Brought in from the cold

People who are homeless experience some of the worst outcomes and highest levels of health inequalities in society; uncoordinated and poorly designed services working in silos too often fail to meet the needs of those with complex and persistent problems.

Cambridgeshire has a history of strong local authority and NHS partnership working in this area. For example, the Cambridge Access Surgery, set up in 2003, is an integrated primary healthcare service hub for homeless people; recent close collaboration in the joint strategic needs assessment process is helping to uncover unmet needs and redesign existing service provision.

The Cambridgeshire joint strategic needs assessment (JSNA) for homeless people showed that, despite being relatively few in number, they are intensive users of emergency and crisis services across the health, community and housing support, police, probation and prison, and voluntary sector services.

Outcomes for the group are also extremely poor. JSNA analysis revealed the average age of death of those registered at the Cambridge Access Surgery who died over the previous five years was 44 years old. More than half of the surgery’s patients had an alcohol problem, two thirds had a drug problem, half a mental health problem and many had a combination of some, or all, of these.  

As a result, those who were homeless continued to be caught in a downward spiral with poor outcomes, unable to access the services they needed. To break the cycle and redesign services around people’s needs, it was clear that qualitative input from service users was key.

In response, a new post to coordinate person-centred care across agencies, which was jointly funded by the NHS, city and county councils and the police, was created. Cambridgeshire successfully bid to become one of three pilot sites for the Making Every Adult Matter charity coalition, enabling shared learning of good practice and a thorough external evaluation covering both economic and person centred outcomes. 

To address the lack of input from service users in the JSNA and commissioning, Cambridgeshire decided to use the Working Together for Change process - a best practice approach to co-producing change with local people and service users to drive commissioning and service redesign. 

The process uses person centred information in the form of statements in people’s own words about what is working in their life, what is not working and what is important to them for the future. Cambridgeshire adapted the method to better suit the client group by gathering information piecemeal over a longer timeframe, allowing key workers time to build relationships with clients, to facilitate collecting and recording information. The statements were then used as the basis for the rest of the process.

Two multi-stakeholder workshops were held, with commissioners, providers and service users all taking part. Delegates worked together in mixed groups to theme the statements, voting on the most important themes under each heading. They then worked in groups to think about the root causes of what is not working, suggest alternative models and develop a series of indicators that might be used to identify success. 

Actively engaged

By the end of the two workshops, delegates had identified four projects for commissioners and managers to take forward:

• a service user board;
• expansion of the cross agency key worker programme;
• a central hub with multi-agency presence; and
• a detox and dry house.

At least eight service users were actively engaged in each workshop, providing a user perspective that generated new ideas and challenged perceptions. 

A strategic level service user board has already been set up and work is currently under way to take forward the three remaining projects. While it is still early days, the engagement of service users through the Working Together for Change process is regarded as a success. As well as providing valuable qualitative input from users, it has been part of a culture change in Cambridgeshire. It has enriched the JSNA and increased the service user input into joint planning and commissioning for person centred care pathways, avoiding duplication of services.

By adopting this approach and engaging users, commissioners and providers, public service commissioners can make better use of scarce resources, improve productivity and improve outcomes by ensuring services provide the things people want and need.

The process supports the statutory duty of the health and wellbeing board to promote integrated working and commissioning for outcomes across health, public health and social care, as well as wider public services such as probation and the police. Training for key workers and frontline staff in the principles and value of person centred reviews also offers them the opportunity to feed innovative ideas and practice into the process of review and evaluation. 

Despite the breadth of funding streams, commissioners and providers involved, a coordinated and person centred approach has the potential to realise considerable savings and improve outcomes by meeting the multiple and overlapping needs of this client group.

Dr Fay Haffenden is a consultant in public health at NHS Cambridgeshire. Michelle Kane is a partner at HK Consulting. Sam Bennett is director at Bennett and Stockton.