This chapter first summarises the integration of the CSSs with other services. As mentioned in Chapter 3, information was gathered from CSS staff during interviews about the extent and nature of their integration with local authority, health and community services. An inventory of services was compiled exclusively for each CSS, and staff were asked to score the extent to which they (1) worked with each service (actual score) and (2) believed they should be involved with each (expected score). They could respond as follows:
0 = no awareness of the service
1 = some awareness of the service, but no communication or shared working
2 = formal brief communication with the service
3 = regular communication with the service
4 = high level of joint working around clients (discontinues if no client in common)
5 = collaborative approach with a focus on the community or population (not solely around clients).
They provided detailed explanation for scores, including ways in which their relationships with agencies had evolved over time, changes in collaborative work practices and future plans. Sessional staff, external service providers and stakeholders also provided scores for their work with the CSS, so the extent of reciprocity could be observed. Reasons for scores and differences between sites and models were explored using qualitative data. To preserve confidentiality, some services are not mentioned in this chapter, and the scores of external agencies are not given. Different scores were given by some staff within the same CSS, depending on their role. In this chapter, the highest score provided by a member of CSS staff for each service is presented.
The second half of the chapter focuses on the views of CSS staff and external agencies about the strengths and limitations of the CSSs. Drawing on their interviews, six themes about the development and delivery of services are summarised.
Integration with community mental health services
All CSSs reported high levels of integration (scores of 4 or 5) with one or more mental health service, and these scores were largely reciprocated by the external agencies. Many had links to community mental health teams. In addition, all except UC1 had connections to a specialist mental health team for people who were homeless, or for those with enduring mental health problems or complex needs. DC1, DC2, MT1, SP1 and UC4 also had links (mostly brief communication) to voluntary sector mental health services, such as Mind.
All CSSs except UC2 either employed mental health practitioners or had external workers hold regular clinics at the CSS. At DC2, for example, one such worker held sessions three times a week at the CSS, attended staff meetings on those days and met regularly with the GPs to discuss patients. Likewise, MT2 staff met regularly with a mental health team for people who were homeless to discuss patient care. MT1 and UC2 staff described ways in which they worked closely with mental health services:
We’ve quite a lot of patients we refer to them [mental health services]. [They send us] weekly updates ... they will tell us who has been referred, who is waiting for a mental health assessment, who has had their assessment, what the plan is, and who’s been taken to the [psychiatric hospital].
MT1 staff
We’ve a long working relationship with [mental health team for people who are homeless] ... one patient had been sleeping rough on the street for some time and recently got into accommodation. The [mental health] worker asked to meet me with the patient [and] his key worker ... we sat down together with the client and they handed over ... [The workers] then made themselves available for ongoing contact afterwards, although his medical care had been taken over by us.
UC2 staff
Some CSS staff discussed difficulties in working relationships with mental health services. Although a mental health team for people who were homeless was based at SP2, there was little contact between this service and CSS staff. According to MT1 staff, not having a GP in the team resulted in problems referring patients to secondary mental health care, as this required a GP or mental health professional referral. MT1 staff also explained that they would have welcomed more information-sharing with mental health services regarding safety aspects:
We’ve seen somebody and then afterwards been told, ‘You shouldn’t have lone-worked with that person’. Sometimes we don’t find out until a few weeks afterwards. So it would be really helpful to have proper collaborative working with mental health services so we can support one another.
MT1 staff
Integration with substance misuse services
Most CSSs reported integration levels of 4 or 5 with at least one substance misuse service, and the scores were largely reciprocated by the external agencies. No CSS directly employed substance misuse workers, but DC1, DC2, SP1, UC1 and UC3 had shared care arrangements in place, whereby substance misuse workers held regular clinics at the CSS, and GPs trained in substance misuse prescribed OST. At all of these sites except UC3, substance misuse workers were at the CSS at least 4 days per week. DC2 and MT1 staff also described collaborative working with residential detoxification services. The former, for example, provided primary health care to patients of a local detoxification unit while they were undergoing treatment at the facility.
At many CSSs, substance misuse workers who held on-site clinics attended staff meetings to discuss patient care, and worked jointly with the GPs. They described the benefits of such relationships:
It’s a high level of joint working because we literally talk to the GPs on a daily basis and it can be several times a day. We can see two or three patients together with the GP. We meet with GPs once a month to discuss more high-risk patients and any safeguarding issues.
Substance misuse worker, DC2
Joint working with a lot of the staff [at CSS], especially with the mental health team ... and obviously the GPs. We’ll have discussions about clients before I’m due to see them or after I’ve seen them. We’ll have quite complex discussions ... we might set up case conferences here with external agencies.
Substance misuse worker, SP1
Where on-site substance misuse services were not in place, CSS staff referred patients to external services. However, communication with these services varied, and integration levels of 3 and 4 were reported. Some MT2 and SP2 staff described being unaware of whether or not their patients attended appointments with substance misuse workers, and were not provided with updates on their patients’ progress (this was apparent to the research team when the medical records were searched). This reflects the findings of SHC outcomes: MT2 was less likely than most other CSSs to have achieved continuity of care for alcohol and drug problems (see Table 27). The following extracts illustrate the difficulties experienced by MT2 and SP2 staff:
We refer people to [substance misuse services] ... but we don’t know if they’re being seen. We don’t know if they’re going ... I can think of one person I referred that was seen but [I only know that] because the patient told me.
MT2 staff member
[The drug service] is quite separate and we don’t do a lot of joint working. I think communication between us and them could be better. [Difficulties occur] when we have to ask for updates on what they are doing with people ... there isn’t great communication, I don’t think, in either direction, and I’m sure that’s something that could be improved.
SP2 staff member
Integration with hostels and temporary housing schemes
All three specialist Health Service Models reported high levels of joint working with several hostels and temporary supported housing schemes. For example, MT1 scored integration levels of 4 and 5 with 11 hostels, and the remaining CSSs, apart from UC1 and UC4, gave similar high scores for at least three hostels. A few hostels in the locality of the Dedicated Centres and MT1 were given low integration scores (0 or 1) by CSS staff. This was partly because the hostels were a distance from the CSS and residents therefore registered at local general practices. SP2, MT2 and UC1 reported similar low scores for four or more hostels, with some CSS staff indicating that insufficient resources prevented them from doing more collaborative work. UC1 in particular had very little involvement with hostels.
Regular clinics were held in one or more hostels by nurses or GPs from DC1, MT1, SP1 and SP2. Instead of clinics, MT2 had weekly meetings with staff at one hostel to discuss concerns about residents, and provided training at hostels on the health needs of residents. The aim was to reduce inappropriate out-of-hours service use. Strong integration links between CSSs and hostels enabled flexible working and prompt responses between the two services. Hostel staff, for example, telephoned the CSS and sought guidance if they were concerned about a resident, without having ‘to go through a lot of red tape’. Likewise, CSS staff liaised with hostel staff if a resident required encouragement to attend a health appointment. The Mobile Teams were sometimes under pressure from hostel staff to hold (additional) clinics at their services, although the former believed that training for hostel staff was more feasible and a better use of resources. The following examples exemplify the positive links between some CSSs and hostels:
We do teaching sessions at the hostels [with staff] to try to help with reducing ambulance call-outs ... there’s a hugely disproportionate use of ambulances at homeless hostels and we try and reduce frequent attendance at accident and emergency ... so we give health promotion talks at hostels, [such as] if one of the hostel residents has a seizure what would you do, when would you call the ambulance.
MT2 staff member
If we’re in a crisis situation, we’ve rung up [the CSS], explained what the situation is and I think because of the working partnership that we have with them, we have the credibility (or they give us the credibility) of not saying it’s a crisis if someone sneezes twice. I think building up that working relationship has paid dividends. It works really well.
Hostel staff member, DC1 locality
In some CSS areas, the closure of several hostels meant that residents were dispersed into small housing units across a wide geographical area, making it difficult for CSS staff to maintain contact with vulnerable patients and support staff. Low staffing levels in the hostels and the use of agency staff also led to challenges in maintaining relationships.
Integration with day centres and street outreach teams
All CSSs within the specialist Health Service Models gave scores of 4 or 5 for integration with one or more day/drop-in centres for people who are homeless. Indeed, SP1 staff reported high integration levels with seven centres. Apart from UC3, there was much less contact between Usual Care GPs and day centres, and some CSS staff had very little knowledge of such services. Day centres were the settings for much of the work undertaken by Mobile Teams, where they held regular health clinics, worked jointly with staff to plan care for service users with complex needs, and assisted with medical emergencies. As one MT2 staff member explained, day centres are now doing a great deal of work with people who have mental health problems that used to be undertaken by health and social services. SP1 and SP2 also held regular clinics at a day centre. DC1 and SP1 visited a centre regularly to encourage registration with the CSS, and DC2 undertook periodic health promotion activities at a centre, such as giving influenza vaccinations. Some day centre staff expressed a wish for closer integration with CSSs as they believed that this would benefit service users. The following examples illustrate the different relationships between CSSs and day centres:
We do some close working with day centres, because they now do a lot of the work that health and social services used to do. A lot of day centres will now do the mental health work with the patient.
MT2 staff member
We’re just another person who might ring [the CSS]. There are no formal links. If we ring up, we get in the queue just like everyone else; there’s no secret passage for our clients ... no one from [the CSS] will ever ring here ... and ask about someone. I think it would be good for them to link with agencies like us who are spending time with patients and clients – we know them and I think that goes a long way towards solving someone’s health issues.
Day centre staff, UC1 locality
All specialist Health Service Models worked closely with street outreach teams. Staff of Dedicated Centres and SP1 accompanied outreach workers on the streets, and the outreach workers accompanied clients to appointments at the CSSs. SP2 worked closely with the street team, but CSS staff explained that they did not have the resources to conduct outreach themselves. Both Mobile Teams undertook regular outreach with local teams. Among Usual Care GPs, only UC4 reported regular communication with a street outreach team.
Other integration and strategic work
The level of integration between the CSSs and housing departments and social care services varied, although most reported some communication, mainly around patient referrals. Dedicated Centres, Mobile Teams and SP1 also had some involvement with local hospitals. For example, DC2 advised hospital doctors about medication for drug dependency and communicated around patient discharge, and DC1 and SP1 were involved in hospital inpatient care and visited patients on wards. The Mobile Teams reported integration mostly at level 5 with some general practices in their area. They encouraged patients to register with a GP, and, in most cases, shared patients’ medical records. MT1 ran joint clinics in a few hostels with a GP, whereas MT2 had weekly meetings with a GP to discuss patients with complex needs and occasionally held clinics in that general practice.
The specialist Health Service Models, but not the Usual Care GPs, were involved in local strategic meetings regarding provision for people who are homeless. The former also attended multiagency meetings concerning people sleeping rough, frequent attenders at EDs, safeguarding concerns and people with complex needs. SP2 highlighted the benefits of multiagency meetings:
One patient has significant physical health problems and substance misuse ... so we had a safeguarding meeting that was led by someone from the substance misuse team. We now have a communication group regarding that patient where we’re all kept up to date. [Multiagency meetings] work for individual cases where there’s an increased level of concern.
SP2 staff member
Strengths and limitations of the work of the Case Study Sites
This section presents the qualitative analysis of the interviews with CSS staff, other service providers and stakeholders. In each CSS locality, these participants were asked for their views of: (1) the strengths of the CSS and what aspects of the service worked well; (2) whether or not the CSS was meeting the health, social and welfare needs of local people who were homeless; (3) the limitations of the CSS and what aspects of the service did not work well; and (4) the ways in which the CSS should change or improve its services. Their opinions are summarised in Appendix 5, Table 56. Six themes relating to the mechanisms and contextual factors listed in this evaluation’s framework emerged from the data (see Table 1): (1) understanding of homelessness and the development of specialist services, (2) CSS staff members’ attributes and delivery of tailored (person-centred) health care, (3) partnership-working and the delivery of holistic care, (4) flexibility and accessibility of the CSS, (5) outreach and engagement and (6) unavailability of supporting services. Each of these themes is discussed in the subsequent sections. UC4 has not been included as only one interview was conducted.
Understanding of homelessness and the development of specialist services
A strength of all the CSSs of the three specialist Health Service Models was that they had been delivering health care to people who are homeless for many years, with services evolving over time in response to needs. The Dedicated Centres and Mobile Teams were established specifically for this purpose, and interested staff at the Specialist GP sites were driving forces in the development of specialist services at their practices. The majority of staff involved in working with people who were homeless had many years’ experience in this field, had considerable understanding of their problems and needs, and were knowledgeable about relevant services in the locality. Staff at both DC2 and SP1 described their service as ‘organically grown’, as the following quotation illustrates:
When the service first started offering health care to homeless people, it was quite a rudimentary service ... it’s developed organically over a lot of years to create a needs-led service with a proportionate response.
SP1 staff member
The Usual Care GP sites were established to provide primary health care to the general population; by default, this included patients who were homeless, such as residents of local hostels. Their involvement with this patient group had grown in recent years. UC2 and UC3, for example, introduced enhanced assessments for patients who were homeless. Unlike the specialist models, however, the staff tended to be less knowledgeable about homelessness services in their locality, and less involved in multiagency meetings pertaining to this population. Both UC1 and UC2 staff acknowledged the potential value of a more proactive approach towards this patient group by, for example, undertaking audits of their needs. A member of the UC1 staff also proposed that there should be a ‘homelessness lead’ within the practice who would focus on this patient group:
We don’t have a lead for homelessness, but it might be something we should look at. We have a lead for carers ... sometimes they [patients who are homeless] present with particular issues the general population don’t [or] it’s more prevalent ... if you’re more used to it, you notice things more ... you’re tuned in.
UC1 staff member
Staff members’ attributes and delivery of tailored health care
Overall, staff of the three specialist models were described as committed, non-judgemental, motivated, enthusiastic, empathetic and patient. They reported working flexibly to accommodate patients’ needs, and devoting time to listening and building trust with them. Several interviewees commented on their skills and positive ways they worked together to deliver high-quality care. Some CSSs, particularly the Mobile Teams, comprised several nurses with different skills. This was believed to be beneficial as each nurse brought their own specialism to the work. Some of these positive attributes were also mentioned about staff at the Usual Care GP sites (see Appendix 5, Table 56). The following extracts illustrate the skills mix and joint working within teams:
We’ve got nurses from a variety of different backgrounds. We’ve got quite a decent skill mix. I’ve got a background in community nursing, so I did extra training on tissue viability, plus I’m prescribing as well. [Name] background is in needle exchange and sexual health. We’ve also got [name] who has a mental health background. There’s a high level of expertise within the team.
MT1 staff member
I think we’re good working in a team. We aspire to have joint working. We share client information ... [so that] each person who’s involved with that care is on a similar wavelength and [there is] a similar focus on how to help that person regain some of their independence and hopefully regain health, if that’s possible.
DC1 staff member
Many CSS staff described ways in which the health problems of people who are homeless tend to be more neglected and advanced than those of comparable ages in the general population. Hence, innovative and opportunistic ways of working were required. Staff at five of the nine CSSs mentioned having ‘to think outside the box’ and ‘go the extra mile’ when planning and tailoring health care to this patient group. The following account by a nurse illustrates this clearly:
Their health needs are not that different [than the general population]. They’re just more neglected and advanced. We see COPD and asthma, but it’s quite a curious presentation because it’s induced by smoking crack, for example. We do tailored respiratory reviews. We have our own bespoke templates. We do patient education as much as possible ... somebody comes in and they’re under the influence of cannabis or alcohol, but as long as they can hold a conversation with me, because they have high tolerance levels, I would still do a respiratory review as long as I’m happy they’ve actually retained information. We do diabetic checks and again ... our lifestyle advice is tailored to the situation. I’m not going to calculate calories with somebody who’s rough sleeping. We’re just addressing safety issues ... we’re holding quite a lot of risk in the primary [care] setting .... We see leg ulcers in young men due to injecting and they usually have huge vascular problems. Ulcers that you would see in a 70-year-old, we’re seeing in a 20-year-old because they have heart failure on top of that or deep-vein thrombosis ... [the ulcers are] really neglected and unwashed and they’re usually colonised by biofilms.
DC2 staff member
Partnership-working and the delivery of holistic care
Partnership-working was an integral and central role of most CSSs. As described in the previous sections on integration, the three specialist models were proactive in their approach to collaborative working with other services; widely promoted their own service; and shared their knowledge and understanding with other agencies, such as homelessness sector staff. Usual Care GP sites also described relatively high levels of joint working with mental health and substance misuse services. The following are examples of how partnership-working developed:
Partnership-working, that’s always been really key and central to what we do ... we’ve tried not to be one of those services who tries to do everything, and actually you are using the expertise and experience of what other services can bring to the table.
SP2 staff member
Homelessness ... is one of the most integrated parts of the city, with homeless services working incredibly well together – the paid sector, voluntary sector, statutory sector ... I think based on good will, good work and good relationships. There are some really good networks and partnerships. I think they happened as people went out and built those links and partnerships and friendships ... and created really a strategic alliance forum for the most marginalised and vulnerable people in the city.
DC1 staff member
As summarised in Appendix 5, Table 56, nearly all CSSs strived to provide holistic care to patients who were homeless. Their integration with other services facilitated this process. DC1, DC2 and SP1 were characterised by ‘one-stop shops’ or ‘service hubs’, whereby primary health, mental health, substance misuse, social work and other specialist services ran sessions or were in the same building. At these sites, CSS staff and sessional workers held regular meetings, at which they shared updates about patients, including risk concerns, and planned care. Co-located services also enabled opportunistic ‘corridor’ discussions to take place. The advantages of such arrangements were explained by a sessional worker at SP1:
Before the clinic starts, there’s a half-hour meeting ... where clients or issues may be discussed. It might be that there’s someone coming in, who may be potentially risky .... It’s just to make us aware of the risk .... It might be one of the doctors has arranged for someone to come in and see us and gives us a bit of heads-up on who it is, what their concerns are ... there’s information passing between the different agencies. The drug service will give us an idea of what’s going on with a particular client. The GPs might have another element to add. It’s a good opportunity to network .... Sometimes, you [also] get quite a lot of corridor talk, which is a useful thing ... you can get a lot of information out of a 5-minute conversation on a corridor.
Sessional worker, SP1
In many cases, co-located services encouraged flexible working between staff, quick access to doctors and nurses when necessary, and joint consultations with patients. A drug worker, for example, sometimes asked a nurse to assess an injecting site if there were concerns, or quickly arranged a consultation with a GP or mental health worker if indicated. It also enabled patients to be seen by different health professionals on the same day without having to visit separate locations. As a drug worker explained in the following example:
I can assess someone ... a nurse will see them and offer wound care; a GP, if we’re concerned, will see them without an appointment and do an immediate screening ... if there’s obviously localised infection they might need antibiotics.
Drug worker, DC1
Accessibility and flexibility of the Case Study Site
The CSSs were generally perceived as accessible to patients in terms of their ability to provide registration. CSS staff and external agencies said it was easy at both the specialist models and Usual Care GP sites for people who were homeless to register at the practice. One hostel worker, for example, described how UC2 provided an inclusive service to people who were homeless:
What I like about [the practice] is that it’s open to everybody ... It doesn’t treat anyone differently. They don’t say you can’t join [register] because you’re homeless or from [our hostel].
Hostel staff member, UC2 locality
All specialist models also provided an accessible and flexible service. The Dedicated Centres and Specialist GPs offered both booked appointments and drop-in clinics for patients who were homeless. The latter were beneficial for those who found it hard to comply with fixed appointments. Even if people arrived late for a booked appointment, they tended still to be seen whenever possible. Likewise, the Mobile Teams operated drop-in clinics. The Usual Care GPs, however, were less accessible and flexible. There were no drop-in clinics and people who arrived late for appointments could not always be seen. According to some hostel staff in the localities of UC1 and UC2, residents also experienced difficulties booking appointments. At UC1, some staff and agencies believed that the practice should be more flexible and provide drop-in sessions for patients who are homeless. The problems associated with Usual Care GPs were acknowledged by CSS staff and external agencies:
The booking of appointments [is] quite difficult ... you have to ring up at 8 o’clock in the morning, but lots of our clients find it hard to get up in the morning. They take quite high levels of antipsychotics which make them quite drowsy ... getting up at 8 o’clock in the morning and ringing in a queue to get an appointment on the day ... it’s not realistic.
Hostel staff member, UC2 locality
Sometimes it’s difficult to get them [people who are homeless] to engage because obviously, with homelessness, the drinking ... you can give somebody an appointment in 20 minutes’ time and, even though they live [close by], they miss their appointment and turn up about an hour late ... the doctor won’t see them unless it’s something really urgent.
UC2 staff member
Concerns about the opening hours of some CSSs were raised by staff and external agencies, who described DC1, SP2 and UC3 as operating ‘office hours’ on weekdays only (see Appendix 5, Table 56). The consensus was that these practices should open some evenings and/or at weekends. Likewise, a staff member of MT1 believed that their working hours should be staggered more to enable staff to be available in the evenings when soup runs operate. The Mobile Teams also referred to restrictions to their service when operating in non-NHS settings such as day centres. They are dependent on the ‘rules’ of services, such as opening hours and eligibility criteria for service users. For example, MT2 used to do some evening work at day centres, but this stopped when the day centres no longer opened in the evenings. Many day centres rely on local authority funding, and service commissioners sometimes impose restrictions on services.
Outreach and engagement
The CSSs of all three specialist Health Service Models delivered some outreach services. All except DC2 ran regular clinics in hostels or day centres, and street outreach was undertaken by all except SP2. Usual Care GPs did not provide outreach services. Many CSS staff and external agencies across all CSSs except UC3 strongly believed that more outreach work in hostels and on the streets was needed, citing their awareness of many people who were homeless and not engaging with services who had unmet health needs. Hostel staff in the locality of Usual Care GP sites also described the difficulties of getting some residents to attend health appointments. This was verified by UC2 and UC3 staff, who reported high numbers of missed appointments among this patient group.
There was concern by some external agencies about the amount of time Mobile Teams spent in day centres. Those in the locality of MT1 believed that the team should hold fewer drop-in clinics at day centres and focus more on people sleeping rough who were excluded from or not accessing day centres. Similarly, some external agencies believed that MT2 should undertake more work in hostels and less at day centres. At most CSSs, staff expressed a desire to expand or commence outreach work on the streets and in hostels, but were prevented by lack of resources and workforce (see Appendix 5, Table 56). The dilemmas in weighing up priorities were described by a DC1 staff member:
We can’t be doing outreach as well as providing a clinic-based service ... you have to choose ... what feels the most efficient use of the resources you’ve got, and what meets most of the need most of the time in the most effective way.
DC1 staff member
Although many external agencies believed that the CSSs should be doing more street outreach, CSS staff acknowledged the impracticalities of delivering health care in this way and the importance of people sleeping rough attending general practices. As explained by CSS staff, the key aims of street outreach by health professionals should be engagement, building rapport and familiarity, and encouragement for the person to attend the CSS:
[Street outreach] is a means of engagement to bring people in ... you can do a basic health check, or flag up problems, or refer somewhere, but for the actual consultations, I think it would be good for people to access the main service [general practice] because we have all the equipment there .... You cannot claim that you really provide health care [on the streets].
DC2 staff member
Our philosophy is not to provide half-baked health care or health care in an environment where we can’t really provide it ... you can make clinical interventions on the street, but [these are] very limited .... A lot of street medicine should be about engagement and getting people into an environment where they can get decent health care.
SP1 staff member
Apart from lack of suitable facilities at some sites, there were other concerns expressed by CSS staff in delivering health care in non-NHS settings. Difficulties arose for staff of Dedicated Centres and Specialist GPs if day centre users who were registered with another GP sought help from CSS staff, but were reluctant to register with the CSS. This was particularly pertinent among people who frequently moved between cities, but remained registered with a GP in their original location. As described by a member of SP1 staff, the CSS was contracted and accountable to provide health care to registered patients only:
Some people I’m seeing [at the day centre] are registered with other GPs and don’t want to change GP. They’re coming to see me saying they need another blue inhaler, something fairly simple. I’d really like to [help], but can’t because they’re not registered with my GP practice. They’ll say they can’t go and see their GP because it’s too far or they can’t get an appointment ... I would presume their GP practice is completely unaware that this person is rough sleeping or sofa surfing in [another city] .... They don’t want me to notify their GP because they’re worried about disrupting their GP registration ... what my GP practice is saying is that we’re commissioned as a service, so if we start delivering a different kind of service, then that involves a whole new service specification and agreement with the commissioners ... about 20% [of people I see] aren’t registered [at the CSS].
SP1 staff member
Unavailability of supporting services
No primary health care service can operate in isolation. They require local supporting services, such as diagnostic and specialist services, to enable them to deliver effective health care. From the staff and agency interviews, however, the unavailability of some services in their locality affected their work. A common insufficiency raised by many staff and external agencies from all CSSs except UC3 was the poor availability of mental health treatment services. This included long waits for people to be assessed and start treatment, insufficient services for people with mild to moderate illness, long waits or barriers to services for people with combined mental health and substance misuse problems, and lack of community mental health nurses and hospital beds. This is particularly pertinent given the high rates of mental health problems among people who are homeless.
Case Study Site staff or external agencies at five of the nine CSSs also mentioned a lack of local dental services for people who are homeless. A third factor raised by several staff was lack of housing, both emergency or respite accommodation for people on the streets who have health problems, and secure independent and supported move-on accommodation. As described by DC2 staff, effective health care treatment is dependent to a great extent on the accommodation status of a person:
Sometimes, it does feel like you’re picking up water with a fork a little bit because we can do all the best dressings we can, or engage as much as we can, but if people are rough sleeping, then there are limits to health improvements really.
DC2 staff member
Summary
All three specialist models appeared to be well integrated with mental health, substance misuse and homelessness sector services. Relationships were founded on a shared client group, and an understanding of the problems experienced by people who are homeless and the complexity of their health and social care needs. Although this work often took place at the individual-client level, CSSs that worked collaboratively with services (not solely around patients) had opportunities to become involved in strategic approaches to tackle unmet need. Usual Care GPs were less integrated with homelessness sector services, and did not have the same extensive networks as specialist models. However, some achieved high integration levels with a small number of hostels, suggesting that positive working relationships can be built between mainstream general practices and homelessness sector services. Overall, for all CSSs, the extent and depth of integration with services largely depended on the resources available, as most expressed a wish to maximise partnerships.
The benefits of a hub of services in the same building were acknowledged both by CSS staff and external agencies. It enhanced partnership-working and enabled easy access to services. Although it would not be feasible or practical to introduce such an arrangement in many locations, more collaboration between services is likely to be beneficial. Poor communication between substance misuse and mental health services and a few CSSs indicates the need for improvement regarding information-sharing. Homelessness sector staff valued greatly the relationship they had with some CSSs, citing ease of access to the practice and staff willingness to advise and provide support as important factors.
The CSS staff and agency interviews highlight the intricacies of engaging people who are homeless in health care, and the importance of designing services that are appropriate and accessible. Staff of the three specialist models in particular had the experience and capacity to develop tailored approaches to health care that were acceptable to patients, could be delivered opportunistically and had some positive health outcomes. Although both CSS staff and external agencies stressed the need for more outreach work by the CSSs, there appeared to be different expectations and opinions as to its aims and how and where it should be delivered. Such interventions also require consideration of the issues raised in this chapter around delivering health care in non-NHS settings.
Caution has to be taken when interpreting the integration scores. In a few instances, staff gave unusually high scores for their involvement with a particular service. They may have overstated the level of integration as they believed they should have been working more with the service (although ‘expected’ scores were collected as well). There were also difficulties identifying a few services mentioned by staff as they could not name the service and were unclear about its purpose.
