In the following sections we discuss the themes emerging from the data, highlighting the challenges entailed in providing integrated care across housing and health and social care services.
Understanding the aims and objectives
Previous research has consistently emphasised the importance of agencies understanding the basic aims of their joint effort [17
]. The experiences of the pilots support this. They illustrate that joint working was most effective when professionals not only understood the aims and objectives of what they were doing, but appreciated the fundamental role of housing as a means to support the individual people they worked with. In essence, dry exhortation to work in partnership was an insufficient catalyst; the potential benefits of joint working had to be apparent to individual professionals through the experience of the people they worked with.
For example, the idea behind the ‘On-Track’ pilot came from professionals working in local health and voluntary services who identified a gap in services for young people with dual diagnosis (people with mental health and substance misuse needs). These young people were ‘falling through the net’, being passed between youth to adult services and between drug and mental health services. Professionals working in different sectors recognised the need for stable housing and intensive support in order to engage young people with dual diagnosis in relevant health care services. They shared an understanding that only rarely could they achieve their own organisational aims and objectives when working in isolation. The pilot was therefore designed to establish a housing related support service that would help young people to engage with appropriate health services. The aim, as one partner described it, was to provide practical help to
“get a house and then look at their mental health. It is fundamental. If housing needs aren't addressed it is unlikely they will address mental health needs. You need to understand that for people with mental health problems everything is connected. To address mental health you have to address housing. It doesn't fit into neat boxes.”
Professionals, including front line staff and senior managers, saw the ‘On-Track’ pilot as a positive response to problems identified by those working directly with young people, rather than a service initiated at a strategic level. Consequently, it enjoyed the backing of a wide range of agencies that were willing to invest time, energy and resources to establishing and supporting the new service. As one health partner commented
“We are working together, we are committed to it, we have common goals, common aims and common wins, it's not simply about achieving outcomes it is about overcoming cultural barriers.”
This level of understanding about the central role of housing was not initially evident across all pilots. For example, the ‘Place to Live’ pilot was inspired by the Valuing People White Paper [27
], which calls for people with learning difficulties to be given more control over where they chose to live. Although originating from discussions within a multi-disciplinary group, the original proposal was written by social care professionals with little or no involvement from community nursing staff whose participation was crucial to ensuring that individuals moving into supported housing had access to appropriate health care service. The initiative was seen as a social care project. As one social worker reflected:
“things should have been done differently during the planning stage; we needed to take more people on board, it was important for everyone to own the project.”
As well as lacking a shared understanding of what the pilot was trying to achieve, few community nurses appeared to recognise the role of housing to well-being. For example, one health professional described how social workers and community nurses had very different ideas about what constituted a ‘health need’ and what constituted a ‘social need’. As a result few referrals were initially made by community nurses for housing assessments for the people they supported.
The ‘Place to Live’ pilot also illustrated that staff working in allied services, particularly the homelessness unit, neither appreciated the housing rights of people with learning disabilities nor understood the links between housing and well-being. This was a theme echoed elsewhere in the evaluation. Four of the six pilots identified the need for staff working in homelessness units or hostels to have training about the housing and support needs of vulnerable people. For example, housing department staff associated with the ‘On-Track’ pilot did not appreciate the need to house young people with dual diagnosis away from housing estates known to have a drug problem. Training resulted in improved working between these agencies and also improved the support they provided to specific individuals. However, in keeping with previous research [28
] this raises serious questions about the role of generic housing officers who, within the current policy framework, have to work with a range of individuals with complex lives and health problems, which have a major impact on their ability to live independently. Inevitably this requires housing officers to work more closely with other services but without specific knowledge of the needs of different groups, or a specialist service to provide this support, this type of co-ordination may prove difficult to achieve.
Having a history of joint working
The importance of building on existing relationships between agencies was evident within the evaluation. For example, at a strategic level the ‘Housing Support Outreach and Referral’ pilot evolved from a long history of partnership working in the field of HIV services between two London Boroughs. Not only had the Boroughs previously commissioned HIV services together but they had also worked in partnership with the Primary Care Trust, which commissioned voluntary sector services. This approach was generally regarded as an effective way of addressing a complex problem. As a result the pilot did not have to spend time developing an ethos of joint working ‘from scratch.’
The two Boroughs commissioned the Terrence Higgins Trust/Lighthouse to develop the housing support service. Although the organisation had no experience of providing housing support services they had an established record of providing a range of services to people living with HIV and a wealth of experience of working with acute health care providers. This led one partner to comment
“I know (the) Terrence Higgins Trust, I know their roles, that helps, we expect realistic and appropriate things from each other.”
The pilot was, therefore, developed within a context that valued joint working as a means to support people living with HIV and benefited from a history of collaboration amongst the central partners.
The ‘SWAN NEST’ pilot also profited from a history of joint working, building on the success of the SWAN programme, a multi agency initiative originally developed to address community safety issues. As well as providing accommodation and ‘floating’ tenancy support, pilot staff also assisted women to engage with health services as part of a strategy to exit sex work. All of the agencies involved recognised that they could only set up the scheme by working in partnership and that joint working had been made easier because as one partner reflected, they had had a
“positive experience of joint working in the past, we trust each other, you will deliver because you have in the past.”
This shared history, however, was based on individuals who had worked together over a long period of time. This made the partnership fragile. Reorganisation of statutory and non-statutory agencies was a constant threat and partners recognised that changes in personnel could unsteady the partnership. Consequently no one took the partnership for granted and partners were willing to invest considerable time and energy into the development and subsequent management of the new service.
The management of inter-professional working
One of the key themes to emerge from the evaluation was the need for joint working to be based on clear arrangements in respect of governance and managerial responsibility, both at strategic and operational levels. Not only does this help establish the democratic accountability of partnerships [29
] but transparent arrangements, agreed by all partners, ensure that staff understand to whom they are accountable and enable the work to be managed effectively. Someone needs to be ultimately accountable for the project. However, as previous research indicates [30
], insufficient thought is often given to the complexity of managing complex initiatives. For example, at several pilots the difficulties of sharing information across organisational boundaries were not resolved because it was not clear where responsibility for this lay.
The governance arrangements for the ‘SWAN NEST’ pilot provide a model for how these complex processes can be made straightforward. Progress was reported to the existing SWAN Partnership Steering group, which met bi-monthly and comprised of senior representatives from the main partner agencies, including the borough council, the Primary Care Trust, the general practice and the specialist housing support agency. Additionally, because the Primary Care Trust held the contract for the pilot with the Office of the Deputy Prime Minister, the Assistant Director for Public Health reported progress to the Primary Care Trust board. These arrangements ensured not only that one individual took overall responsibility for the pilot but also that there was an effective forum in which to tackle problems across the partnership. The pilot also had an operational manager who provided the link between strategic and front line working. This was crucial to the pilot's success at meeting their aims and objectives.
The pilots also demonstrated that operational staff working across organisational boundaries need specialist supervision, as well as managerial supervision. This became evident early on, specifically in pilots that were working with people with particularly complex needs and chaotic life styles such as sex workers and homeless people with HIV. Staff at these pilots had to work intensively with individuals in order to link them into a variety of general and specialist health services and other agencies such as housing and probation. Not only did this require them to have a detailed knowledge of a range of services it also required them to have an understanding of how best to support individual clients. Through the provision of specialist supervision, pilots were able to ensure that the practice of individual workers was effective and safe. It also provided them with time to ‘off load’ and reflect on the difficult nature of the work they were doing.
For example the ‘Housing Support Outreach and Referral’ pilot held regular team meetings, sometimes on a daily basis depending on the cases they were covering. As one of the workers described it,
“we catch up every day, we are always talking cases over, it's a tight team.”
The pilot also used professional supervision to ensure that practice met the expectations of Terrence Higgins Trust/Lighthouse. These monthly sessions usually lasted for over an hour and gave the workers an opportunity to deal with the demanding nature of their work. Both project workers valued these sessions, as one said
“you need a channel to off-load. A couple of our clients have tried to commit suicide so it is good to have supervision.”
Not all of the pilots recognised the need for professional supervision systems. The ‘On-Track’ pilot, for example, did not initially establish formal supervision systems with the result that project workers were anxious about the appropriateness of the support they were providing. These systems play a crucial role in maintaining professional standards [31
] and as more integrated services develop agencies will need to provide matrix supervision systems that allow workers to receive professional support for the different elements of their work. After several months the ‘On-Track’ pilot ensured that workers had access to supervision from housing managers as well as from specialist drug agencies. Whilst these systems are already common place in many voluntary sector agencies it will be important to ensure that as the sector begins to play a bigger role in the provision of support to vulnerable groups these systems are in place in all agencies. One way to do so would be for commissioners of services to require these arrangements as a contractual condition [31
The role of the voluntary sector
9.1 In this evaluation, effective joint working (defined as the pilots ability to achieve its aims and objectives) was associated not only with an understanding of the purpose of the joint venture, a history of joint working, and clear and effective governance arrangements, but on two other characteristics: the extent and nature of statutory sector participation and whether or not the service is defined, by a history of voluntary sector involvement.
Those pilots working in service areas with little or no tradition of statutory sector provision—for example with sex workers, or where services have developed more recently (HIV services)—appeared to have less difficulty working across organisational or professional boundaries. Indeed these pilots seemed to be based on a profound sense of ‘needing’ to do something to fill a gap in provision. The HIV sector, for example, has a strong ethos of partnership working across the statutory and voluntary sectors, which appears to lend itself towards a more flexible approach to supporting vulnerable people. As one health partner from the ‘Housing Support Outreach and Referral’ pilot commented, all partners were
“committed to providing a service for the client group that cuts through the inter-agency bureaucracy and rivalry.”
In contrast, although the core partners in pilots working in the fields of learning disabilities and older people services displayed a high level of commitment to joint working, this did not always appear to be as widespread within the agencies concerned. For example, the ‘Place to Live’ pilot was based in an integrated team but the different professional groups were not co-located, nor did they meet together on a regular basis or share an understanding of the relationship between housing and well-being. All of these factors are associated with successful joint working [17
] and without them, the pilot struggled initially to develop an ethos of joint working. Ironically, although there is a long history of community nurses and social workers working in the field of learning disability and, more recently in integrated teams, this seems to have led to the emergence of strong professional boundaries that may inhibit multi-professional working. As one social worker reflected
“in integrated teams people can get precious about their roles.”
The pilots demonstrate the important contribution that the voluntary sector can make in supporting vulnerable people to live independently in the community. The involvement of the voluntary sector brought additional credibility to the work of several pilots. As well as harnessing the expertise that exists within the voluntary sector, pilots were able to draw on their networks. For example, the involvement of the Terrence Higgins Trust in the ‘Housing Support, Outreach and Referral’ pilot provided extra credibility because the Trust was well known amongst people with HIV and brought with it an extended network of voluntary services that the Trust was involved with. Consequently the service was able to refer people to a wide range of voluntary organisations, such as community transport services and charitable food projects. As previous research has found [21
] it is support with these practical tasks that helps enable service users to live independently.
The development of new services in the voluntary sector also provided powerful models of how services could be provided. For example, a health professional involved in the ‘On-Track’ pilot remarked that the pilot had demonstrated how,
“The traditional ways of providing services from the statutory sector aren't always the best and that other providers can do it more successfully.”
Importantly those pilots that were based outside of the statutory sector demonstrated a high degree of flexibility in the way in which they supported vulnerable people to live independently. Pilots worked intensively with individuals to identify what they wanted to address in order to live independently and supported them to achieve the goals they set for themselves. This person-centred approach helped people engage and maintain engagement with services, which they had often failed to do in the past and echoes findings from previous research which suggests flexible and person-centred housing support services are more likely to offer an effective solution to social exclusion [21
]. The appropriateness of this approach was alluded to in interviews conducted with people who used services. For example one person supported by the ‘Housing Support Outreach and Referral’ pilot commented
“I have taken life more seriously now, she (the project worker) accompanies me to the alcohol centre and checks how I am doing.”
Similarly another person supported by the pilot described how “someone (the project worker) is keeping me on track with my appointments”. As a result he had started regularly taking his HIV medication. This pilot, like ‘On-Track’ and ‘SWAN NEST’, was based within the voluntary sector and suggests that some people, particularly those with chaotic and complex lives, may find it easier to engage with, and remain engaged with voluntary sector services. This may be because they are not based around statutory professions such as social work and community nursing, or because of their enhanced flexibility and responsiveness. This is relevant to current debates regarding the role of the voluntary sector within welfare services.
Difficulties associated with working across statutory, non-statutory boundaries
The involvement of voluntary sector agencies in the Health Pilots was not without difficulty particularly with regard to how professionals from different sectors work together. Several pilot workers reported that statutory sector colleagues were reluctant to work in partnership with them. For example, despite the tradition of cross sector working within HIV services some tensions were reported from the ‘Housing Support Outreach and Referral’ pilot. These were most notable amongst staff working in a homeless persons unit who were initially reluctant to identify a link worker between the pilot and the unit. This reluctance appeared to be based on a perception that voluntary sector organisations were not as ‘professional’ as statutory services. One of the outreach workers commented that some “statutory services see us as do-gooders, they don't see us as a professional service or as an equal.”
These professional rivalries were most notable when pilots tried to establish effective ways of sharing information with colleagues in the statutory sector. These systems are particularly important when people have complex needs and chaotic lifestyles. In these circumstances services need to be co-ordinated in a timely manner and based on up-to-date information. Initially some statutory sector agencies were reported to be unwilling to share information with colleagues in the non-statutory sector. To resolve this problem several pilots, including ‘SWAN NEST’ and ‘On-Track’ built on local practice, for example adapting existing ‘release of information forms’ which service users were asked to sign as proof that they had agreed to the pilot contacting other agencies as a means to seek or share relevant information. Occasionally the authenticity of these forms became the focus of disagreement between agencies. Whilst these disagreements were always resolved they reflect what Secker and Hill have referred to as ‘a reluctance or structural inability to share information and a lack of clarity about the constraints of confidentiality’ [32, p 348]. These disputes support the need for national guidance and protocols, which would remove the potential for disagreement and would smooth the path of those working at the front line.