The new NHS plan for mental health services has a clear offer for people sleeping rough

For organisations who have campaigned for many years on homeless health, the NHS Mental Health Implementation Plan is a cause for celebration. Beatrice Orchard, St Mungo’s Head of Policy, Campaigns and Research, explains why the plan must deliver on its ambition to make sure everyone sleeping rough can access the mental health support they need.

When the Government’s Rough Sleeping Strategy was published exactly one year ago by MHCLG, there were some positive signs that other government departments would also be doing their bit to reverse the dramatic rise in the number of people sleeping rough in England.

One of the most solid commitments was in relation to improving mental health support for people who are sleeping on the streets. Last month, the details of this commitment became clearer when the NHS Mental Health Implementation Plan was published.

The plan is clear that by 2023-24, 20 areas with high levels of rough sleeping will have established new specialist mental health provision for people sleeping rough, which will be made possible with £30m of central NHS funding invested for this specific purpose.

This is a fantastic result for St Mungo’s Stop the Scandal campaign and our continued efforts to press the Government for investment in specialist mental health services to ensure people sleeping rough can access the support they need.

Sleeping rough and mental health – the links

It is fairly easy to understand that sleeping rough has a negative impact on a person’s mental health and wellbeing, as well as their physical health.

Evidence shows people sleeping rough are 17 times more likely to be victims of violence compared to the general population. News reports describe horrifying attacks and abuse on people sleeping rough and our clients tell us about their experiences of feeling lonely, frightened and even suicidal.

Furthermore, we mustn’t overlook the fact that some people sleeping rough have already been through many traumatic experiences in their lives, including violence and abuse from a young age.

All of these experiences can cause mental health problems to develop or worsen, but also impact on the type of mental health support people need and how easy they find services to access.

New avenues into support

The new, NHS-funded, specialist services will make sure that people sleeping rough can access to clinical mental health support by integrating with existing homeless outreach, accommodation and physical healthcare services.

They will be required to adopt a trauma-informed approach, known to help improve the psychological and emotional wellbeing of people with complex needs. We also expect the new services to help people who have drug and alcohol problems and are currently excluded from some mainstream mental health services as a result.

This specialist support breaks down all of the barriers people sleeping rough often face when trying to get help to improve their mental health. Really effective specialist teams can also influence mainstream health services in their local area, encouraging them to become more knowledgeable and understanding of the needs of people who are sleeping rough.

So far, so good. But what about people sleeping rough in other areas not in receipt of this new funding?

A welcome step forward

Research shows 4 in 10 people sleeping rough in England have an identified mental health problem. The latest data from the CHAIN reports on rough sleeping in London shows 50% of people sleeping rough in the capital in 2018-19 had a mental health support need.

It is welcome, therefore, that the new plan for mental health requires all areas of the country to complete a mental health needs assessment for people sleeping rough and take action to increase access to mental health services for this group.

This new approach to mental health for people sleeping rough is a real step forward.

Specialist mental health services have been tried in the past. We know they can make a dramatic difference to individuals’ lives, and help to reduce rough sleeping by supporting people to move on from homelessness for good.

Better still, it doesn’t stop with specialist services this time. Instead all NHS services will need to think about how people sleeping rough can access the healthcare they need in order to rebuild their lives.

St Mungo’s will be watching closely and encouraging all areas to ensure the plan delivers.

Creating change for women facing homelessness

St Mungo’s has published a new three year ‘Women’s Strategy’ setting out how we plan to improve our services for women and influence policy on women’s homelessness. Our Women’s Strategy Manager Cat Glew introduces our approach.

Five years ago St Mungo’s published our ground-breaking Rebuilding Shattered Lives research into women’s homelessness. We found that homelessness services are often designed with men in mind, and were often failing to support women effectively.

Sadly, it remains the case that women facing homelessness are still at a disproportionate risk of harm from those they love and trust, alongside the existing dangers of homelessness. Since 2014 a growing body of evidence has highlighted the connections between women’s experiences of violence and abuse, poor physical and mental health, substance use and homelessness.

According to the latest figures, 642 women sleep rough on any one night in England, up from 509 in 2016. Many more women are likely to be experiencing hidden homelessness – seeking shelter with abusive partners, squatting or sofa surfing with friends and family – so may be missing from the statistics.

Women’s homelessness often occurs after prolonged experiences of trauma, including physical, sexual and emotional abuse by those closest to them. Violence and abuse are both a cause and consequence of women’s homelessness, with women experiencing further abuse, exploitation and violence while homeless.

Women-only spaces are a matter of safety for many women. Despite this, just 7% of homelessness services in England offer women-only provision, according to data from Homeless Link.

Our greatest challenge and our most important aim is to create an environment of physical and psychological safety for women in homelessness services. We’ll be working hard to make sure that each of our female clients has a safe place to live and has every reason to feel safe in our services.

We know that funding for women-specific work is falling, but we also understand that our female clients cannot wait for the Government to prioritise women’s homelessness.

As a homelessness charity, it is our responsibility to make sure that we are achieving the best possible outcomes with women, as well as men. We have made the decision to make women’s safety and women’s recovery a priority. Our new Women’s Strategy sets out some ambitious aims that will help us improve our practice and influence government policy.

Our ambitions for the next three years include:

Offering women-only services and spaces as an option for all female clients, at every stage of their recovery
Supporting and equipping St Mungo’s staff to better recognise and respond to violence and abuse
Improving rough sleeping services so that they are even safer and more effective for women
Working with specialist agencies to offer individual support to women around domestic and sexual abuse

There’s plenty to do, but I’m really looking forward to working with all our clients, staff and partners to make our ideas a reality. Listening to the ideas and experiences of St Mungo’s women is an amazing privilege and the very best part of my job. I hope that partners, politicians and the public will read our strategy and join us as we create change with women facing homelessness.

Read our brand new women’s strategy here

“There are no words”

Tracey Jacob, St Mungo’s Housing Management and Lettings Coordinator, based in Westminster, shares her experience of working with people who are homeless and near the end of life.

When a person has been diagnosed with a terminal illness, there are no words that can describe the emotions or feelings.

When a client has no family, or has not been in contact with them, or wishes for them not to be informed of their illness. When a client makes a decision that he does not want to go to hospital or a hospice but wants to stay at home. This is when you realise they may see you as their family.

Over the years, I have known and supported people who have been diagnosed with a terminal illness.

There are guidelines, other colleagues, to help support and direct us as staff in that situation. But it’s those words – “I want my keyworker” – which cannot be substituted.

With one of my clients, I had to start a conversation with him about being resuscitated. I didn’t know how.

I called his GP who arrived the same evening to ask the questions and do the paperwork.

I had to fight back the tears as I did not want the client to see me crying.

The GP had a one to one with me after the meeting as well, to debrief me and make sure I was OK. These are the situations that don’t get seen, or talked about.

On another occasion, I had to go through my client’s clothes to take some to the funeral parlour, wiping away the tears as I have never dressed a person who had passed away.

My thoughts were, I want the client to look lovely, hoping that I chose a good outfit. I was given a cup of tea and they explained that I was not expected to do this, they would do it. These are the things that don’t get seen, or talked about.

I have worked for St Mungo’s for many years. Any death is difficult. I have learnt that it’s ok to say “I need help and support” and to step back, take a few minutes to regroup your thoughts.

For me, I take away that the person was not alone and I did the best I could do.

It was Dying Matters last week . Please see our other blog by St Mungo’s Palliative Care Coordinator, Niamh Brophy, on the work being done to prevent people who are homeless dying on the streets.

Towards a new rough sleeping strategy

Beatrice Orchard, St Mungo’s Head of Policy, Campaigns and Research, writes about our priorities as the Homelessness Reduction Act and other measures seek to end homelessness

The Homelessness Reduction Act comes into force today. This is a landmark piece of legislation with the potential to have a hugely positive impact on the lives of many more people who are homeless, or at risk of homelessness, compared to the previous system. It places new duties on local authorities to help prevent and relieve homelessness for people regardless of ‘priority need’ criteria.

This follows news last week of a new initiative to reduce rough sleeping and a decision to reinstate entitlement to housing benefit for all 18-21 year olds. These are very welcome steps towards ending the misery of sleeping rough, an aim that surely unites us all.

In 2016, we at St Mungo’s launched our Stop the Scandal campaign calling for a new national strategy to end rough sleeping and this is what we want to see next.

The government has committed to halve rough sleeping by 2022 and to eliminate it altogether by 2027. To meet this pledge, a ministerial taskforce has been established to produce a new rough sleeping strategy. A Rough Sleeping Advisory Panel made up of homeless sector representatives, including St Mungo’s, is providing guidance to this ministerial taskforce.

Rough sleeping has increased by 169% since 2010. On any given night, 4,751 people sleep rough in England.

Behind these stark figures are people who are living each day at risk of violence, abuse and serious ill health. We have evidence of this from the people themselves, from our outreach teams and our research with people who have experienced rough sleeping. Put simply, it is a scandal.

That’s why it is good to see a sense of urgency from the government.

We agree immediate action is needed to move people off the streets and out of danger. Effective outreach services are part of this. So is emergency accommodation and access to mental health and substance use treatment and support. This must also be aligned with measures to prevent people sleeping rough in the first place and long term support to ensure people don’t return to the street.

The new strategy must protect and expand existing services, which support people off the streets. That includes supported housing, which is the primary route out of rough sleeping for people who need both a safe place to stay and support to recover from homelessness and associated problems, including poor health and experience of violence and abuse.

However, the government’s current proposals to change the way homeless hostels and other short term supported housing is funded puts the future of these life-saving services at risk.

As rough sleeping continues to rise nationally, available places in supported housing have fallen due to major cuts in local authority funding. Research by Homeless Link found there was an 18% reduction in bed spaces in homelessness accommodation between 2010 and 2016.

Despite this, the government now wants local authorities to become responsible for funding the housing costs in hostels, in addition to the support services which councils are already struggling to fund.

Instead, we think the government should adjust its plans in line with calls from the supported housing sector and continue to provide funding for housing costs via the welfare system.

Beyond this, ministers will need to consider the role for innovative approaches, such as Housing First, which has proven successful for ending rough sleeping among those with the most complex problems. Government investment in three Housing First pilots is, again, welcome, but ministers will need to establish long term funding arrangements to make this approach work.

An integrated rough sleeping strategy will also need to be underpinned by a legal framework to help ensure services benefit from sustainable funding and can respond to fluctuations in demand. The Homelessness Reduction Act is a good start, using new legal duties to shift the focus of councils in England towards providing help to prevent homelessness in the first place.

But if the Act is to be a success, councils must be able to help those in danger of sleeping rough find the right housing and support. Sadly, the reality is the unacceptable shortage of affordable housing options for too many people, and this is another long term challenge for the ministerial taskforce.

St Mungo’s has always supported people to move off the streets into accommodation and to access the services that can help them rebuild their lives. This can take days, weeks, sometimes years.

We don’t think it is an easy challenge the government has accepted, but we share their ambition of ending rough sleeping and welcome the opportunity to help get on with it.

On a typical day…

“For me, if I can go home knowing I have helped at least one person away from the streets, or just one person away from the distress of mental health illness, I feel blessed.” St Mungo’s Mental Health Practitioner, Fatima, shares her experience of working in Outreach, helping people sleeping rough in the Tower Hamlets area.

I’ve been a mental health nurse for 18 years. In 2011, I became and an approved mental health professional, which incorporates social work. I will work typical outreach shift in terms of going out early in the mornings and staying out late in the evening, as late as two or three in the morning, speaking to clients who are sleeping rough to try to form therapeutic relationships with them to help them move away from a life on the streets.

‘Blinded to homelessness’

I was one of those people who was blinded to homelessness. I could walk past a homeless person or rough sleeper and not really see them to understand what they’re going through. It’s been an eye opener for me and I’ve fortunately been able to influence others to see homelessness through what I do at St Mungo’s.

It can take a week or months to be build a relationship with a person. Sometimes they are in denial – they have no insight about what is happening to them so I try and to slowly educate them. I take decisions out of people’s hands when they’re experiencing mental distress.

I enjoy my work. I can get people registered with a GP surgery, then get them to start medication, stabilise their mental health illness and then help into accommodation whilst we support them. Many people may have been de-registered and have been turned away from Accident and Emergency (A&E) wards. They can go through those revolving doors three or four times a month, back and forth from A&E.

I also work with the clients to ensure they engage with the process of recovering from homelessness. You cannot take someone off the streets and expect them to turn up for every appointment. I have to build that relationship, that rapport and that routine of them coming to see me to talk about their mental health, the medication and the side effects.

‘Long days full of drama’

My days can be very long and full of drama. Sometimes I get abused, which can be quite stressful. But my job is also fun and flexible. For me, if I can go home knowing I have helped at least one person away from the streets, or just one person away from the distress of mental health illness, I feel blessed.

It’s brilliant to see someone who has been sleeping on the streets for five or six years leave that life behind. The kerb becomes their family so getting them into accommodation is not easy. When you put them in a room in a hostel it can be very lonely. The silence can be deafening for them because people out on the streets give them money and say hello – some people get to know them as they walk past them on their commutes. So they run back onto the street and people wonder why because they have accommodation.

‘Everybody is unique, everybody has a journey.’

A lot of clients can lose their accommodation in hostels because of poor mental health – some people cannot understand their journey. Everybody is unique, everybody has a journey. How you hold their hands to support that journey is what makes a difference. People might think, ‘go to housing and get a property, get off the road and get your benefits’, it’s a much longer journey, however.

Different clients talk about their living conditions. Finances are a problem. People have not been used to managing money and paying bills. Universal Credit has also caused a lot of problems for our clients.

I have one client, for example, who believes he has all his money invested in stocks and shares. He says when his investments mature, he’ll pay his rent. He has a diagnosis of schizophrenia with delusional disorder. I ask for my colleagues to work with him in terms of hand-holding to ensure he does not get evicted from his hostel.

I’m working with this lady that I’ve known since I was a student nurse. Up to now she will not allow anyone else to work with her. She was sleeping in a bin shed. She became mentally unwell, and started using drugs to self-medicate the voices she was hearing. Her children were taken into foster care when they were young. I worked with her and got her a place in a hostel. He son got in touch after 15 years and they’re building a relationship again.

‘You cannot be judgemental’

Because of the nature of the people we work with, many with chaotic life styles, who are extremely marginalised, it’s very difficult to get through to the NHS. Even though I am that link between the NHS and homelessness services. Sometimes the nurses have no understanding or knowledge of homelessness. They’ll say, ‘he needs to go, he might bring drugs in here’. It’s a big challenge to get my clients treatment because of the way they look, or dress and their circumstances.

Working in outreach, you cannot be lazy. I have gotten used walking everywhere. You must be able to multitask as you’re dealing with more than one client, sometimes up to seven a day, who are in crisis. I’ve jumped over six feet walls and walked along canals to help people – it’s part of what we do. You must have people skills, respect humanity, and you cannot be judgemental at all. It takes a lot of character to try and support people who are not ready to receive help.

It’s a nice feeling to know you’ve helped someone from being a hermit to re-engage back into society and to be part of a community. I think that’s what has been missing in [conversations about] homelessness. Our country has forgotten how to be a community. To me, it feels like in London everyone is in a rush, so in that mad rush, we are blinded to homelessness.

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