Housing and Health The Brighton and Hove Experience Geraldine Hoban Chief Operating Officer Clinical Commissioning Group

Housing - A Key Determinant of Health Increasing recognition that if you want to improve people’s health you focus on the wider determinants and not just on the health services you provided to them. Recognition that it is as much the people and the environment around them that influences health and well being. Which is why it is all the more important that public services, statutory providers like the NHS, Local Government, Police, Probation, third sector etc all have to work in a far more co-ordinated way to both do the best by the people we serve but to make the most of the ever scarcer resources there are.

Links Between Housing and Health Quality of housing has a substantial impact on health needs Utilisation healthcare particularly for vulnerable groups The Building Research Establishment has calculated that poor housing costs the NHS at least £600 million per year * I don’t need to make the case to you I’m sure but it goes without saying a warm, dry and secure home is associated with better health. Vulnerable groups such as older people, people with disabilities, people with mental health problems are concerned. * Nicol, S. et al., Quantifying the cost of poor housing, BRE press, 2010 Tell you a bit about our experience in Brighton and Hove – bit of context CCG co-terminous with the City Council and took over the boundaries, relationships and many of the people working in the PCT previously so unlike many areas we didn’t go back to scratch when CCGs were established a couple of years ago. Excellent relationships and collaborative commissioning arrangements to start from.

Brighton and Hove Housing Strategy 2015 Vision We want Brighton & Hove to be an inclusive city with affordable, high quality, housing that supports a thriving economy by offering security, promoting health and wellbeing and reduces its impact on the environment. Housing Strategy confirms that link between housing and Health – collaborative working is ntrinsic to the B&H Housing Strategy

Brighton & Hove Context & Housing Challenges City of contrasts - with areas of extreme affluence and areas of deprivation Drug and alcohol, homelessness, mental health Pressures from an increasing population and limited space for new development One of the highest average house prices outside London within the top 10 L.A’s but relatively low wages High rents in the private rented sector making rent unaffordable for many. Popular place to live and work - within easy reach of London making it an easy location to commute to and from. Contrasts within population – pockets of extreme affluence and deprivation, very high level of mental health need, drugs and alcohol related problems and homelessnes Large and growing student population and influx of workers putting pressure on a very limited housing stock with v limited potential for expansion High house prices, high rents, making the rental sector unaffordable for many and in particular rental to people with high level of social need unnatractive to landlords

Partnership Working Strong City-wide strategic partnerships City Management Board Health & Wellbeing Board Strategic Housing Partnership Joint Commissioning Approaches – Better Care Fund - focusing particularly on vulnerable groups CCG Sustainability Plan – strengthening links into Council services – ie warm homes We know we have a challenge! On the plus side – very strong partnerships between CCG, The City Council and other stakeholders across the City All statutory providers come together ie Police, Probation, CCG, City Council, Business Community, Third Sector at CEO level in a City Management Board. Strategic Housing Partnership which feeds into the CMB. Health and Wellbeing Board oversees the strategic priorities for the City and manages the BCF – within which is a key focus on housing and homelessness in particular – will say more about this in a mintue CCG Sustainability Plan – makes stronger links between General Practice and the City Council – promoting awareness around warm homes, housing adaptions with GPs in the City and making sure that referals are made by practices into these services – we’ve appointed a GP clinical lead with this focus.

Case Study Supported Accommodation Pathway for Mental Health Jointly reviewed supported accommodation mental health pathway Identified that there was insufficient capacity at all tiers in the pathway - particularly for people with most complex needs e.g. dual diagnosis Pooled budgets and undertook a joint procurement process Example of collaborative commisisoning between us and the City Council: Recently recommissioned supported accomodation for people with mental health problems Recognised there was insufficient capacity at all tiers in the pathway – paticularly dd Pooling resources - better value for money

Key Successes 100 additional units within the same financial envelope Multiple providers working together within pathway to increase move on opportunities Greater range of accommodation options from the most complex (24 hour support) to start up tenancy support Pooling resources – greater vfm Streamline the pathways of care so that we werent duplicating support or leaving some people to fall down the gaps between the two. Move on – improved use of resource and focus on recovery

Better Care Fund Opportunities Strategic opportunity to further integrate health, social care and housing support. Two key priorities – frailty and homeless Multi-agency involvement in the development of integrated care teams based around clusters of GP practices Incorporating statutory and third sector providers and taking a broader holistic view of health and social care needs In addition to the joint working arrangements we already had in place. BCF has increased the focus on joint working between social care, housing and health. Use of pooled budgets gives us greater freedoms and opportunities for integration B&H in addition to the frail often elderly cohort of patients which is the focus nationally, we’ve looked at the needs of homeless people as a key strand in our BC Plans. Developing a multi-disciplinary integrated teams working around clusters of general practice

Homeless Health Need Increasing numbers of homeless –increase of approx. 40% over the last 3 years (JSNA, 2013) Increasing health &wellbeing needs & complexity 84% reported at least one physical health problem 53% had a diagnosed m.h condition 40% take drugs or are recovering from a drug problem 26% drink four or more times a week (Homeless Health Needs Audit, 2014) Recognised the needs of homeless people in the City in particular were being poorly met: Seeing higher numbers of homeless in the City – people living on the street, in hostels, temporary accomodation and sofa surfing. Greatest health inequality within this population – life expectancy for a man living on the streets in brighton is 47 years compared to 77 Complexity of need - Physical health, mental health, substance misuse Difficulty with access ie not registered with a GP, often neigher booked appointments or walk in clinics well used by this group but also in the model of care we delivered in the City – boundaries to ways of working meant some people living in hostels didn’t qualify for community nursing service for example Therefore a very high level of unmet need

Homeless Health Need High utilisation of unplanned care National figures indicate homeless people are 5 x more likely to go to A&E and 3X more likely to be admitted to hospital, longer lengths of stay and higher re-admissions Locally, the Homeless Health Needs Audit (2014) showed 36% of respondents had attended A&E in last six months As a result what we experienced was very high use by homeless people of urgent care services: 5 x more likely to use A&E, 3 x more likely to be admitted to hospital, will have much longer lengths of stay once in hospital and more likely to be re-attend and be re-admitted. Locally – third of our homeless poulation had attended A&E in the last six months.

Starting Point System of Care Dedicated homeless GP practice Some excellent individual services and teams – but inconsistent Care largely commissioned and delivered in silo’s – not co-ordinated or proactive Strengthening capacity across all organisations Integrating ways of working into one MDT working to proactive care plans What have we done. Under the auspices of the BCF – used our dedicated GP practice for homelessnes as the starting point, as we see the co-ordination of care being built around GP practices, Some excellent islands but recognise that our services were very fragmented, and not working in a co-ordinated way around the individual. Invested in primary care, dedicated clinical capacity within hospital, strengthened role of third sector organisaitons in supporting people out of hospital St John’s Ambulance and support workers to assist them with housing applications, taking them to clinical appointments, registering with a GP if they havent got one etc as well as the whole range of other social support that someone will need to continue to make their lives and homes function.

Vision Multi-agency Homeless Integrated Health & Care Board. “To improve the health and wellbeing of homeless people by providing integrated and responsive services that place people at the centre of their own care, promote independence and support them to fulfill their potential” Homeless Board – brings together the partners across the system

Future Model of Care Vision for new of care – more pro-active – less reactive – holistic rather than service/settings specific. Based around GP practice – outreach (spokes) to deliver care in community settings Training and education role Expert support and consultation to mainstream services

Summary Joint working is essential and increasingly direction of travel address inequalities improve outcomes of care Make best use of scarce resources Housing, Social Care and Health need to forge better working relationships Housing needs to be embedded within JSNAs, Health and Wellbeing Strategies and working of the H&WB Joint working essential Housing social care and health organisations – I mean departments within the Council as well as the wider organisations who fulfill that function Greater integration between health and local authorities is on the horizon – so make those contacts and begin to forge those relationships now. I’m no expert on housing – so please don’t ask me any difficult questions – I just want to make a case for CCGs working in a more joined up way as in even some limited examples we have demonstrated what a significant difference it can make.