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Care Provision Service Improvement Plan for Homeless with Mental Health Condition

Info: 9329 words (37 pages) Dissertation
Published: 9th Dec 2019

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Tagged: Health and Social CareMental Health

TopicUsing a critical approach examines the care provision for a specified service user group, identifies a challenge and proposes a service improvement plan to address this.

The purpose of this essay is to critically examine the health and social care provision of people that are homeless who live with a mental health condition in Manchester. I will utilise, ‘’SBAR’’ a standardised communication tool as recommended by Haig, Sutton, & Whittington (2006) as a structure for this essay. I will look at the situation, which encompasses the identification of the service user group, service area and the current service challenge encountered by this group of service users. Furthermore, I will critically analyse relevant policies, including guidance, quality documents, epidemiology, stakeholder involvement, which underpin health and social care delivery at both local and national levels.  In addition, I will go on to identify the current service provision of homeless people in Manchester, and then critically appraises the current quality mechanisms, and the resource allocation structure while relevant data to evidence will be measured to demonstrate the need for service improvement. Finally, I will recommend a service improvement plans to address the identified service challenge.


According to Manchester Joint Needs Assessment [MJSNA] (2017), homelessness amongst individuals who live with mental health conditions in Manchester continues to be a challenge in spite of numerous interventions. Kerman, Sylvestre, Polillo (2016) suggested that homelessness has become an extensive problem among people with mental illness, resulting in substantial economic and social consequences. Studies reveal that individuals facing continuing homelessness suffer from significantly poorer physical and mental health than the general populace which makes accessing health care services more difficult for this user group and as such leaving their needs unmet (Manchester Homeless Health Needs Audit 2016; Homeless Link, 2014; MJSNA, 2017; Stergiopoulos, Dewa, Durbin, Chau, & Svoboda, 2010). Consequently, this is due to negative experiences from lack of adequate care, health inequalities, stigmatisation, as well as discrimination associated with individuals living with mental health conditions, thereby making it challenging for this group of people to engage with healthcare services (Henderson, Evans-Lacko, & Thornicroft, 2013). While mental health illness contributes to homelessness; it is also acknowledged that the condition can worsen their homeless situation (Local Government Association, 2017; Patten, 2017; Phillips, 2015; Narendorf, 2017; Mental health foundation, 2016).


According to the Crisis (2012) and Mental health network (2012), the rate of homelessness is directly proportional to the rate of mortality which is seen to be significant among young people. In addition, a study by Morrison (2009) reveals that there is a higher prevalence in hospital admissions amongst homeless individuals with drug-induced mental health problems who are seven times more prone to the untimely death than housed individuals with similar reasons for admission. In 2012,  Acker suggested that funding for mental health services is one of the challenges faced in the process of providing adequate and efficient care for individuals with mental illness. Also, Mental Health Foundation (2013) accentuates that insufficient financing reduces the availability of assistance in caring for individuals with mental illness to access their care delivery. In the same way, National Audit Office [NAO] (2016) argued that the quality of care given to individuals with mental illness varies. Thus highlighted that some areas receive the quality of care, while others require improvement in providing unique and quality care to individuals with mental illness (NAO, 2016).

In the United Kingdom (UK), the National Health Service (NHS) has continuously generated a significant progression in reforming health care to improve good and quality care in the community (The King’s Fund, 2014). Similarly, in 2015, the abolition of Primary Care Trusts (PCT) and the creation of the Clinical Commissioning Group (CCG) was generated to have the responsibility for the most and the majority of the NHS budget (The King’s Fund, 2015). Also, the government has relentlessly strived to enhance the delivery of health and social care by involving the CCG to play an essential role in delivering sustainable care, due to the financial difficulties experienced by the NHS, as remain very significant (The King’s Fund, 2015).

However, in 2014, NHS England highlighted that the highest percentage of NHS funding is outsourced from taxation (Petsoulas, Allen, Checkland, Coleman, Segar, Peckham, & McDermott, 2014). Therefore, health care, which is a significant issue, received budgets of about £107 billion annually, of which 47% of this funding is allocated for acute care (Andrew, Knapp, McCrone, Parsonage, & Trachtenberg, 2012). Recent statistics suggest that the annual cost of homelessness in England is around £1 billion a year, and that the average cost to society is £20,128 and that homeless people cost an average of 4,298 pounds per person, NHS service provider, £2,099 per person for mental health services, while £11,991 per person in connection with the criminal justice system (Crisis, 2015; 2016; Department for Communities and Local Government [DCLG];  2011).

In 2011, Mental Health Network (MHN) Factsheet updated figures and statistics reveal that the population meeting the standards for one common mental disorder had increased from 15.5 per cent in 1993 to 17.6 per cent in 2007. The annual reports by Mental Health Bulletin (2017) indicate that approximately 2,637,916 people were known to be in interaction with learning disabilities, autism services, and secondary mental health at some point in the year, and 556,790 of these people were under the age of 18. As a result, some services in England, including social workers, mental health worker, and the key worker should come together to demonstrate good practice in working with homeless people with mental health needs (Homeless Links, 2012).

Correspondingly, a report by Homeless Link (2014), suggests a higher prevalence in the proportion of homeless people with mental illness is 45% higher than the general public. According to the Mental Health Network (2012) & Homeless Link (2014), it is estimated that about 70% of individuals using homelessness facilities in England reported experiencing mental distress with psychosis being about 15 times more prevalent in homeless individuals while 45% expressed the need for more support to cope with their mental health needs. Equally, Silove & Ward (2014) highlights that the commissioner and care provider supporting individuals with mental illness need a broader range of service to help them establish and maintain healthy lifestyles in providing the current care provision.  Additionally, Mental Health Network (2012) emphasised that improving access to mental health services for people who are homeless can be enhanced by educating staff awareness and service delivery, including the use of non-clinical settings, as well as effective collaboration with partner organisations.

Emphatically, Mental Health Task Force Strategy (2016) recommended that Public Health, England should develop a National Prevention Concordant Program that will support all Health and Wellbeing Boards (along with CCGs) to put in place updated Joint Strategic Needs Assessment (JSNA) and joint prevention plans that include mental health and co-parenting programs, and housing. According to  Ham, Dixon, & Brooke (2012), individuals experiencing mental illness require holistic care approach with quality care delivery which confirms the guidelines given by National Institute for Health and Care Excellence (2015). The King’s Fund (2014) added that individuals with mental illness must be supported to empower and to obtain an education, employment and housing as well as organising with health and other sectors.

According to the national policy on mental health, such as the White Paper, No Health without Mental Health, a mental health and social justice strategy, describes the impact of government policy on mental health management and treatment in the UK (Department of Health, 2011).  This study Lester, Glasby & Tylee, (2004) further explain that several government policies focus on modernising every sector in government, which includes enhancing partnership working between several areas of government with the voluntary and private sectors, without undermining the aspect of the patient’s consultation. Lester, Glasby & Tylee (2004)  referred to this novel way of working as the next alternative approach towards the delivery of welfare and health care promotion most especially, mental health management. Correspondingly, Means, Richards & Smith (2008) explained from a policy perspective of the government that there had been mandatory directives of shared care approach since the emergence of the new government, which is reported to reflect the partnership approach within the modernisation agenda in a broader range.

Furthermore, Lester et al. (2004), highlights that primary care possesses some primary specific responsibilities for proper delivery of second and third standards of the National Service Framework for Mental Health.  However, mental health services have undergone policies on five-year forward view in transforming mental health care, to improve the consequence of people with mental health problems by supporting them to achieve greater well-being (National Health Services, 2017). Therefore, this issue is a pertinent influence and consolidated involvement in delivering the other five standards of care which include the secondary care mental health services (Lester et al., 2004). Homeless Links (2011, 2012), emphasise that mental health policy affects the needs of the homeless, and argued that the relationship between homelessness and mental health can be complex as each condition could be the cause and result of other.

Based on significant policies guiding healthcare provision, UK is actively involved in providing efficient care for the people with various health conditions including those with mental illness (Health and Social Care, 2017). Therefore, the quality of health care received by individual pertinently impacts their quality of life (Consultants to Government and Industry, 2014). In contrast, some studies highlight some significant factors associated with the cost of managing and treating ongoing mental health issues and causes of homelessness, which is hugely expensive to both the public purse and society at large (Department for Communities and Local Government [DCLG], 2011). Nevertheless, it is highlighted that mental health is known to absorb more NHS funding than any other area of health (Mental Health Foundation [MHF], 2013). 


Since 2008 Manchester City Council has been working with a partnership homelessness strategy to coordinate and focus on activities of homelessness, and to improve services for homeless people (Mental Health Taskforce Strategy, 2016). MHTS(2018) emphasised that a comprehensive review of homelessness in Manchester strategy has identified a data such as primary research and desktop analysis for the council in determining the population, economic factors, housing market, and health inequalities in Manchester (MHTS, 2018). In 2017, Manchester Joint Strategic Needs Assessment (MJSNA) was established to improve efforts to reduce homelessness, which led to the creation of the Manchester Homelessness Charter and the Manchester Homelessness Partnership (MJSNA, 2017). These establishments challenge the working-age adults experiencing chronic homelessness, including those who are sleeping rough, alongside action to enhance health and well being and to reduce health inequalities, and as such, has become the major priority for organisations in Manchester (MJSNA, 2017).

Manchester Joint Strategic Needs Assessment (2017), highlighted above that 73% of the respondent to the survey reported having a mental health condition. Also, doctors and other health professionals have identified the respondents who reported their mental health condition (JNSA, 2017). In 2014, the King’s Fund highlighted that stakeholders are meant to determine the components of mental health local provision. The King’s Fund in 2014 further added the absence of collective effort in striving to achieve systemic change. Rethink Mental Illness (2011), argued that a dysfunctional system that is unable to deliver the right and quality treatment that patient’s needs for recovery and included essential recommendations to ensure the promotion of change. Nonetheless, the Rethink Mental Illness (2017) campaign priorities have been seen to be informed by the commission.

In contrast, a survey of needs and provisions ‘’SNAP’’ by homeless Links (2017), reveals that a large number of services such as 2nd stage accommodation projects and direct access hostels across England are still not receiving any funding in spite of sustainability projects delivered by such services to combat homelessness. However, a significant vision known as a world-class city was generated by Manchester City Council (MCC) to provide better opportunities for residents through the building and sustaining economic growth (MHS, 2018). Emphatically, MCC has potentially engendered priority in helping homeless people to access opportunities for education, structural, economic and policy factors, employment, training, support people to raise and meet their aspirations (MHS, 2018; Crane, & Joly (2014). In other words, homeless people can get themselves out of their situation with positive indicators from social inclusion, meaningful occupation, and also the addition of clinical input resources that are available (Cockersell, 2011).

Consequently, targeting to meet the controversy on homelessness in Manchester, the local authority has set a secure permanent accommodation for households who are homeless or at risk of becoming homeless (MCC, 2011). Manchester City Council figures out an affordable housing strategy such as social rented and intermediate housing, which focuses on increasing the amount and range of affordable housing for Manchester resident (MCC, 2011). Shelter (2018) accentuates that the cause of homelessness varies as many believe that homelessness is the result of personal failures and regardless of the economic status, there is no excuse for being homeless. In relation to the above statement by Shelter (2018), having mental health difficulties and getting involved in gambling, family breakdown, unresolved disputes at an early age is a major factor that leads to the contribution of homelessness (Holdsworth, & Tiyce, 2012).

Furthermore,  in 2011, MCC set out a group strategy in Vision to end rough sleeping: No Second Night Out nationwide, which work in connection with a group of Making Every Contact Count; A joint approach to preventing homelessness was established in 2012 to focus on tackling the complex underlying causes of homelessness, preventing homelessness at an early stage for everyone at risk (MCC, 2013; 2018).  Hence, in ensuring there are sufficient support and temporary accommodation available to people who are or may become homeless, MCC formulated and published ‘ The Homelessness of Act  in 2002’ to respond to priority need an order by extending the categories of priority, these include, 16 and 17 years old (except relevant children, i.e. those who Social Services have a responsibility under the Children (Leaving Care Act 2000), Care leavers aged 18 to 21 who are former relevant children, People who are vulnerable as a result of absconding violence (or threats of violence), and individuals who are helpless as a result of spending time in the armed forces, serving time in prison or care background (Manchester Housing, 2003).

However, Manchester Homeless Health Needs audit (2016) reveals that the main issue people have come across is that people feel less supported by their physical and mental health needs, particularly mental health. Support Network  (2017), argues that Manchester City Council has provided the needs of homeless people,  and has contributed a significant change by bringing together people experiencing homelessness, charities, grassroots groups, the council, businesses, and individuals to end homelessness in Manchester. Evidence from Manchester Homelessness Charter ‘Action Groups’  work together to tackle a critical challenge that people are experiencing homelessness, such as access to mental health support, emergency accommodation, and employment (SSN, 2016). Also, Homeless Links (2012) acknowledged that counselling and psychotherapy as a positive result for the homeless. St Mungos (2016), suggested that individuals who are homeless with mental health must have access to a choice of support and treatment options including psychological therapies to manage and improve their mental health.

Additionally,  MCC (2018) has made a significant change in campaigning and support working with sector organisation, voluntary, and charities to provide a long-term solution to homelessness. However, encourage people to donate effectively by pooling their donations to ensure that people who sleep on the street have access to housing rather than just helping them survive on the street. ( MCC, 2018). Wright & Tompkins (2006) supports this study that many other factors might contribute to the risk of homelessness, some of which are mental health problems, unemployment, inadequate social network as well as alcohol and drug abuse.  Also, Kerman et al. (2016) and Gaebel and Zielasek (2015) argues that homelessness is a complicated issue, involving homelessness in disguise such as sofa surfing, sleeping on the streets, squatting with friends and overcrowding which are considered to be detrimental to the general well being. Therefore, the Manchester Homelessness Partnership calls on the citizens of Manchester, the City Council, the health services and other public services, charities, faith-based groups, businesses, institutions and other organizations to adopt the values ​​of this charter; and implement it through better work practices, specific commitments and working together in new ways (SSN,2016).

Since 2018, a new night shelter to help rough sleepers opens by Manchester City Council funded shelter, run by Riverside and made possible by the Church of England Diocese of Manchester with bed spaces for 20 people to help those who are homeless ( MCC, 2017). Also, Deputy Leader of Manchester City Council, Councillor Bernard Priest ensure to help rough sleepers off the streets and into accommodation, thereby providing the wrap around support they needed to help them, building more positive and stable lives at the heart of the effort that the council and its partner organisations are doing to wrestle this challenging issue (MCC, 2017). A study by Kushel, Vittingholf & Haas, (2001); O’toole, Gibbon, Hanusa & Fine, (1999) concluded that helping homeless individuals by obtaining health insurance and ensuring that the complex admission procedure faced by homeless individuals are made simple is a crucial aspects of ensuring that there is an improvement in accessing care.

Also, Manchester City Council proposed a plan for service improvement in creating a festive season across three charities in Manchester, namely the Booth Centre, Lifeshare and Cornerstone drop-in centres for the homeless. Booth Centre brings up the change in the life of the people who are homeless or at risk of homelessness, thereby helping them to plan and realise a better future to improve peoples health and well-being through sport and activity (Booth Centre, 2018). In the same way, Lifeshare’s centres are another recommendation for service improvement for Crisis Assessment & Referral Diversity Service Project, which aims to assist young people in the city who are at risk of homelessness and to ensure safe, secure and stable accommodation (Lifeshare, 2018). In the same way, Manchester Engagement Team (Homeless Pathway) provides services in the City of Manchester, working with homeless people who have let fall out of trust services, and this service was established for visiting day centers, and also for outpatient clinics in an effort to improve the service user’s quality of life (Pathway, 2015).

However, Riverside’s Area Manager of Care and Support, and Rt. Revd David Walker, Bishop of Manchester, has worked in partnership with Manchester City Council to provide a fantastic shelter, emergency provision for rough sleepers in whatever the weather, and vital services for some of the most helpless in our populaces (MCC, 2017). In support of the above statement, Anderson, Baptista, Wolf, Edgar, Benjaminsen, Sapounakin & Schoibl, 2006; Griffiths, (2002) argues that the level of collaboration between mental health and social welfare and services to the homeless people could prevent homeless people from being connected with the services they need at the earliest opportunity. Nevertheless, Anderson, Baptista, Wolf, Edgar, Benjaminsen, Sapounakin & Schoibl, (2006); Griffiths, (2002) concluded that the lack of this collaboration had been identified as the major barrier to the provision of good and quality care to patients.

Additionally, Local Authorities and Voluntary Sector, a Leaving Care pathway to be co-designed with young people’s forum and Local Authorities as corporate parents, both to ensure representation and co-production of approach for hospital and prison discharge and care leavers will be established by the year 2019 (Greater Manchester Homelessness Action Network, 2018). Subsequently, a GP practice known as Urban Village Medical Practice (UVMP) was established since 1998, at Ancoats Primary Care Centre in  Manchester city centre,  which as well as providing primary health care to over 10,000 registered general patients, and they also provided a primary health care service to homeless patients (Crisis 2010).  In addition, Urban Village Medical Practice (UVMP) was commissioned to practice and provide a hospital in reach service to homeless patients in both clinical and non-clinical team member offering assessment of medical and social needs and discharge planning for homeless patients(Crisis 2010).  Another significant recommendation was established in the Catholic Diocese of Salford known as Cornerstone to provide service in helping young people and families in addition to the vulnerable and disadvantaged adults (Cornerstone, 2018).

Moreso, the effort of improving the health and well being for homelessness in Manchester has moved into another dimension, whereby MCC  has wisely proposed a new centre that will be for single’s who are above 18 and couples without children who have low to medium support needs (MCC, 2018).  Hence this proposed site will help people get back to living a place of their own and get into work, training, or education and other invited organisations will come to the centre and provide activities like arts, gardening, and cooking (MCC,2018). Additionally, Manchester Health Care Commissioning has developed a strategic context plan on how the health and social care system will become financially sustainable and improve population health by 2021 (MHCC, 2017). Also,  Greater Manchester and Manchester have determined on how to guide the health and social care system and also how to guide the system through difficult times regarding finance, service resilience and the wider impacts of austerity (MHCC, 2017).

In support of the above statement, CCGs and Manchester City Council have requested the establishment of single hospital service in Manchester to bring benefits relating to clinical standards, workforce resilience, patients experience which will directly improve care in the city ( MHCC,2017). More importantly, Greater Manchester is building a strong partnership will all other sectors including public, private, voluntary, and faith to ensure that everyone is safe and have a secure place to stay by the year 2020 (MCC, 2017). Nonetheless, Local Government Association, (2017); Patten,(2017); Phillips, (2015); Narendorf, (2017); Mental health foundation, (2015) acknowledged that mental health illness contributes to homelessness; it is also agreed that the condition can worsen the homeless situation.

Furthermore, Joint Health and Wellbeing Strategy, Manchester Health and Care Commisioning, Manchester’s Locality Plan have established a pure vision for health and social care system in the city to make a better resource and help in joining up and improving services towards prevention of problems and intervening early before getting worse (MCC, 2018). Additionally, other partnership boards are working through the Manchester City Council,  including the Children’s Board, the Work and Skills Board and the Confident and Achieving Manchester Partnership Board in turning around the lives of distressed families as part of the confident and an achieving Manchester programme (MCC, 2016). Furthermore, St Mungo contributed that accessible psychodynamic psychotherapy has a high uptake and positive outcomes for homelessness (St Mungo, 2014).

However, coordination is required amongst across multiple services including Health and Social Care Act 2012, NHS England, CCGs, and upper tier local authorities to ensure consistent efforts to address the health inequalities faced by homeless people. Many studies have found that (JSNA) and (JHWS); from local authorities and (CCGs) have a joint duty to prepare the JSNA and JHWS, health and wellbeing boards, Healthwatch, representatives of local voluntary and community sector organisations to improve the health and well-being of local communities and to reduce health inequalities for all ages (Inclusion Health, 2013; homeless links, 2010). Arguably, it is widely reported that those individuals who are vulnerable, particularly high health needs,  are hard to reach through mainstream services, thereby making it difficult to measure vulnerability and compare health needs across all the subsets of homelessness (Aspinall, 2014).


Homelessness is arguably having a direct impact on an individual psychological and general well-being. Hence it is a very sensitive issue that calls for quick and conscientious attention. There are many ways to improve services for homeless people with mental health issues. Jennings, Goguen, Britt, Jeffirs, Wilkes, Brady, & DiMuzio, (2017) argue that individuals with mental illness may show treatment resistance, and is one of the factors that can limit the progress of treatment.

As part of my service improvement for homeless people with mental health problems, awareness of food bank accessible charity will be promoted, since feeding among other issues, is one of the challenges facing the homeless in general. Having a shared vision to raise donations from the public, I hope to work with some grocery stores across Manchester, and then allocate charity centre for the free food collection and deliver straight to the doorways of the homeless people. This initiative is in line with Tse, & Tarasuk, (2008), who highlight that much of the assistance given to homeless people about providing basic needs such as food and shelter are anchored in community-based initiatives.  For that reason, NHS (2016) emphasised the need to develop effective schemes that will significantly reduce homelessness in people and as such promote good mental health.

Further, working alongside with Homeless Health Teams across Manchester areas will provide me with an opportunity to educate, and train, homeless people on how to access services and gain continuity of care by displaying information with graphics on vehicles, Street light poles, and billboards. Based on this, DeVerteuil, May, & Mahs (2009), agree that awareness and evidence of welfare should be accessible to homeless people, providing information with a focus on affordable housing program and the provision of emergency services.

In 2010, Crisis, advocates for the creation of a festive season drop-in centre across three charity organisations in Manchester. Therefore, I will promote the awareness for the use of the drop- in centres to set up of all-inclusive, flexibility in the provision of health services, a one-stop day facility consisting of hot meals, wet rooms, laundry facilities, soup kitchen, of all strategic points across Manchester. Nevertheless, St Mungo’s (2012) argues that access to mental health services for homeless people can be improved by enhanced service delivery, providing non-clinical frameworks and effective teamwork between organisation partners.

Additionally,  empowerment of the youth through extensive and real-life training to groups of youth on how to end homelessness (across Manchester area), with a range of involving youth in helping homeless people to access various social services benefits, entitlements, and assisting in arranging for medical appointment and counselling sessions in line with their intervention requirements. In line with this statement, Silove & Ward (2014), assert that without treatment, patients will experience prolonged institutionalisation, neglect, and abuse in the continuity of their care.

In conclusion, I will promote quality mechanisms service improvement by providing concise, pictorial and structured health information leaflets, which will be distributed across hospitals in Manchester, Transport for Greater Manchester, Street, Groceries Stores, and houses with a plan to end homelessness. However, when an individual becomes homeless, what makes the most significant difference between them is to make sure the right facilities are in place to help address their challenges and homeless combat issues (Homeless Link, 2014). Correspondingly, all the services mentioned so far have the highest tendency to provide service improvement and to ensure adequate support to end homelessness (Hwang, Tolomiczenko, Kouyoumdjian & Garner, 2005).


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