Health and Homelessness standards

Health and Homelessness standards

Section 7:
Delivering the Standards - Practice and Innovations

Practice and Innovations

This section of the Health and Homelessness Standards gives examples of services, practices and innovations that have developed through the delivery of Health and Homelessness Action Plans, in accordance with the Health and Homelessness Guidance (Scottish Executive, 2001). The examples are illustrative and are not necessarily intended for duplication, although elements from each can be distilled for local use. For further information on each example please use the local contact.

Standard 1: Corporate Approach

NHS Lothian

NHS Lothian has developed a series of approaches to ensure there is a sound corporate approach to developing and implementing the Health and Homelessness Action Plan. This approach has ensured the effective delivery of the Health and Homelessness Action Plan.

The first element was to ensure Board level commitment. From the earliest stages the Chairman took an interest in health and homelessness issues and sought to ensure that this was a central area in NHS Lothian's thinking around reducing health inequalities and improving health. The degree to which health and homelessness is a feature of the working of the Board is reflected in the way that health and homelessness is one of the issues included in the Chief Executive's regular reports to the Board.

The second element is ensuring that health and homelessness is part of the overall planning processes of the Board. The Pan-Lothian Health and Homelessness Planning Group has direct relationships into the planning mechanisms for health improvement, for mental health and wellbeing and the Drug and Alcohol Action Teams. These direct links provide not only access to the funding streams associated with the three programme areas, but also mean that corporate planning in these areas take the issues of homelessness and its consequences as part of their work.

The final element is performance management. The Scottish Executive Health Department has undertaken performance management of the Health and Homelessness Action Plan and its delivery. NHS Lothian agreed that there should be an annual formal meeting, as part of the Accountability Review, between members of the Health and Homelessness Steering Group and the two Directors with responsibility for the delivery of the Action Plan, the Director of Public Health, with responsibility for health improvement, and the Director of Partnerships, covering mental health and well-being and the work of the Drug and Alcohol Action Teams. This forum also provided a further means of linking the Board directly into the delivery of the Health and Homelessness Action Plan.

For further information please contact NHS Lothian on 0131 536 9000.

Standard 2: Preventing and Alleviating Homelessness

Scottish Executive

In recognition of the need to involve service users in influencing policy development, the Scottish Executive Health Department commissioned The Lemon Tree in Aberdeen to work with homeless people to explore their experiences of health services. This was to inform discussions at the Health and Homelessness Conference held in Dundee on 20 and 21 May 2004. As part of this process The Lemon Tree made a short film to provide a further opportunity for homeless people to have their voices heard.

A DVD copy of the film is included in this publication for use as an educational tool, for example in training front line health workers, or general awareness raising within the public health workforce. Viewers will see that the homeless people who participated in the making of the film shared very personal experiences and so this should be taken into consideration when broadcasting.

Please note that the copyright for the film belongs to The Lemon Tree ( www.lemontree.org) and that any use in other than in an educational capacity must be with the explicit agreement of The Lemon Tree. The company can be contacted on 01224 647999 or by emailing info@lemontree.org

Standard 2: Preventing and Alleviating Homelessness

NHS Lothian

Ensuring the involvement of service users in the planning and implementation of health care services is a priority for all NHS systems in Scotland. This includes those who are homeless. In NHS Lothian, the aim has been to include homeless people, and those who work with them, as routine stakeholders in patient involvement and consultations. So, for example, when the first NHS Lothian Local Health Plan was developed, a focus group of young homeless people was brought together to let the Board know what they thought of the Plan and how it would affect them.

More recently, NHS Lothian has simultaneously consulted on its acute care services, its mental health and well-being services and its hospital services for older people. This consultation, Improving care: investing in change (NHS Lothian, 2004), recognised that homeless people needed to have a significant voice in such processes. As well as the usual consultation channel, an open meeting for groups involved in working with and for homeless people was organised to reflect on the proposals and to comment. The overall approach was broadly welcomed.

One final area of specific user involvement is also worth noting. Health and homelessness conferences have been organised by the Scottish Executive Health Department and the Scottish Council for Single Homeless. In 2004, NHS Lothian offered its subsidised place at this conference to a service user from one of the local health and homelessness groups. A formerly homeless person, who was working with one of the local projects in Edinburgh on a voluntary basis, was able to attend and provide other conference participants with a very clear insight into what was needed and wanted.

For further information please contact NHS Lothian on 0131 536 9000.

Standard 3: Understanding Needs

NHS Argyll and Clyde

During the development of NHS Argyll and Clyde's initial Health and Homelessness Action Plan, alongside the Board's five Local Authority partners, the requirement for a local Health and Homelessness Needs Assessment was acknowledged. With the funding in place to progress a structured interview for use with local homeless people was devised and pilot tested. After revision and approval by the Local Ethics of Research Committee, interviewers were recruited and trained.

A total of 119 participants were interviewed with each interview lasting 45 minutes. The results were analysed, and were broadly similar to those in published work, with high proportions affected by family relationships breakdown, physical and mental health problems, and addictions.

However, when the results were re-analysed for the proportions of this group with one or more issues, the complexity of problems faced by homeless people became more obvious. In summary, 76% of this sample had three, four or five other significant difficulties in addition to being homeless.

One challenge in the process, not unique to the Argyll and Clyde area, was that of identifying hidden homeless people; hence the needs assessment had a focus on those who had presented to Local Authorities as statutorily homeless.

An important conclusion of the analysis is to emphasise the necessity of the various agencies working together timeously in order to resolve all of the problems presented by homeless people. In addition there are implications for joint training and working, and resourcing this with time, expertise, staff and money.

For further information the needs assessment can be found at: www.nhsac.scot.nhs.uk/publications/healthandhome.pdf or by contacting NHS Argyll and Clyde on 0141 842 7200. Further reading on health needs assessments can be found in the References section at the end of this publication.

Standard 3: Understanding Needs

NHS Greater Glasgow

In 2004 NHS Greater Glasgow commissioned the Glasgow Homelessness Network (GHN) to undertake research to improve knowledge of the experiences of women who are vulnerable to homelessness and rough sleeping who use Primary and Acute Health Services.

The initial pilot involved three projects that collected data from their female clients over a 9-month period. The data were captured and collated via the addition of a health module to GHN's existing Common Monitoring System currently used by Rough Sleepers Initiative projects. This allows for the collection of information on women's experiences of health services and their levels of satisfaction with the service provided, as well as allowing for the analysis of these data against various data profiles of this population.

The need for the pilot was established in response to concerns being raised about anecdotal evidence of statistically small populations of homeless women who were dissatisfied with the services they had received. It was felt that these women had particular histories and characteristics and the pilot was developed to test whether such health information on this particular group of women could be identified.

This innovative pilot will allow for a better understanding of the needs and experiences of homeless women as well as facilitating the identification and measurement of any other sub-population. On the basis of the viability of this system being established the NHS Board hopes to be able to build on the pilot and further develop this facility. This would allow for the early identification of women in comparatively small populations and the development of appropriate protocols to improve their experiences of health services. It will also inform other opportunities for service development, delivery and improvement to be identified.

For further information please contact the Glasgow Homelessness Network, www.ghn.org.uk,info@ghn.org.uk or 0141 302 2760.

Standard 4: Access to Health Services

NHS Highland

The Streetwise Directory began as an update of a basic information leaflet within the Inverness area, but developed into a project which involved a comprehensive mapping exercise and a questionnaire delivered across Highland. The process also included locality seminars as well as a Highland launch.

The main partners involved in pulling this project together included NHS Highland, Inverness Council for Single Homeless and Highland Council. The remit of the project was to carry out a mapping of the main services for homeless people so that the Directory would not only assist service providers in signposting homeless people to appropriate services, but also help to form a network of providers that had previously not existed.

The services that are included in the Directory are not simply health services or housing services; they are based on a wider interpretation of the kind of services that homeless people may wish to access, including leisure and educational opportunities. The Directory helps homeless people to access health services by giving homeless service providers information about the health services that are available, but more importantly relevant information about the ways in which services can be accessed. The Directory is produced in both hard copy and as a website that allows it to be updated rapidly, and contains both Highland wide and localised information across the Highlands.

There have also been a number of local events held involving all agencies to introduce the Directory and to help people make the best use of it. In this way it has been much more than just a way of providing information; it is a tool to bring agencies together with the aim of providing better access to information and ultimately improved access to services themselves.

The Directory can be accessed at: www.streetwise-highland.org or by contacting NHS Highland on 01463 717123.

Standard 4: Access to Health Services

NHS Greater Glasgow

NHS Greater Glasgow Primary Care Division, in partnership with Glasgow City Council Social Work Department and the voluntary sector, have developed a range of services to respond to the health care needs of homeless people. Health services operate on an outreach basis which allows patients to be seen in the clinic of their choice; this maximises attendance and in turn ensures greater treatment compliance. However, in order to provide specific clinical work it was recognised that suitable premises were needed.

Premises on Hunter Street in Glasgow were identified as a base for delivering health services to homeless people as well as providing an office for various health and social work teams. The service opened in April 2004 and has added choice to the existing outreach health services, an enhancement to health provision, and a stepping stone in the patient's journey back to mainstream primary care.

On assessment by the health service, if a patient is already on a General Practitioner's list and has been accessing mainstream primary care health services then the patient has their immediate and necessary treatment dealt with; they are then encouraged to re-engage with their registered GP. The patient's GP will then have all details of the consultation sent to them for inclusion in the patient's notes.

If a homeless person is not registered with a GP, or is not engaging with them, then the patient will join the Hunter Street practice and at the appropriate time the specialist GP will assist the patient in finding a suitable mainstream practice to join.

Addictions problems within the homeless population are high so services have also developed to meet this need. However, the Homelessness Addiction Team works tirelessly with mainstream addiction services and GPs to re-engage patients with local services through agreed protocols.

The Physical Health Team (district nursing service) and affiliated sexual health team provide nursing care to homeless people on behalf of their own GP as well as the specialist GP. There is also liaison with sexual health mainstream services in order to keep patients fully linked into the mainstream. Similarly the mental health service actively re-engages patients with Community Mental Health Teams by agreed protocols and handover.

The Hostel Resettlement Team is comprised of both health and social work staff and works specifically with patients in the hostels that are due for closure as part of the re-provisioning of accommodation services for homeless people in Glasgow. This ensures that residents within these settings are provided with a comprehensive assessment, which allows them to move on to the most appropriate accommodation in a planned way, whilst ensuring linkages into mainstream health provision.

For further information please contact NHS Greater Glasgow on 0141 201 4444.

Standard 4: Access to Health Services

NHS Dumfries and Galloway

Within the NHS Dumfries and Galloway area Local Rural Partnerships, an arm of the Community Planning structure, bring together representatives from local businesses, education services, housing services, primary care services and the full range of voluntary sector providers to address the specific needs of their rural communities.

Public Health Practitioners have been identified as the locality leads for the development of services which cater for the health needs of homeless people, and they also sit on their Local Rural Partnership. As a result they are able to both raise awareness about the specific health needs of homeless people and influence the development of services in such a way as to cater for these needs.

By this use of existing structures the needs of the homeless population and the response from the community is coordinated from the outset. This is also a particularly useful approach in an area such as Dumfries and Galloway which has a diverse mix of small- and medium-sized communities within a large rural area. By localising the approach to improving the health of homeless people a greater understanding of the issues can be developed by local people.

For further information please contact NHS Dumfries and Galloway on 01387 272700.

Standard 5: Service Responses

NHS Ayrshire and Arran

CLHASP, the Children's Learning, Health, Support and Play Initiative, aims to integrate education, health, play and leisure services for children in homeless accommodation in East Ayrshire, and is funded through the Changing Children's Service fund. It is based on the recognition that services were failing to meet many of the health and social needs of homeless children, initially in hostel accommodation but subsequently in temporary furnished flats.

The initiative provides children and families with a range of services that include:

• An initial health and social care assessment by
  a named health visitor or school nurse when families present as homeless.

• Link social worker.

• Play equipment in both hostels, including computers.

• Crèche facilities and sessional play workers in hostels and in Yipworld.com, a local youth facility with whom there is a service level agreement for play and leisure.

• Free access to local leisure facilities.

• Welcome play packs.

• Home safety equipment.

• Support workers to assist parents and children in establishing a routine that enables children to prepare for and attend nursery, school and locally based leisure facilities.

• Transport to allow children to continue to attend their existing school, nursery or other pre-five facility.

Other developments that have taken place include the appointment of a part-time co-ordinator; the extension of health visiting/school nursing service to two other hostels and homeless flats; cooking skills training for support workers and provision of classes for parents and older children; links with local community pharmacies for provision of direct care; agreement for a dedicated health visitor.

An external evaluation has assessed the impact of the service and findings demonstrate that:

• There has been good uptake of all aspects of the service.

• It provides a needed service in a flexible and user friendly manner.

• It supports the play and care needs of children at a stressful time.

• It has led to the development of new forms of integrated provision.

• It has enthused the staff and added to their personal and professional learning.

For further information on CLHASP please contact Lead Public Health Practitioner, East Ayrshire LHCC, on 01563 538849 or the Homeless Strategy and Services Manager, East Ayrshire Council on 01563 576986.

Standard 5: Service Responses

NHS Fife

Making Connections is a pilot multi-agency training programme that aims to develop the health related knowledge and skills of frontline staff from Fife Council, NHS Fife and the voluntary sector to better meet the needs of homeless people. It is based on the premise that the quality of advice, guidance and support homeless people receive, from whatever quarter, depends largely on the knowledge, experience and importantly attitudes of staff. The initiative is a joint objective within the Health and Homelessness Action Plan and Fife Homeless Strategy. It is also jointly funded.

The programme is comprised of four modules, run three times on a locality basis in order to encourage multi-agency networks to develop between staff. Informed by a needs assessment, the modules cover:

• Maximising your potential - a personal development opportunity for staff, looking at motivation, self-awareness and self-management techniques.

• Mental health - including reviewing attitudes, presenting symptoms and behaviours, management strategies and local NHS services.

• Substance misuse - including drug use and its effects, the law, tenancy agreements/policies, dealing with aggression and local services.

• Health and Homelessness - a concluding module on partnership working for homelessness, community planning, health and homelessness/ sustainable tenancies and reflective learning.

Each programme has 20 participants drawn from housing, the Fife Local Office network, criminal justice, primary care services and voluntary sector projects. Trainers are almost all local professionals with training expertise. In this way costs are minimised and the local perspective is maintained.

For further information please contact NHS Fife on 01592 712472.

Standard 5: Service Responses

NHS Lothian

Based on its long experience, Edinburgh Cyrenians recognises that health and well-being is a critical component in an effective strategy for tackling homelessness and poverty. Their strategy includes a mix of innovative projects and creating pathways to mainstream services and community resources.

The Health Improvement Service provides specific interventions targeted at the particular health needs associated with homelessness. Current initiatives include healthy eating, drug use management and promoting exercise and relaxation. It also gives a health improvement dimension to all other provision; for example, hostel staff are supported in a role of practical health promoters, supporting residents to eat well, to exercise and generally to make healthy choices.

In 1999 lack of access to an adequate diet and the multiple benefits of good food were identified as priorities through consultation with service users; this was backed up by research that revealed that 70% of long-term homeless people showed symptoms of malnutrition. The charity has gone on to develop a health improvement programme aimed at transforming food access and food use for homeless people in Lothian whilst being "a hand up, not a hand out".

The Good Food in Tackling Homelessness programme involves four elements:

• Accessing large quantities of high quality food for distribution to supplement the food supplies of local hostels and centres to improve the choice, nutritional value and enjoyment of meals. 350 tonnes of quality checked surplus fresh food is distributed to 40 projects adding variety, nutritional value and enjoyment to approximately 150,000 meals.

• Involving large numbers of homeless or formerly homeless people in running the scheme, thereby improving social engagement and employability. This includes 12,000 hours of volunteer help each year with approximately 75% provided by people who are or were homeless. These volunteers are given assistance to benefit from volunteering, support in whether to remain alcohol and drug free and away from homelessness or progressing to training and employment.

• Providing educational and personal development opportunities around the use of good food to promote healthy choices. Cooking at Home - a specialist small group learning model - works directly with 50 people and assists local services to establish ongoing cookery classes of their own whereby service users will be enabled to learn about the safe, healthy and enjoyable use of food in improving their quality of life.

• Promoting the creative use of good food in tackling homelessness to the hostels and centres receiving food donations.

For further information please contact Edinburgh Cyrenians, 0131 475 2354 or www.cyrenians.org.uk,admin@cyrenians.org.uk.

Standard 5: Service Responses

NHS Tayside

Central Healthcare is a nurse-led service, funded through what was the Personal Medical Services Scheme, and is for vulnerable and hard to reach groups in Perth and Kinross.

The service targets the health needs of these groups focusing in particular on homeless people, women and children living with or escaping from domestic abuse, looked after and accommodated children and young people, looked after young people leaving care, gypsy travellers and prisoners facing homelessness on discharge from local prisons.

The service seeks to address both current and projected future social inclusion and healthcare issues, and focuses on reversing the exclusion of disadvantaged groups by managing their care pathway back into mainstream primary care.

Central Healthcare was established in early 2003 and has introduced a number of new ways of working which concentrate on offering a unique service targeted towards disadvantaged groups. This is underpinned by collaborative working with mainstream primary care, secondary care, the Local Authority and voluntary organisations using approaches which cut across traditional boundaries to ensure that care is patient rather than organisation/agency led.

The service works particularly closely with local primary care teams and will support individuals and families who meet the service's criteria, regardless of whether they are registered with a local General Practitioner or with the Central Healthcare Medical Practice.

Individuals and families who choose to register with Central Healthcare are supported through a time in their lives when their homelessness is further exacerbated by a number of problems leading to complex needs and difficult life circumstances.

When an individual or family's circumstances become more stable and more permanent accommodation is found, the Central Healthcare team work with the individual/family and local primary care teams towards permanent registration with ongoing support for an agreed period of time, which can range from 6 weeks to 6 months. This ensures a smooth transition for the individual/family and additional support for the primary healthcare team who will provide ongoing care.

For further information please contact NHS Tayside on 01382 818 479.

Standard 6: The Health and Homelessness Action Plan

NHS Highland

There are a number of key ways in which the NHS Highland's Health and Homelessness Action Plan is implemented. Within the NHS itself there is a working group that was responsible for pulling together the Action Plan; this then reformed into a monitoring and implementation group. Key people involved include many of the main health services such as mental health and drug and alcohol services, as well as locality representation from each of the areas of Highland. There are also representatives from the Highland Council and voluntary sector organisations. The Action Plan was endorsed by the NHS Board and many of the actions are translated into other appropriate service strategies in order to be taken forward.

There is also a multi-agency working group which completed the Highland Homelessness Strategy of which the Health and Homelessness Action Plan is a component part. The partners include Highland Council, Northern Constabulary, NHS Highland, voluntary sector organisations, Scottish Prison Service, Landlords' Association and service users. This Strategy has also been adopted and endorsed by the main partners.

Finally, through the Community Planning structure, the Wellbeing Alliance, the Joint Health Improvement Plan carries forward into the Community Plan an emphasis on health improvement and tackling health inequalities, which includes homeless people as a priority group.

In this way, actions are taken forward through a number of processes and have ownership from both the NHS and other appropriate partners at both strategic and local level.

For further information please contact NHS Highland on 01463 717123.

Standard 6: The Health and Homelessness Action Plan

NHS Tayside

In response to national guidance, the aim of NHS Tayside's Health and Homelessness Action Plan is to provide an outline for addressing service improvement together with a suggested implementation programme. Initially the NHS lead officer met with each Local Authority homelessness steering group to establish views and current work across all agencies. Building on this work, a series of three workshops were then held as a joint exercise between NHS Tayside and the three Local Authorities covering the area. The process consisted of four parts:

1. The establishment of a steering group consisting of the NHS lead officer, NHS planning and key service managers, and lead practitioners from each Local Authority and Local Health Care Cooperative (LHCC).

2. An assessment of baseline information in respect of housing and health and the identification of key issues from the local homelessness strategy groups.

3. Three workshops were held in February 2002 across Tayside. These workshops consisted of a series of presentations and discussion centred on group work and answering and commenting on key questions formulated from the Health and Homelessness Guidance. Invitations were extended to a wide range of agencies including voluntary sector organisations, the Scottish Prison Service, Tayside Police, Local Authorities, housing and social work services and community planning, NHS primary and secondary care, lead managers and development officers from each of the Local Health Care Cooperatives and lead officers within the NHS Board and Public Health with responsibility for planning and strategy development.

4. The identification of key themes and issues in terms of health and homelessness, service provision and service development.

This work then provided a key platform to formulate the Action Plan which was divided into the following areas:

a) An introduction to the policy context, a Tayside profile and the history to health and homelessness in Tayside.

b) Current processes with the key people involved in planning and service provision.

c) A breakdown of key issues and action plans divided into issues specific to each Local Authority/LHCC area, reported in three separate sections, and issues that are Tayside wide and which need to be considered on this basis.

d) Conclusions, recommendations and suggestions on a way forward.

Corporate Structure

An initial and key priority was the need to clarify direction and leadership for health and homelessness within health services and across all agencies to achieve a strategic overview for homelessness planning and service development in Tayside. To address these issues, discussions started in each Local Authority/LHCC area and in reviewing all current homelessness groups, structures and membership. Following interagency consultation and discussion, an interagency steering group was formed consisting of the lead Local Authority representative from each area, and from NHS Tayside the lead health and homelessness officer, a planning representative, Assistant Director of Finance, secondary care representative, public health/health promotion representative and a public health officer.

The terms of reference for the group were initially to:

• Provide a strategic forum to oversee and plan health services in relation to homeless people for NHS Tayside, in partnership with other agencies.

• Agree, clarify and detail priorities for action.

• Quantify resource implications.

• Ensure agreement and cohesive and shared actions on priorities across Tayside and between agencies.

• Oversee and support the development, implementation, monitoring and evaluation of the Tayside Health and Homelessness Action Plan and Local Action Plans.

• Develop a financial framework for health and homelessness in Tayside.

• Dovetail local plans with overarching Tayside wide plans.

Links

It was agreed that Local Authority representatives and the NHS lead officer would represent all local voluntary organisations, prison services, etc. Clear links were also in place via the lead officer with the NHS Board's Senior Management Team, Health Improvement Committee, Drug and Alcohol Teams, Health Inequalities and local mental health heads of service and performance assessment. Local health and homelessness groups were set up in each locality linking into the Local Authorities' homelessness strategy groups to pull together all nursing and health disciplines, Drug and Alcohol Action Teams, etc.

To progress service developments, priorities and issues are put forward by the steering group to a prioritisation panel discussion forum within NHS Tayside. The Board is then able to clearly discuss and reflect on key homeless issues and where these sit within the prioritisation process for NHS Tayside. Examples of priorities routed through this channel include:

• Proposals for training and development.

• Personal Medical Services and nurse-led services.

• Key workers for health promotion and drug and alcohol services.

For further information please contact NHS Tayside on 01382 818 479.