NB: This article first appeared in Community Care magazine, 2nd March 2006
See also “The Twain shall meet”, Community Care, 23rd February 2006
The previous article describing the new national Supporting People strategy consultation had suggested that the SP programme aims to repatriate to local authorities their role as the brokers of a comprehensive inter-agency vision in community care – a role that has for 20 years been eclipsed by their responsibilities to share and shoulder, with Health, the ever increasing burden of high dependency care. [i]
The proposed new SP strategy[ii] re-opens the debate about the value and the 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. In this second article, we explore the potential impact of the proposed new strategy, taking for illustration one suitably broad and complex area of community care – mental health.
What could it mean in practice for mental health support services in future to be able to span the care/support divide? And, crucially, what will it mean, to say that other funds could be transferred into the local SP “pot”, if local agencies agree that housing support services need expanding?
In 1999, the National Service Framework for Mental Health[iii] 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 NSF at that time had offered no actual mechanism for achieving these aims. More curiously, perhaps, the NSF 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 – many on the voluntary sector, and so quite used to this sort of thing - 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. They did whatever worked. And they found that what worked best was supporting vulnerable people in doing what they themselves actually wanted to do, to pull their lives together in their own way.
Meanwhile, across the housing/health divide, with the creation of the National Institute for Mental Health for 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 a growing focus on social inclusion, a greater stress on inter-agency partnerships, and on the approach known as “recovery” – an elusive concept that, to over-simplify radically, 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 not surprising. 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 on “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 SP strategy impact on this modernisation agenda?
Firstly, if support services can span the care/support divide, with funding from both sources, we must remember that the regulatory framework[iv] 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, toileting, cutting up food, and similar bodily functions. But such needs, and such hand-on in-put, are the exception, not the rule, in mental health.
It follows that many services currently regarded as “care” services – both home care and residential care – should properly be regarded as support; and the funding which currently goes into homecare, residential care, could equally well be purchasing support services, via SP. 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 firmly locked into institutional and high-cost care. As relatively few areas have yet undertaken any comprehensive accommodation needs analysis, this wider need is often obscured. The problem is experienced instead as a casework problem - to find suitable alternatives for THIS individual occupying THIS bed. But we do know that in some areas there is currently little or no supported accommodation, and consequently an excessive reliance on registered care homes, and on hospitalisation in crisis.
However, it is not social care funding alone which 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 alternatives, it is not inconceivable that health, through health act flexibilities, could also opt to put funds into housing support services. Or 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 NSF?
The opening of the local SP pot to additional in-put 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 currently. Any new local strategy must also be based on a fully 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.
In the end, 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 SP “pot”. There will be some complex and some difficult negotiations to be had. But the mechanisms of Supporting People were always designed to give SP the brokering role for inter-agency programmes and partnerships at local level. That ambition, it seems, is back on track. We must now see where it can take us.
[i]See: Supporting People; a new policy and funding framework for support services. DETR, 1999; also The state of Social Care in England, 2004-5, Commission for Social Care Inspection, 2005
[ii] Creating Sustainable Communities: Supporting Independence – Consultation on a Strategy for the Supporting People Programme ; ODPM, 2005
[iii] National Service Framework for Mental Health, DH, 1999
[iv] Guidance on residential care and supported accommodation; joint DH/ODPM, 2002