This is HSJ’s fortnightly briefing covering quality, performance and finances in the mental health sector.

Feedback and comments are welcome, so please feel free to email me in confidence.

The policy vacuum

Housing is a huge part of the Five Year Forward View for Mental Health due to the impact stable accommodation can have on a person’s mental health.

It is mentioned in the document more than twice per page on average, so it is disappointing that it is only mentioned once in NHS England’s FYFV implementation plan.

On the one hand, this is understandable – housing is primarily the responsibility of local authorities.

Unfortunately, councils are feeling the pinch on their social care budgets and the stock of general and supported housing is limited.

With no national NHS policy on supported housing, the policy vacuum is being filled with a hodgepodge by NHS leaders working with their local authorities and housing associations.

A cog in the machine

Supported housing is a vital cog in the machine because a lack of appropriate housing can cause a bottleneck from inpatient wards right through to community services when patients who are ready to move on have nowhere safe to go.

In areas with good relationships with housing and care providers, mental health trusts have managed to reduce lengths of stay, close unnecessary beds and repatriate people from out of area.

But a new study by the Housing Associations’ Charitable Trust, published last week, also shows the financial benefits that good supported housing can provide.

A review of the Tabard forensic service delivered by housing and care provider Look Ahead in partnership with East London Foundation Trust and the London Borough of Tower Hamlets – which provides residential step down support for secure forensic patients – found that it was much cheaper than secure inpatient care.

The review found the service was £2,972 cheaper per person, per week than the average cost of medium secure mental healthcare, and in the first two years saved health and social care commissioners in Tower Hamlets £750,000.

This was alongside six of the 19 service users moving into independent tenancies and four stepping down from high to low support.

But while the care model is one that could be replicated in other areas, the difficulty stems from the relationships – or more often lack of them – between NHS commissioners and providers, local authorities and housing associations.

The £750,000 question

This problem has been compounded by the fact that many of the biggest housing associations no longer take on mental health patients.

There are number of reasons for this, including:

  • the risk of taking on and caring for patients with acute mental health problems;
  • the high cost of building or adapting existing facilities to make them safe to support mental health patients;
  • cash strapped councils trying to reduce the contract values through tendering; and
  • councils rolling all the supported housing stock into a single supported housing contract, which few specialist providers can do at that scale.

This leaves the question: how can the NHS encourage more housing associations to open their doors to mental health patients?

With no clear national policy on supported housing, the only thing compelling anyone to address the lack of supported housing is the effect it has on services and patients.

One option is for mental health commissioners and providers to take matters into their own hands and invest millions in building new services or adapting existing buildings.

But it is unlikely that many mental health trusts have the capital to do this, especially when much of the sector’s estate needs modernising.

In Tower Hamlets, Look Ahead invested £500,000 to refurbish and adapt its building to accommodate Tabard, but not all housing associations will be willing to stump up these costs.

A reliance on goodwill

Even in places where there is sufficient stock, leaders will need to negotiate sometimes complex contracts to provide day care in supported housing, with the backing of social services and mental health clinicians.

This is possible, but depends on the goodwill of the parties and existing relationships.

Sheffield Health and Social Care FT agreed to take on a devolved budged for locked rehabilitation services in 2012 via a risk and gain share agreement with commissioners. The trust then set up an enhanced community team and worked with the housing association to repatriate locked rehab patients.

This has reduced its locked rehab costs from an average of £140,000 per patient, per year to £70,000.

It is also addressing the issue of locked rehab, which the Care Quality Commission is “particularly concerned” about and expected to publish an investigation into later this year.

But trust leaders admit this was only possible due to the support it had from the housing association – something other areas cannot count on. Until they can, they will not be able to replicate Sheffield’s success.