All in the same boat

In his final article on Supporting People, Robin Johnson uses the mental health sector to explore the implications for the development of integrated services and commissioning

What would it mean in practice if mental health support services could span the care-support divide? And, crucially, what would it mean if other funds could be transferred into the local Supporting People pot should local agencies agree that housing support services need to be expanded?

In 1999, the National Service Framework for Mental Health called for a continuum of accommodation for those with mental health problems, with staffed and supported accommodation, long-stay secure accommodation, crisis and refuge places, service user-run sanctuaries, family placement and respite, and supported living options, including individual tenancies and shared living with flexible support.

However, the framework at that time offered no mechanism for achieving these aims. More curiously, perhaps, the framework itself made no reference to Supporting People, which was launched in the same year. The early growth of mental health housing support services was therefore largely uncoordinated, piecemeal and needs-led, with housing services simply responding to the problems they found.

Mental health housing support services came into being with no baggage of theory or contractual preconceptions from funding agencies as to what they should do. Their only limitation lay in what housing benefit would fund. Otherwise, they were free to evolve in a purely pragmatic, needs-led fashion.

Meanwhile, across the housing-health divide, with the creation of the National Institute for Mental Health in England, there was new thinking coming from within the NHS. There is a greater impetus now to consider a broader modernisation of the vision and practice of community mental health care, with more focus on social inclusion, a greater emphasis on interagency partnerships and on the approach known as “recovery” – an elusive concept that, to over-simplify, suggests that individuals may be encouraged and supported to define their own goals for independence.

Such user-led support planning may be radical in the statutory services: but it is where housing support services largely began. From its origins, what we now call “housing-related support” was person-centred, goal-oriented and, in many respects therefore, closer in spirit and in practice to the “recovery” approach. This is unsurprising. It is always easier to develop new thinking in new services. Rather than turning round the supertanker, it is often much simpler to launch a flotilla of small boats.

Mental health services that now wish to move towards a recovery approach could do worse than look to those services whose practice already works on this basis. Similarly, services bent on modernisation and “service redesign” could well look to the housing support sector as natural partners in developing new models for the new century – particularly where keen to review the role of voluntary sector, and of user-led and user-managed services.

How then might the new Supporting People strategy affect this modernisation agenda? First, if support services can span the care-support divide, with funding from both sources, we must
remember that the regulatory framework(1) defining the demarcation line between services that must be registered as care, rather than as support, remains the routine provision of intimate “hands-on” physical care – assistance with bathing, going to the toilet, cutting up food and similar functions. But such needs and such hands-on input are the exception, not the rule, in mental health.

It follows that many services such as home care and residential care should be regarded as support; and the funding which goes into them could equally well be buying services through Supporting People. It becomes possible again to envisage a programme of reconfiguration of care homes as supported accommodation schemes. There is no windfall funding now to ease and incentivise the process. But if the pattern of local services does not meet local needs, there is now the flexibility to change the pattern.

In many areas, the pattern of mental health resources remains locked into institutional and high-cost care. The problem is experienced as a casework problem – to find suitable options to this individual occupying this bed. But we do know that in some areas there is little or no supported accommodation and an over-reliance on registered care homes and hospitals.

However, it is not social care funding alone that can be moved to recommission and reconfigure support services. Where local health budgets are tied up in hospital provision, whether acute or long-stay, simply for want of something different, it is not inconceivable that health, through Health Act flexibilities, could choose to fund housing support services. How otherwise will we ever see the creation of alternatives to admission, early discharge services, “stepdown” accommodation, user-led or user-managed services, and extra-care sheltered accommodation, as called for in the framework?

The opening of the local Supporting People pot to additional input from other local agency sources, therefore, has potentially huge implications for integrated commissioning. It would require levels of shared budget and co-operation some way in advance of what we find in most areas now. Any new local strategy must also be based on a comprehensive mental health accommodation needs analysis, which includes all areas, from “hotel” services in continuing care to floating support for those at risk. Quite how far this whole process could go remains to be seen.

Of course, it will come down to money, as it always does. But one key feature is clear: the decisions will be taken down at locality level, with the local authority playing a key facilitating role, through the Supporting People pot. There will be some complex and difficult negotiations to be had. But the mechanisms of Supporting People were always intended to give the scheme the brokering role for interagency programmes and partnerships at local level. That ambition, it seems, is back on track. We must now see where it can take us.

Robin Johnson is a social worker, researcher and adviser on mental health and housing, and a member of the National Institute for Mental Health in England’s national housing reference group. He was the principal author of the At Home? study for the institute on mental health issues arising in social housing.

Training and learning
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

Abstract
The proposed new Supporting People strategy re-opens the debate about the value and potential of housing as a setting for provision of support; the role of low-key preventive services; and the changing nature of community care in the 21st century. This second article explores the impact it could have on mental health care.

References
(1) Department of Health/Office of the Deputy Prime Minister, Guidance on Residential Care and Supported Accommodation, 2002

Further information