In its fourth year of operation the Psychology in Hostels (PiH) project - delivered in partnership by Thames Reach homeless charity accommodation provider, South London and Maudsley NHS Foundation Trust (SLaM), London Borough of Lambeth Integrated Care Commissioning Cluster (LBL) and funded for three years (2014-17) by Guys and St Thomas Charitable Trust (GSCT) - offers a truly innovative integrated mental health and accommodation-support services. It does this through the creation of government best- practice Psychologically Informed Environment (PIE) approach that enable high engagement with previously hard to reach homeless clients with multiple complex needs.
What We Did
In its fourth year of operation the Psychology in Hostels (PiH) project – delivered in partnership by Thames Reach homeless charity accommodation provider, South London and Maudsley NHS Foundation Trust (SLaM), London Borough of Lambeth Integrated Care Commissioning Cluster (LBL) and funded for three years (2014-17) by Guys and St Thomas Charitable Trust (GSCT) – offers a truly innovative integrated mental health and accommodation-support services. It does this through the creation of government best- practice Psychologically Informed Environment (PIE) approach that enable high engagement with previously hard to reach homeless clients with multiple complex needs.
The PIEs – set within three Lambeth homeless hostels – are environments where everything that happens takes into consideration the user’s psychological and emotional needs; from the range of psychological interventions offered (individual, group, & art therapy) and approaches to risk management; to the building environment and the support and training offered to staff.
On a background of repeated deprivation and trauma, research suggests that up to 70% of homeless people experience mental health problems, drug and alcohol addiction, criminal justice contact and are nine times more likely to commit suicide than a member of the general population . Nonetheless, despite many services working to support this population they are often unable to sustain accommodation, trust in and make use of support services when they are available or present chaotically or in crisis to emergency services. They are a revolving-door cohort of individuals that have been unable to find a place they can settle and that this service has been able to offer an innovative approach which is gaining great outcomes.
One of the defining features of this model is felt to be the onsite nature of the psychology service (incl. five full time NHS Psychologists of differing grades, 1 session Consultant Psychiatry) creating access to flexible familiar specialist mental health support and allowing for close partnership working with voluntary sector hostel staff and care integration. In the last year the project has engaged between 61% and 100% of residents living across the three sites (approx. 100 clients at any one time) and delivered over 1000 formal psychological interventions with high levels of attendance. As a result notable outcomes have been achieved stabilising individuals in accommodation and reducing alcohol & drug misuse; aggression; self-harm; inpatient and emergency service use and mental distress (medium-large effect size on clinician – Health of the Nation Outcome Scales – and service user measures – Clinical Outcomes in Routine Evaluation). This is noteworthy in light of the severe and enduring nature of this group’s mental health difficulties.
Findings in our last annual review report access to onsite, timely, flexible and familiar psychology and hostel support team has led to high levels of engagement from a previously hard to reach complex needs population with unmet needs.
Sarah’s story: Sarah (pseudonym) is a woman in her 50s with a history of alcohol use, impulsivity, self-harm, frequent emergency service use and poor engagement at planned appointments. She has had numerous hostel stays including in another borough and been repeatedly evicted or transferred following a serious violent incident. She used to be involved in a high number of incidents, many of which related to her substance misuse and often involved the police, the ambulance service and A&E. Sarah was initially reluctant to have contact with services in a planned way including the in-house psychologists and so the team began working indirectly to stabilise Sarah in accommodation. The hostel key worker brought Sarah for discussion at a reflective practice session where the hostel and psychology team developed a psychological understanding of Sarah’s behaviour and a consistent boundaried intervention plan around how to best manage her self-harm, substance misuse and emergency service call-outs. This began to contain Sarah who became increasingly less chaotic and more motivated. She agreed to begin meetings regularly with the psychologist after getting to know her around the project and they agreed to think together about some of her past experiences underlying her use of alcohol. Sarah also began meeting her hostel support worker regularly and went on to engage in addiction services and complete an alcohol detox. Sarah is no longer on the A&E frequent attenders list and is attending her planned health appointments rather than presenting in crisis. It is felt the onsite nature of the psychologist slowly building up trust and engagement has been particularly important in helping Sarah go on to engage in formal psychological therapy, key working and subsequently Addiction Services.
Wider Active Support
We work in partnership with a wide range of stakeholders to deliver an integrated service beyond the immediate accommodation-MH PiH partnership. The three Thames Reach hostels where the PiH project is based were already well established within the network of care services prior to PIE development, with physical health and addiction service provided by local stakeholder partner agencies. However, development of the PiH service has enabled a further focus on integrated approaches to care and – along with obvious integration of Mental Health support from the PiH psychologists and psychiatrist – the hostels have visiting primary care nursing and GP clinics and a opiate scripting service delivered by Lambeth Addictions Consortia. This allows for an integrated service approach, supports close joint-working and liaison and the coordination of regular case conferences for shared care planning; vital for such a complex needs client group. The service also works closely with local social care services due to the vulnerable nature and complex needs of the client group. The hostels sit within the wider Lambeth Borough commissioned “Vulnerable Adults Pathway,” a range of supported accommodation designed to address the specific needs of the local rough sleeping and single homeless population. The pathway includes hostels with 24/7 support, specialist drug and alcohol projects, women only accommodation, pre and post detox programmes and more independent supported housing with visiting support. We work closely with the vulnerable adult pathway coordinator to input into move-on planning to support individuals in findings and sustaining future accommodation.
The new Consultant Psychiatrist PiH post (created Jan. 2015), the Psychology Transition Service (able to work with residents, where needed, for a period of time after they move- on) and SLaM Care Pathway development have also all supported service integration continuity of care and mental health service access. This has involved the transition service in the last year delivering training, reflective practice and consultation to over 34 staff in six settings beyond the PiH hostels to further enhance the skills and approaches within the Lambeth Vulnerable Adults Pathway.
The project also has local government support such as from Councillor Jim Dickson (Lambeth council’s Cabinet Member for Health and Wellbeing) who highlights how our work is set within with wider borough’s strategy to homelessness – “our Rough Sleepers & Street Population team have conducted in depth work to get to grips with what are challenging issues to tackle. At Lambeth council we are determined to do all we can to help the most vulnerable people in the community and use of the Psychologically Informed Approach is an example of our work with those who are the hardest to reach.”
We have an integrated Service User Involvement (SUI) framework for the project which outlines current and planned service user and carer involvement throughout all organisational and operational levels of the project and developed by hostel staff, psychologists and service users. This includes for example SU participation in all staff recruitment, SU voluntary job roles within the hostel to create an ‘interdependent’ community culture and co-facilitation of therapeutic groups (e.g. Tree of Life group, Mindfulness group, Therapeutic Art group). We have found job roles have boosted self- esteem, confidence and life skills/responsibility whilst reducing low mood and incidents, whilst crucially improving the overall quality of the service.
Hostel staff and SU have also been involved in the design and delivery of the PiH by participating in working groups focused on developing the psychologically informed nature of different aspects of the project (incl. input over individual and group therapeutic offerings, improving the design and layout of the environment, reviewing the menu and assisting in meal preparation, overseeing a gardening committee).
For the last 18 months, based on SU feedback, we have had a ‘Transition’ arm of the service to work with clients and new accommodation providers when service users move- on and are in the process of developing a Peer Mentor arm of our service taking an asset based approach, involving service users who wish to “give something back”. The Peer Mentor service has been developed directly as a result of feedback from current SUs that they would value more opportunities to work with peers who are slightly further on in their journey of recovery and who can support and inspire them. The Peer Mentor service will be developed and managed by a Peer Support Coordinator who themselves will have lived experience and drive inclusion and service improvement.
Looking Back/Challenges Faced
Our learning from early phases of introducing psychology into hostels was the importance of attending to change management theory and the importance of working effectively with the existing staff teams expertise to introduce change and attend to bottom-up processes of change. As some of the hostel staff first reflected in an independent staff focus group – they felt as there was a sudden change in ways of thinking and working that they valued in retrospect but hadn’t been prepared for. This learning led to more detailed change management planning with a further PIE hostel expansion January 2015. As a large team, with a combination of both longer term members of staff and newer members of the team this proved effective and looking back we have been able to see the importance of commencing this process as early as possible in service development and redesign.
We recognised the value and importance of our Partnership and appreciate that as organisations we can bring different expertise, expectations, cultures and some difference in values. Early investment in the partnership was crucial for the effective establishment and integration of a multi-agency service and required the brining together of different organisational cultures from the health and voluntary sector to develop coherent processes and ensure effective service delivery. This was achieved by developing clear governance structures, Service Level Agreements and Operational Policy which support the partnership and was careful to reflect each organisation’s style, priorities and values. There was also thoughtful negotiation around service design and implementation to overcome the obstacles of working across organizational boundaries in non-traditional settings/ways. Some examples include: integrating Reflective Practice space into existing hostel meeting schedules, installing NHS IT network to ensure timely updating of clinical records, developing a joint-organizational policy for risk, safe guarding and clinical governance. As a result of this hard work from all sides we are very proud of our partnership project and the work we are able to deliver together.
Developing referral and treatment pathways into mainstream mental health services has also continued to be a challenge despite the specialist expertise of having NHS psychologists based onsite engaging, assessing and referring clients. As a result of this we appointed a Consultant Psychiatrist for half day a week as part of our service expansion with the aim of increasing the accessibility of timely psychiatric input, to make referrals into mainstream services and further work to enhance service pathways.
Ongoing work is taking place to assure the future funding and sustainability of the service model and delivery beyond our current three year charitable trust funding, with the aim of gaining mainstream MH commissioning. Stakeholder mapping has enabling us to consider the relationships which already exist amongst our partnership and its members and how these can best be utilised to assist business development. Throughout the year we have hosted visits from key Commissioners and Stakeholders from housing/homeless, health, local government and provider agencies for dissemination and future service development purposes. In addition, as outlined below, a considered approach has been taken to publication and promotion of the project.
We are considering the increasing restrictions on funding and resources within the homeless sector, Local Authorities, and health provision, and recognise the potential impact for our project. This involves understanding and evidencing the economic impact of the work of the project, analysing the critical elements of delivery (i.e. ‘must haves’) to determine future delivery models, and identifying funding and commissioning approaches in different areas and locations.
We are seeing increased desire to consider and progress service integration, and supporting this through integrated funding. The NHS Five year forward view is a good example of this. The nature of our partnership and the bringing together of statutory and third-sector provider indicates we are early adopters of indicated future direction.
Alongside in-house outcome monitoring, independent specialist evaluation teams from University of Southampton and Resolving Chaos Consultancy have been commissioned to conduct clinical and health economic evaluations respectively. This aims to further develop the evidence-base for working with this population and demonstrate an economic case by generating savings in use of crisis services and more effective use of specialist hostel provision in order to make the case for future mainstream commissioning.
The University of Southampton are conducting an extensive and in-depth evaluation design involving measuring different mental health and behavioural variables, to assess change over time, amongst staff and residents in the three hostels. Results from the hostels receiving the interventions will be compared with a control hostel receiving accommodation support ‘as normal’.
As discussed above, notable clinical outcomes have been achieved with a population with high levels of complex trauma, undiagnosed or treated severe and enduring mental health difficulties. This was demonstrated on service user rated (CORE) and clinician (HoNOS) rated measures assessing global distress. Of particular note are the improvements in depression, self-harm, agitation and aggression, substance misuse, other symptoms such as anxiety, relationship problems and activities of daily living. These have been backed up by early outcomes from the Southampton University Clinical Evaluation Outcomes.
The Economic Evaluation is still in development and so health economic data is not yet available from this arm of the evaluation. However, The University of Southampton has found some early indications of stead reductions in health service usage during the evaluation period, which will have associated cashable costs savings.
We are highly committed to disseminating our work in order to advance practice-based evidence for working with complex needs homeless populations, as well as considering the potential service implications and benefits beyond this client group. As a result we have a dissemination strategy within our service which outlines the importance of sharing good practice and the ethos of that being co-produced by different combinations of stakeholder voices (incl. service users, psychologists, hostel providers, researchers and collaborators). In the last 18 months some notable project dissemination has occurred including – presenting at national conferences (six conferences 2014-2016, Royal Society of Medicines Medical Innovations Summit VIP speakers address 2015); publications in academic journals (incl. winning article of the year in the British Psychological Society Clinical Psychology Forum journal 2015); promoting the needs of the client group in both mainstream media and specialist forums (incl. Independent newspaper article Jan. 2015; TV documentary profiling the needs of homeless women May 2016, BPS The Psychologist Magazine article April 2016). We have hosted visits and had hostel open days through out the year to support and encourage sharing of best practice. We are also committed to enhancing the development others by delivering training across the sector drawing on our most up to date findings (incl. working with other health professionals, local authority, other providers within the homeless sector, teaching on Clinical Psychology doctoral training programmes). This work aims to continue with upcoming opportunities to share our work in a book chapter and publish the outcomes of our expanded independent evaluations – putting homeless needs at the fore.
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We feel the partnership working between Thames Reach and SLaM is the cornerstone of our work and vital to the success in working with the most socially excluded service users and preventing further homelessness.
The PiH project delivers the principals of a ‘Psychologically Information Environment’ (PIE) – which by it’s nature is a service model of integration and partnership. The project has the support of SLaM and Thames Reach CEO’s and executive and non-executive Director’s who like us feel the project offers a great example of staff from different organisations working together to improve outcomes and experience for service users.
The co-location means that Psychologists and hostel staff are able to work closely to incorporate a psychological understanding of users’ needs into all aspects of the project. They assess new referrals together, visiting offsite in hospital or other accommodation if necessary. They discuss move-on to maximise chances of a successful move back to the community. They also formulate strategies after incidents to ensure they manage similar behaviours in the most effective way in future. Joint meetings are conducted between service-users, management and psychology to combine the need for care and support alongside clear boundaries and hostel management. This provides a containing frame for the clients and ensures a joined-up and consistent approach. They have created a service that is truly integrated at all levels, rather than operating as a visiting psychology service or separate accommodation provider.
As one service user fed back – “My keyworker and my psychologist would work together to help me; both with areas they were specialist in. They was good!”