and their clinical, supported housing and social care teams.
Investment in developing a comprehensive evidence base that addresses both the quality case and the financial case for investment, clinical integration and excellence.
Enhanced appreciation of mental health and the impact current policy and practice by mainstream housing and homelessness services has on people experiencing poor mental health. A commitment to doing ‘no harm’ in mainstream housing management by landlords.
This report captures insights from a programme of engagement that considered what can be done at policy and practice levels to achieve greater integration of housing and NHS mental health services. This includes:
- hosting a Mental Health and Housing Summit, held in February 2022, which brought together senior stakeholders to explore the key actions and recommendations needed for achieving greater collaboration and integration between health, housing and social care
- convening four virtual roundtables with a range of stakeholders on key issues that enable and prevent integration and growth
- engagement with key stakeholders, including people with lived and professional experiences, from NHS and supported housing providers, clinicians, social care professionals, commissioners, policymakers, and representative bodies.
The roundtables explored four key themes:
- Delivering greater integration and partnership working between mental health providers and the housing sector
- Ownership of the issue and management of the market
- The role of systems, collaboratives and integrated commissioning
- The policy and investment environment for integration
Summaries of each session can be found in the appendix.
While we took a broad view of housing, we were particularly interested in enhancing the opportunities for supported housing.
Alongside the roundtables, Peter Molyneux, chair of Sussex Partnership NHS Foundation Trust and leading national expert and advocate on housing and health integration, developed a paper setting out the historical context and current policy landscape, which has helped to inform this report. 
In the sections that follow, we consider what is needed to integrate housing as part of the mental health pathway.
Towards an integrated future
Our engagement revealed three main areas where progress is
needed to enable mental health and housing integration to flourish:
- Vision, strategy and investment
- New models of delivery and partnerships
- Accelerated innovation and sharing of good practice
Vision, strategy and investment
Successful supported housing has been shown to reduce out-of- area placements and improve service users’ experience and outcomes.  Despite its many merits and proven cost-effectiveness to the NHS, there is a strategic vacuum around supported housing. This is impeding patient flow, pathway design and service delivery.
The current market is a product of years of underinvestment stemming from cuts in local commissioning over the last 15 years of all forms of supported housing. With the abolition of the Supporting People ringfence in 2009, the supported housing sector has seen large cuts of around 45 per cent compared to 28 per cent across the board at local authorities.  By 2015, it was estimated that 33,000 people were being housed in mental health supported housing in Great Britain – 29,500 of those were in England.  Decades of funding cuts have led to low confidence in investment and challenges for the longer-term sustainability of supported housing services and other housing-related support.
The strategic vacuum around supported housing is impeding patient flow, pathway design and service delivery
NHS teams previously had access to a range of different community-based housing support services to support discharge and recovery. But as a result of sustained disinvestment, they can no longer rely on this being available. Some housing providers have re-purposed specialist provision and targeted it at other groups, or used it to address more mainstream housing pressures.
Specialist skills and expertise have also been lost. What was once a thriving supported housing sector is now much depleted. This has placed increasing pressures on pathway flow and, for some, the only available local option is in NHS inpatient or residential care environments.
To re-invigorate local markets, the NHS and its local authority partners need to show greater ownership of active market development, with frontline clinical integration forming a key part. The default of moving people into more restrictive environments – such as out-of-area locked rehab – due to gaps in local markets, lack of long-term strategy and market development is neither desirable nor sustainable. It also leads to poor clinical outcomes.
Given the greater drive for integration and collaboration as a result of the Health and Care Act 2022, it stands to reason that market development should feature as a core component of integrated care partnerships’ and boards’ strategies and plans.
National agencies, such as Homes England and NHS England and NHS Improvement, are critical to driving forward a more strategic environment. Long-term capital and revenue investment can only be unlocked if national investment agencies are clear of the longer-term need and direction of travel for service configuration. Too often these agencies work in silos; if a more integrated environment is to happen locally, it needs to be supported nationally.
Co-producing a National Supported Housing Strategy, and removing some of the designation enforced through capital investment programmes over what types of homes can benefit which people, could go some way to break down silos. While investment is needed, so too is longer-term flexibility that maximises the impact of investment and builds homes of all types.
In addition, a mental health and housing vision and strategy, developed by NHS England and NHS Improvement, could take a broader view beyond supported housing and drive the integration agenda into local areas further and faster. Integrated care system (ICS) and place-based mental health and housing strategies and plans would also help to translate national ambitions into local approaches.
Sussex Health and Care Partnership has shown significant leadership in the production of an ICS-wide mental health and housing strategy (see case study below).  ICS strategies can encourage whole systems and pathways to be more partnership based and give clear expectations to integrated care boards (ICBs) of their commissioning responsibilities.
They can also bring together place-based partners – in the NHS, local authorities, social care, housing providers and the wider voluntary, community and social enterprise sector – to explore how housing-based solutions and services can deliver recovery outcomes. Housing also has a clear role to play in population health, a key responsibility of the ICB.
Sussex Health and Care Partnership is a multi-agency partnership that serves a large and varied population of 1.7
million people. It is responsible for £4 billion of health and care spending and delivers on the local health and wellbeing priorities of people living across East Sussex, West Sussex and Brighton and Hove. To enable the partnership to move forward with housing, health and social care integration, it commissioned HACT to support development of its first mental health and housing strategy.
The strategy  was agreed in July 2020 by the newly formed Sussex Mental Health Collaborative, led by Sussex Partnership NHS Foundation Trust (SPFT). From the outset, partners in the collaborative wanted to see the strategy translated into a specific workstream, driving forward integration alongside other priorities such as the transformation of community mental health services, urgent and emergency care, and support for children and young people.
The shared ambition for the Sussex Health and Care Partnership is to ensure that housing is a cornerstone for
delivering positive mental health outcomes for adults across Sussex. As partners across the NHS, social care, housing and community sectors, they are committed to working together to take a more strategic and integrated approach to housing and mental health. They recognise that addressing housing issues for specialist mental health service users can be a key enabler in their recovery. A key driver for the collaborative is to ensure that mental health care, treatment and support are delivered in the least restrictive environment possible. The home environment has a key role to play in providing recovery and reablement support for many people.
The strategy outlined a range of objectives, including creating mental health and housing plans for each place in East Sussex, West Sussex and Brighton and Hove; ensuring housing expertise is embedded in community mental health services, piloting and extending discharge to assess; delivering new integrated models of supported housing for people with multiple and complex needs; and supporting SPFT to develop support strategic and operational partnerships with housing to improve quality and reduce unwarranted variation.
The housing workstream is steered by a multi-agency group drawn from key stakeholders across Sussex. During its first two years of operation, the group has not only supported the delivery of the strategy and the development of local place-based plans, but also supported the system and the trust to address some of the more challenging impacts of COVID-19 on demand for urgent and emergency care. It is clear that a focus on housing enhances both pathway flow and improving performance around discharge.
The collaborative has appointed an associate director of housing to provide leadership across the partnership and within the trust for the delivery of the strategy and the integration of housing within the care pathways.
The recently released consultation on the ten-year cross-government mental health plan  is a prime opportunity to focus on those issues that support positive mental health and wellbeing. Housing is a fundamental part of this and should be a major focus of the final plan.
Creating the right strategic environment may be more straightforward than unlocking the necessary capital and revenue resources. The investment case into supported housing has always felt challenging, particularly for HM Treasury. However, the opportunity of the £300 million Housing Transformation Fund outlined in the social care white paper could result in much-needed investment.
Capital investment is available through Homes England via the Affordable Housing Programme, but whether or not it is achieving the 10 per cent target for supported and specialist housing is unclear. Many social landlords have withdrawn from investing in supported housing, as the revenue has been squeezed and overall demand for all types of affordable housing escalated. A recent National Housing Federation member survey on the appetite for new supported and older people's housing development showed significantly fewer plans for schemes for people of working age, with the three major barriers being lack of revenue funding, capital grant levels and access to land. 
NHS England and NHS Improvement is taking steps to monitor how mental health investment in accommodation and support is taking place. New categories within the wider community services transformation category of the Mental Health Investment Standard returns are being introduced in 2022/23.  This will, for the first time, give a more granular account of local investment. This is a welcome move and ultimately by having this under the spotlight, it could stimulate more investment and support.
ICSs and ICPs are a vehicle that can stimulate demand. There is real appetite for supported housing from the NHS at a time when there is a huge shortage of supported housing. Specialist providers cannot provide the volume, as many larger housing associations have exited from the market. The key question is how do we build a position of confidence in investment? How do we bring confidence back into the market?
A key area of opportunity is how to involve housing providers and wider VCSE providers of housing support in integrated care systems, integrated care partnerships and provider collaboratives. While recognising the practicalities of partnership working across large systems, thought should be given about how to involve and ensure that housing expertise, resources and perspectives are fully integrated into strategy and delivery at all levels.
Action is needed on many fronts if we are to rebuild confidence in local markets and demonstrate that housing is a valuable partner in delivery mental health support. A more coherent national strategic environment that is translated locally, with clear longer-term investment and engagement in partnership creation and delivery, can greatly enhance this.
- Homes England should develop a National Supported Housing Strategy, endorsed by NHS England and NHS Improvement, underpinned by long-term investment. This would inspire greater confidence from housing providers and developers to better meet the NHS’s appetite and demand for supported housing.
- NHS England and NHS Improvement should develop a clear vision and national strategy for mental health and housing. It should demonstrate the importance of housing within mental health pathways and current transformation priorities, which can be translated locally through integrated care systems and their integrated care boards.
- The cross-government mental health plan currently in development must recognise and propose action on housing, recognising how important it is for good mental health and wellbeing for the whole population.
New models of delivery and partnerships
The current commissioning landscape, planning architecture and delivery models in health and care are experiencing considerable change. Integrated care systems and their commissioning boards will be on a statutory footing by July 2022. Integrated care partnerships are being put in place, and provider collaboratives are becoming increasingly responsible for commissioning and delivering whole pathways across wide geographies.
Perspectives, understanding and plans for integrating housing are needed at all levels. It is unclear where housing’s contribution is being encouraged and heard at ICS/ICB levels but where it does happen, integrated strategy, planning and commissioning works.
Trusting partnerships and collaborations are needed between providers of different services
For frontline integration to be effective it needs respect, confidence and people feeling they are on the right team. Putting the person at the centre of support is critical, and creating a more integrated practice environment needs strong leadership and time to build relationships. Our focus must be on outcomes for people.
Flexibility of care is important and the models and level of support must be right to meet individual needs and minimise the number of moves that people have got used to. Resources need to flow through in a better way and focus on delivering a secure and stable home environment.
To achieve this, trusting partnerships and collaborations are needed between providers of different services, with the person playing an active role in the co-production of their own support. Commissioning along silos acts as a significant barrier and many housing and wider VCSE providers get frustrated that their value is not well understood by statutory health and social care agencies. Too often people experience a lack of social care and health integration that translates into costly and poor commissioning of housing support.
Home Group is a social enterprise and a charity with a turnover of over £350 million and one of the UK’s largest providers of high-quality housing and integrated housing, health and social care. It works with NHS and local government partners to provide integrated health, housing and care that makes a real difference and relieves pressure on the NHS. It focuses on supporting individuals in getting the right care at the right time, while empowering them to live and thrive in society, with an example being the hospital discharge service (HDS) model. 
Home Group’s HDS offers housing support for patients in a ward-based setting and, following discharge, in the community. Based on the ward and working alongside the existing multidisciplinary team, the team support those identified as presenting with a housing-related need. They work with customers from their point of admission to the ward, helping to secure safe and suitable housing. This means that when the customer is deemed medically fit for discharge, there are no housing-related barriers. The type of support offered includes advocacy and advice, practical support and emotional support.
Home Group established the hospital discharge service at the beginning of April 2021. Home Group support coordinators worked in partnership with ward-based teams to provide support for patients who presented with a housing need, with the aim of preventing delayed discharge for those awaiting suitable accommodation.
Partnership working is critical to the success of the model, with an understanding that they may only be one part of a
customer’s support plan. The team aim to liaise closely with other agencies who are already working with the individual, to enable the best possible outcomes.
Analysis of the average duration of inpatient stay for those identified as having a housing need highlighted a significant difference between those admitted prior to the implementation of the hospital discharge service and those admitted once the service was in place.
For the service users that were admitted to the ward from the beginning of the service, having timely access to the hospital discharge service, the average duration of inpatient stay was 45 days per person. The average duration of inpatient stay for service users who were admitted to the wards prior to the beginning of April was 140 days per person.
This equated to a saving of 95 days per person, which at an average rate of £385 per night equates to an approximate saving of £37,000 per person. (Based on a sample group of 157 service users).
When designing and planning local mental health pathways, the importance of housing and the role of housing support is critical. The idea of additional beds in the community is one way to think about the overall capacity for planners in the NHS. However, the focus should not drift away from the core of our understanding that this is about people’s right to a home.
Provider collaboratives can provide the right vehicle to co-produce end-to-end pathways and for integrating the expertise of different providers. The first wave of the COVID-19 pandemic was very much ‘everyone put in place what people needed’. This speaks to empowered local people and organisations with the budgets and a local market to work with. This can be done through collaboratives but will require some change in culture.
Look Ahead is a leading housing, care and support provider in London and the South East. Since April 2014, it has been delivering an excellent example of integrated health, housing and social care in the form of its specialist forensic service in East London. The service provides housing and support for 19 male residents aged 18-74 with significant offending histories and enduring mental health needs. The service was co-designed with Tower Hamlets Council, East London NHS Foundation Trust (ELFT) and Look Ahead. As part of the partnership, Look Ahead has created a psychologically informed environment with self-contained flats alongside communal areas to encourage engagement in positive practical and therapeutic activities.
Onsite clinical support is provided by ELFT. As part of the service’s recovery-focused care and support package, it
provides medication management support and alcohol/ drug testing from a highly-trained staff team, who receive clinical supervision from ELFT. Staff also receive specialist training, including being involved in a pilot for forensic training,
and training on the usage of specific forensic mental health documentation in the past (such HCR-20, RSVP).
Tabard Forensic Service plays a pivotal role in the mental health pathway, enabling people from medium/low secure hospital to step down into the community. It also creates an internal pathway offering step down to lower support whilst maintaining support from the same team. This allows residents to physically and psychologically progress in their recovery, before moving on to independent accommodation.
At Tabard Forensic Service integration is more than just a concept. Its long-term success is based on multi-agency partnership working. It requires detailed shared systems and processes governing information sharing, shared communication pathways, risk management and service user engagement between housing, clinical services and key stakeholders, such as the police.
Tabard recognises that, as individuals, staff members only get to glimpse at small fragments of their customers’ internal world. Bringing this together as a team allows them to build a clearer picture of the customers’ challenges and triumphs and, most importantly, a clearer understanding of potential risk factors.
As a service fully committed to using the See, Think, Act model of relational security to deliver a psychologically informed environment, this service understands that it is just as much about the physical environment as the customers inhabiting it. Delivering care and support in a welcoming and friendly environment facilitates discussions and openness which is important to delivering person-centred care. Even down to decoration choices such as choosing the perfect couch or wall colour creates a sense of co-productivity crucial in seeing customers invest in their own recovery. This approach has resulted in a very low number of incidents or hospital recalls at the service.
For commissioners and health partners, the service reduces out-of-area placements and length of stay in secure mental health inpatient services, improving outcomes and resulting in significant cost savings. This high-needs step-down service is around 40 per cent cheaper than the average cost of a medium-secure unit.
More capacity and technical expertise are needed to deliver a more integrated commissioning and practice environment. A lot is often asked of individuals to deliver on programmes of work that need a greater level of resource, capacity and expertise than is available.
When looking at the question of mental health and housing from the perspective of mainstream housing policy and practice, those with lived experience often feel that little regard is given to mental health by mainstream housing services, systems and policy. There is little confidence in how these housing systems interact with health, take account of mental health and respond sensitively to issues. There is clearly much that can be done within available resources to change practice alongside the ‘do no harm’ principle.
- Development of expertise and workforce programmes that deliver a higher consistency of specialist skills in multidisciplinary teams across health, housing and social care settings. A focus on workforce should encourage collaboration between clinical and non-clinical teams, with a shared understanding of quality and risk.
- Enhanced appreciation of mental health and the impact current policy and practice by mainstream housing and homelessness services has on people experiencing poor mental health. A commitment to doing ‘no harm’ in mainstream housing management by landlords.
Accelerated innovation and sharing of good practice
It was noticeable that many participants at our virtual roundtables felt that the strategic environment has not kept pace with the innovation that is happening in many places across the country.
While there is clearly great leadership in many areas, often the examples of innovation are too rare. New integrated mental health and housing services are novel and get badged as a ‘pilot’, with little early commitment to long-term funding and integration. Too often new integrated models of health, housing and social care are stimulated using short-term funding, such as for winter pressures, or budget underspends. While stimulating and supporting innovation is welcome, not planning for long-term sustainable funding from the outset undermines the impact that can be made. It also risks putting strain on the many new relationships that are needed if we are to transform our approach.
Too often new integrated models of health, housing and social care are stimulated using short-term funding
The important role of supported housing is increasingly being recognised in mainstream programmes that are driving up standards and delivering greater consistency in mental health care. Recent work and reports from Getting It Right First Time (GIRFT)  in both rehabilitation and acute and crisis care describe how housing support should be an effective part of an effective care pathway.
This clinical endorsement is important. But access to a range of housing and support services is still far too inconsistent and lacks a clear definition within local pathway design and delivery.
Many felt that we are at risk of re-inventing the wheel, and that while there has been significant decommissioning of supported housing services over the past ten years, we still have the knowledge and know how to make things work. A key challenge will be whether the physical housing itself and the capital needed to build more, is available at the volume needed. A more strategic approach to planning and investment, coupled with a commitment to build new evidence and share this to encourage rapid adoption, should be able to address these issues.
Good integration and collaboration need to be accompanied by a clearer understanding of models, practice, workforce development and a shared understanding of quality and risk. As the chair of the Health and Housing Summit commented, “we need to get our own house in order around standards” if we are to seek investment, rapid expansion and greater clinical integration.
The supported housing sector has perhaps been a little reticent to do this in the past, but a major programme of models and standards development is needed. Leaning into the available evidence base, backed by a commitment to create new evidence, could make this work impactful. Aligning this with national programmes such as GIRFT [28,29] could also enhance the clinical integration between the NHS and housing that is essential for delivering high-quality support and outcomes.
A sector-wide commitment to build the evidence base of the effectiveness of housing and support interventions is a significant opportunity. Major work has already taken place to lay the foundations for an improved evidence base [30,31] and a commitment from major research funders, academics, supported housing and NHS providers, could ensure that best practice is understood and applied.
There is also potential in the use of digital technology to bring together patients, carers and professionals and improve the care that is provided. This is an area of innovation that is often overlooked in conversations around mental health housing, and opportunities to use digital technology to enhance support should be explored.
- Development of more consistent and explicit models of supported housing services that are built on good practice, quality and collaboration between people with lived experience and their clinical, supported housing and social care teams.
- Investment in developing a comprehensive evidence base that addresses both the quality case and the financial case for investment, clinical integration and excellence.
- Scaling up the pockets of excellence across the country so that there is consistent guaranteed access to supported housing services, regardless of where someone might live.
There is little argument that good quality housing and positive mental health are inextricably linked. For people living with serious mental illness, the right housing can be a critical factor in supporting people to live as independently as possible, while also accessing the support they need to live and thrive in local communities.
With large, sector-wide transformation and investment taking place across the health and care landscape, now is an opportune time to invest in and make explicit the relationship between mental health and housing. Recognising this opportunity, we set out to explore what more can be done at policy and practice levels to achieve a more integrated and strategic approach between health, housing and social care.
We are optimistic about the potential for greater integration, collaboration and partnerships between health, care and housing
Three key themes emerged throughout our engagement with colleagues from across the health, care and housing sectors which will be essential to drive forward future plans for mental health and wellbeing in local communities, and deliver a more integrated and strategic approach between health, housing and social care:
✓ A need for national strategies and a vision for mental health and housing to unlock resources and build partnerships
✓ Building new models and partnerships
✓ Accelerating innovation and good practice, using the opportunity of the evolving health and care landscape
We are optimistic about the potential for greater integration, collaboration and partnerships between health, care and housing. There is strong leadership and enthusiasm across the sectors for this agenda to be achieved, underpinned by a shared ambition for more integration, collaboration and co-production. Building on outstanding examples of good practice models already working around the country will be key to supporting people with serious mental illness to live as independently as possible in their community, while accessing the care and support they need.
Through strengthening the strategic and operational environment, and investing in the right models and partnerships, we are confident a more integrated and strategic approach between health, housing and social care can be delivered nationally.
The mental health and housing roundtables and summit were supported and attended by a wide range of organisations and individuals who are involved in providing and/or accessing mental health and housing services. They include clinicians, managers, service users, researchers, carers and campaigners. This report could not have been developed without their contributions, and we thank them for their time and expertise.
Chair: Lord Victor Adebowale CBE, Chair, NHS Confederation
Facilitator: Andrew van Doorn, Chief Executive, HACT
- Nadia Barakat, Director of Mental Health, Learning Disabilities and Children and Young People, Frimley Health and Care Integrated Care System
- Melanie Brooks, Mental Health Policy Lead, Association of Directors of Adult Social Services
- Rachael Byrne, Director, Home Group
- Laura Caton, Senior Adviser (Community Wellbeing), Local Government Association
- Sean Duggan, Chief Executive, Mental Health Network
- Beatrice Fraenkel, Chair, Mersey Care NHS Foundation Trust
- Chris Hampson, Chief Executive, Look Ahead Care and Support
- Dr Sridevi Kalidindi CBE, Consultant Psychiatrist and National Clinical Lead on Rehabilitation, Getting it Right First Time (GIRFT)
- Becky Leonard-Dixon, Engagement Manager, Home Group
- Sarah Lewis, Head of Operations, Greater Manchester Mental Health NHS Foundation Trust
- Marsha McAdam, Expert by Experience
- Andrew Molodynski, Consultant Psychiatrist and Committee Member, RCPsych Rehabilitation and Social Psychiatry Faculty
- Peter Molyneux, Chair, Sussex Partnership NHS Foundation Trust
- Charlie Norman, Chief Executive, Moss Care St Vincents
- Alexander Palmer-Wales, Housing Policy Lead, Department of Health and Social Care
- Bobby Pratap, Deputy Head of Mental Health, NHS England and NHS Improvement
- Sue Ramsden, Policy Lead on Health, Supported Housing and Care, National Housing Federation
- Clare Skidmore, National Housing Lead, Strategic Commissioning Team, Learning Disibility and Autism Programme, NHS England and NHS Improvement
- Darrell Smith, Senior Policy Advisor, Department of Levelling Up, Housing and Communities
- Tony Stacey, Chief Executive, South Yorkshire Housing Association
- Deborah Stephenson, Associate Director Accommodation Services, Rethink Mental Illness
- Ronnie Treston, Expert by Experience
- Alex Stewart, Business and Programmes Manager, Mental Health Network
- Gemma Critchley, Event Manager, NHS Confederation
- Sarah Parsons, Health and Research Lead, HACT
Appendix: Roundtable talking points
Roundtable 1: Delivering greater integration and partnership working between mental health providers and the housing sector
What we heard
For integration to be effective, it must happen at the front line, through multidisciplinary teams and partnership working that combines clinical and non-clinical expertise and perspectives. How expertise is understood and shared across different stakeholders, with services and pathways becoming more co-designed, was a key consideration within this theme.
While collaboration and co-design were seen as essential, with shared perspectives on quality and risk between clinical and supported housing teams, it was recognised that there is often a lack of confidence in supported housing providers and recognition of the expertise/skills they bring. There was also a lack of knowledge within the NHS of available local resources, often resulting in the design of mental health services across an area taking place in isolation of wider community-based services. This often leads to fragmentation and poor placed-based co-design.
The lack of explicit, consistently defined and understood models of mental health supported housing is seen as a significant barrier. The absence of recognised standards and descriptions of good practice and multidisciplinary working, supported by a robust evidence base, hampers integration. This also leads to a lack of confidence in supported housing services, and challenges in designing them into comprehensive care pathways that enable recovery in least restrictive environments.
The need for clinicians to be embedded in supported housing services and models was clear, as was the importance of champions and an enabling commissioning environment. The NHS needs to feel more agency in the housing sector, rather than defaulting to colleagues in local government.
Roundtable 2: Ownership of the issue and management of the market
What we heard
How the current market for supported housing is able to meet the current and future demands and what the future opportunities and challenges are for creating local provision that delivers integrated services, pathways and supply chains was a critical theme to explore.
The current market is a product of many years of considerable underinvestment. There is a lack of strategy at all levels that impedes flow and pathway design and delivery. It also results in low confidence around investment and challenges for the longer-term sustainability of services and support.
There is both capital and revenue funding available, and willing providers who want to make it work, but to support the development and growth of local markets, urgent attention is needed by the NHS and their local authority partners on market development. Many mainstream social housing providers and developers exiting the market due to capital and revenue uncertainties. Once converted or disposed of, specialist housing can be very difficult to re-provide.
The NHS needs to show greater ownership for active market development, with frontline clinical integration a key part of this. It should be a key part of the strategies and plans for integrated care partnerships and boards. The default of moving people into more restrictive environments due to gaps in local markets and a lack of long-term strategy and market development is not desirable or sustainable. It also leads to poor clinical outcomes.
Roundtable 3: The role of systems, collaboratives and integrated commissioning
What we heard
We explored the opportunities that new relationships could bring for ensuring an integrated environment between mental health, housing and social care and how it is designed and delivered.
Perspectives, understanding and plans for integrating housing are needed at all levels. It is unclear where housing’s contribution is being encouraged and heard at ICS/ICB levels but where it does happen, integrated strategy, planning and commissioning works.
A range of mechanisms are available for ensuring housing perspectives and expertise are available to system-wide planning and commissioning, with housing forums and sub-groups recognised as a key way forward. Local authorities have a key role to play, through place-based health and wellbeing plans and in building networks and collaborations. But it will only be successful if health feels ownership and shows leadership on housing.
Integrated care systems should take a long-term view on capital investment and could be a key sponsor for funds available through Homes England and the GLA. What role the Care Quality Commission (CQC) and other regulators should take in ensuring integration with housing was raised. As the delivery of quality becomes increasingly linked to how local systems, partnerships and collaborations work, CQC inspections in this space should be more explicit about how integration with housing happens.
Provider collaboratives are an opportunity for system and service level integration, with the responsibility for pathway configuration and supply chain development. Direct relationships with housing providers are important to achieve this. Provider-to-provider partnerships with social landlords and others are needed if provider collaboratives are going to be successful in providing end-to-end services and support for those with more complex mental health needs.
Roundtable 4: The policy and investment environment for integration
What we heard
The final theme explored how the current and future policy environment can be used to encourage and support greater integration and investment. We looked at the legislative framework of the health and care bill and the policy opportunities of the social care white paper. Together with the Supported Housing National Statement of Expectations and the current Affordable Housing Programme, strategy and investment can result in improving the supply of supported housing.
While there is a significant legislative and policy agenda for government, there are also other levers, such as the NHS annual operational planning guidance, which is able to grow and improve mental health and housing services and integration.
Programmes such as Getting Right First Time (GIRFT) have placed a spotlight on rehabilitation and adult crisis and acute care, recognising the critical role of housing. This is backed up by guidance from organisation such as the National Institute for Health and Care Excellence, on rehabilitation for adults with complex psychosis.
A cross-government plan for mental health is currently being consulted on and is expected to be published in autumn 2022. How housing is discussed, understood and represented in this discussion will be key. While there is currently no funding attached, the resulting strategy will be key in informing the direction for the next NHS Long Term Plan. Thinking more creatively about the future of mental health support is an opportunity to take even bolder approaches. Should most supported housing, regardless of stated client group, be seen as mental health services, with a need to think of them as trauma services? Is the NHS best placed to deliver community mental health support and could it be transferred to the housing sector?
Finally, we explored the importance of improving and bringing together evidence and data. Further work is needed to build up the data systems that can evidence impact, to inform both quality and standards, as well as the economic case for investment.
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The NHS Confederation is the membership body that brings together and speaks on behalf of organisations that plan, commission and provide NHS services in England, Northern Ireland and Wales. The members we represent employ 1.5 million staff, care for more than 1 million patients a day and control £150 billion of public expenditure. We promote collaboration and partnership working as the key to improving population health, delivering high-quality care and reducing health inequalities.
The Mental Health Network (MHN) is the voice for NHS-funded mental health and learning disability service providers in England. As part of the NHS Confederation, it represents providers from across the statutory, independent and third sectors. By working with government, regulators, opinion formers, media and the wider NHS, it promotes excellence in mental health services and the importance of good mental health. www.nhsconfed.org/mental-health
HACT partners with organisations across the housing and health sectors to drive value for service users and communities through insight-led products and services encouraging innovation and fostering collaboration. HACT is a leading authority on the connection between NHS provider organisations and Housing Associations and is a key partner in the delivery of the government’s MoU between Housing and Health. HACT has worked extensively across the country with mental health trusts, housing and housing support providers, and commissioners to reform care pathways with a stronger connection with housing. www.hact.org.uk
Home Group is a social enterprise and charity with a turnover of over £350m and one of the UK’s largest providers of high-quality housing and integrated housing, health and social care. It works with NHS and local government partners to provide integrated health, housing and care that makes a real difference and relieves pressure on the NHS. As a large housing and care provider, they have a wealth of expertise and deliver a wide range of specialist and support services to people with complex health and social care needs. www.homegroup.org.uk