Research into Practice: Developing a Community of Practice

Multiple Exclusion Homelessness Seminar 1 Workington, Cumbria

11th August 2011

Michelle Cornes (King’s College London), Sue O’Halloran (University of Cumbria), Neil Waller (CASS)

and Gary Humphries (Hand Consulting)

Seminar Aims

To present the findings of a two year exploratory research study which explored how different agencies and professionals work together to support people with experience of multiple exclusion homelessness

To help refine policy recommendations and to discuss how this research might impact locally and nationally

To outline what development work has already taken place in West Cumbria

Due to report September 2011

The Research Findings

How do different agencies and professionals work together to support

people with experience of multiple exclusion homelessness (MEH)?

Methods

� Fieldwork in Cumbria, Calderdale and Inner London� Interviews (n=48) and focus groups (n=17) with

stakeholders from a wide range of agencies across health, housing, criminal justice and social care including housing support workers/hostel staff

� Interviews with people with direct experience of MEH (‘Experts by Experience’) following their journeys through the ‘system’ over a six month period (32 first interviews and 22 follow-up interviews)

What is MEH?

Overlaps Between Domains of Deep Social ExclusionSource: Census Questionnaire Survey of People Using Low Threshold

Services [Base: 1,286] (Fitzpatrick et al. 2011)

Who is Most Vulnerable to MEH?

“The most complex forms of MEH being associated with childhood traumas of various kinds and concentrated amongst men in the middle age range” (Fitzpatrick et al., 2011)

MEH CASE STUDY:“There is a man who has a long-standing alcohol problem... He has a chronic infection in one of his legs… The hostels felt they couldn’t manage him and then very shortly after that he threatened one of the hostel staff and he was evicted so he is back on the street. He doesn’t want any help with his substance misuse so he doesn’t meet their threshold… He has a degree of physical disability but he won’t meet the threshold for ordinary residential care. He has a degree of cognitive impairment but we are not sure how much, probably not too much so he doesn’t fit the mental health criteria and he is a very difficult person in his behaviour. So if you parcel it up he has got multiple needs but there isn’t actually a service… he remains on the street”.

(Housing Support Worker)

Health and Social Care Housing Related Support

22.12.10

REFERRAL: Bob is admitted to an acute

in-patient mental health unit.

Diagnosis: mental and behavioural

disorder due to multiple drug use, and

social anxiety problem. Depression and

attempted suicide.

Because Bob is homeless he is referred

to a housing support project. A locum

consultant psychiatrist supports the

referral with a letter which is intended to

“expedite the tenancy”.

PROMISES In the letter it is noted that

any discharge plan will include initial

support from the Crises Resolution and

Home Treatment Team. His CPN will

then provide regular monitoring and

review. It is noted that the drug and

alcohol team are involved and that he

has a drugs worker allocated to him.

8.3.10 Discharged to local hotel for fournights B&B before accessing supported

housing

Bob’s Journey

Accepted onto a Supported Housing

Scheme but there is a waiting list…

Health and Social Care Housing Related Support

Bob’s Journey Continued…

10.3.10 (CRISIS) Bob has badshakes face and legs. HousingSupport Worker calls doctor andis told to take Bob to A&E. Wastold medication needed

changing.Accident and Emergency

Community Mental Health

Team:

Bob has had CommunityPsychiatric Nurse (CPN)involvement from 2007onwards to help with ‘selfharm’. However, CPN has oftenbeen off sick so has only seen

her 5 times since 2007.

Ongoing often daily

support…

Health and Social Care Housing Related Support

Bob’s Journey Continued…

6.5.10 Not engaging with drug and alcohol services anymore… Locked up last night –

bought some Temazepam to ‘calm down’

23.10.10 Probation officer reports that Bobhad taken overdose of anti-depressants.Said it was an impulse thing as he felt bad

about shoplifting… food parcel given.

Care Plans

Support Plans?

Criminal Justice

Workforce Issues

‘It’s just such a chaotic environment… we were all very stressed out… I had a couple of weeks off and I was not in a good state after [one of the service users] died. I didn’t get a debrief after the incident and I didn’t ask for one as I blamed myself for his death. I eventually got a five minute chat with one of the managers but by then the rot had set in so I had to go off sick for two or three weeks and by then I had mental health issues that I have never had before in my life, like anxiety and depression’

Support Worker

Summary

� Lots of commitment to joint working but a lack of integration in support planning, monitoring and review stages

� Uniprofessional working can make workers feel out of their depth and isolated (stressed)

� Agencies often unwilling to take on ‘sole’ responsibility for those people whose needs are perceived to go beyond the remit of existing services (inverse care law)

Potential Solutions: High Level Strategic

Care Plans

Support Plans

?

1. How can we promote more integrated support/care planning across health, housing, social care and criminal justice?

2. How will austerity measures impact on joint working locally?

3. How will ‘Integrated Offender Management’ (IOM) and the new Supporting People ‘Common Access Point’ impact?

20-30 Minutes Discussion

Supported Housing Provider

Drug and Alcohol Services

Community Care Assessment

Support Plan Mental Health Services

Strategic Solutions - Common Assessment Framework (CAF)

IndividualBudget

Integrated Personal Plan Identifying Outcomes to wh ich all Agencies and Professionals Agree to Work Towards Achieving Toget her

Support Plan

GP & Community Health Services

Personal Care

Support Plan

Case Management

Employment/Training Big Society etc,

Care Plan

Monitor & Review… Ensuring Continuity

Routine Exclusion of ‘Homeless People’ from (statutory) Community Care Assessment

MEH CASE STUDY

“There is a man who has a long-standing alcohol problem... He has a chronic infection in one of his legs… The hostels felt they couldn’t manage him and then very shortly after that he threatened one of the hostel staff and he was evicted so he is back on the street. He doesn’t want any help with his substance misuse so he doesn’t meet their threshold… He has a degree of physical disability but he won’t meet the threshold for ordinary residential care.

(Support Worker)

Fair Access to Care Services

Critical risks to independence are when:

� life is, or will be, threatened; and/or � significant health problems have developed or will develop; and/or � there is, or will be, little or no choice and control over vital aspects of

the immediate environment; and/or � serious abuse or neglect has occurred or will occur; and/or � there is, or will be, an inability to carry out vital personal care or

domestic routines; and/or � vital involvement in work, education or learning cannot or will not be

sustained; and/or � vital social support systems and relationships cannot or will not be

sustained; and/or � vital family and other social roles and responsibilities cannot or will not

be undertaken.

Scenario Taken from SCIE Training Module

Example of Critical Risk to IndependenceMr X is a refugee who was imprisoned and tortured during conflict in his country. There is no information about his family, but they are thought to have been killed. Adult services and Mr X's community group are involved. His friend is referring him because Mr X's behaviour has recently become frightening. Mr X says he has nothing to live for, has refused food for a week and will not let anyone into his rented room.

http://www.scie.org.uk/publications/elearning/facs/index.asp

Discussion‘The cultural change needed to embed good practice locally has not benefited from the senior management support and leadership and that as a consequence, personalised and integrated care planning in [adult social care] is still not widespread and barriers persist’ (Department of Health, 2009)

1. What could be done to embed this change locally?

2. How could we ensure that these processes are accessible to people with complex and multiple needs including experiences of homelessness?

Potential Solutions: Community of Practice

Gary HumphriesHand Consulting

The simple art of Community of Practice facilitation

Three Crucial Aspects1.Contract Diligently

2.Get the right people on the bus

3.Enable Self Directed Learning

1.Contract Diligently

Commissioners

Facilitator COP membership

2. Get the right people on the bus

Hierarchy Cooperation Autonomous

3. Enable Self Directed Learning

COP Activity

� complex case studies� communicate changes� sharing practice expertise� inter agency/ professional working� inter agency cooperation� Inter agency problem solving

Evaluated benefits

� Effective complex case planning and interventions

� Sharing and understanding of professional expertise

� Efficient inter- professional and inter-agency working

� Awareness and accessibility of service availability in the locality

� Better working relationships� Improved application of research into practice

Potential

� Hub for the development of effective practice� Focal point for the gathering and dissemination of information� A feedback loop for practitioners and organizations� A lighthouse for practice values and principles� A model and promoter of CPD� Shared expertise, knowledge and skills� Identification of training needs � Support of inter professional practice� Promoter of inclusive practice and inclusive service

development� Development of reflective and research guided practice.

No silver bullet