Timescale: 1 September 2021 - 31 October 2023
Funder: Department of Health and Social Care
Project description
In 2020, the Department of Health and Social Care, Ministry for Housing and Local Government and Ministry of Justice allocated £16 million through the Shared Outcomes Fund (SOF), to ‘roll-out’ and robustly evaluate models of out-of-hospital care for people who are homeless.
As part of this, funding and improvement support was provided to 14 Local Authority test sites and 4 sites working across London by DHSC. The aim was to test how successful models can be scaled across a wide range of areas and adapted to new contexts and circumstances post Covid-19.
In August 2020, a new hospital discharge operating model was implemented across England to manage the increase in hospitalisations due to the pandemic. Discharge to Assess (D2A) aims to transfer people as soon as it is clinically appropriate to do so. The programme will provide short term support to enable assessment for longer-term care and support to take place out-of-hospital and in a range of settings including people’s own homes, care homes and hotels. A key objective of the OOHCM programme was to explore how support for homeless patients can be integrated as part of the new D2A operating model.
In September 2021, King’s College London, London School of Economics and Expert Focus were commissioned to undertake a 24-month evaluation of the OOHCM programme. The overall aim of the evaluation is to capture the learning from the test sites and to evidence the outcomes that are being achieved.
Objectives
The objectives are to:
- Provide an understanding of the most effective way of implementing (scaling) out-of-hospital care across a wider range of areas – including how to shift to this position and the conditions needed to maximise the effectiveness and sustainability of the services.
- Describe how models are being integrated into the evolving health, housing and social care system, supporting D2A (the new NHS hospital discharge operating model), the NHS Long-Term Plan and Covid Care/Recovery.
- Identify the challenges that remain to systems and service delivery that require changes outside the direct control of organisations in the locality.
- Further test the key components of effective and cost-effective models especially where they have not previously been brought together into a single system.
Methods
The evaluation adopted a mixed methods approach comprising four work packages (WPs):
- WP1 supported the DHSC with designing and implementing a robust audit framework to capture the outcomes being delivered across the test sites.
- WP2 was a qualitative study of ‘what works’ regarding the successful ‘roll out’ of models across different areas.
- WP3 was an economic evaluation; and
- WP4 was a choice modelling study, analysing data collected with a iscrete Choice Experiments (DCEs) survey to establish services user preferences and utility scores for different types of OOHC.
Alongside the delivery of the work packages, the evaluation team actively participated in all aspects of the programme (e.g. contributing to webinars and events and attending quarterly monitoring meetings where test sites report their progress to the DHSC).
Performance data are now accessible in a series of dashboards via at a glance visualisation of key metrics. These use clear labelling and are configured in line with existing NHSE integrated care and health inclusion frameworks. They include static reports and presentations as well as more digital interactive dashboards for different stakeholder users (at national and local levels). The latter have the ability to explore relationships between variables and drill down to look at subgroups, with low requirements for computing resources. Findings are shared as they emerge supporting the programme to achieve maximum impact over its lifetime and beyond.
Findings
The OOHCM Programme has delivered various new services and has had a significant impact in bringing about changes in practices, enabling areas to experiment with novel collaborative working methods. Aligned with NHS England frameworks on intermediate care and health inclusion, the future automation of integrated management dashboards aims to facilitate swift improvements in data quality and coverage. This will embed real-time data into day-to-day operational practices at the local system, regional, and national levels, contributing to the enhancement of healthcare management.
- The OOHCM Programme has delivered many new services and been influential in securing many practice changes and allowing areas to test new ways of collaborative working.
- The Programme worked with 1,254 homeless patients (for whom we have data for analysis). Many experienced improvements in quality of life and had positive experiences of the services feeling that they were treated with dignity and respect. Relatively small numbers of people (7%) returned to rough sleeping after a stay in hospital and/or step-down (compared to earlier reports that indicated around 77% of people were returning to rough sleeping).
- Beyond the performance analysis completed against the DHSC business plan 2020, this programme marks the initial attempt to standardise over 50 metrics, encompassing demographics of the individuals, process outcomes (e.g., the flow of individuals in and out of care, staff composition, workload, and more), economic outcomes concerning the NHS and broader public budgets, investment costs, health outcomes, housing outcomes, care experiences, and preferences for various care models.
- In alignment with NHSE, the future automatisation of the integrated management dashboards aims to facilitate rapid improvements in data quality and coverage, and embedding real-time data into day-to-day operational practices at the local system, regional, and national levels.
- However, the danger is that these impacts will be short-lived unless a way is found to maintain the momentum of the Programme delivery and its continuous monitoring and evaluation. One leading homeless health charity has also raised the issue that much work is still needed to change practices in areas beyond the Test Sites.
- Workshops are planned by the evaluation team to showcase the full potential of the dashboards and discuss the roadmap to adoption by local sites and commissioners as well as national stakeholders (if interested in participating please contact the team here: m.tinelli@lse.ac.uk).
- Feedback from stakeholders was incredibly positive. The Programme was described as conferring great opportunities for developing new ways of doing things and improving relationships locally. “There is nothing like a million pounds to get people round the table.” However, this positiveness was dampened by the lack of effective action at government level to address the sustainability issue. At the end of the programme, stakeholders were left feeling demoralised.
- Qualitative feedback from service users was incredibly positive about the value of these specialist services and their potential to change lives. “I was not allowed to go back to my own flat and I had nowhere to go. I remember laying in my hospital bed sobbing, then I was told about step-down and that I could go there, just till I was able to look after myself and that they would help me get the help I needed and believe me they did just that.” (Service User).
- Overall, the evaluation supports the findings of the Hewett review which highlights that Integrated Care Boards (ICBs) do not currently tackle health inequalities as a routine part of their wider transformation work around delayed discharges and other intractable issues. Specialist out-of-hospital care services for people who are homeless are still considered a “nice to have” that commissioners will only fund once they have tackled what they perceive to be more pressing pressures on the NHS.
- Top Tip: When planning for future service developments, the discrete choice experiment (DCE) preference data indicates that service users have a strong aversion to returning to rough sleeping after a stay in hospital and highly appreciate any alternative options offered to them. The ideal models feature longer-term accommodation (for a minimum of 10-12 weeks) with multidisciplinary teams providing consistent support (3-4 times per week) without imposing behavioural restrictions.
Impact
The Department of Health and Social Care published the homelessness discharge guidance and the LSE dashboards are cited as management tool to support continuous evaluation.
The Project dashboards have been advertised by NHS England as part of the new Frameworks:
Read also the guidance published by the LSE as part of a larger team led by King's College London for the LGA and ADASS on Home First Discharge to Assess and Homelessness.
Further information
Principal Investigator at LSE: Dr Michela Tinelli
Co-Principal Investigator: Dr Michelle Cornes (University of Salford)
CPEC Research Team: Kyann Zhang, Joanne Madridejos, Raphael Wittenberg, Michael Clark, Jessica Carlisle, Areej Malik, Anusha Ganapathi, Jack Gibbs (LSE Communications)
Collaborators: Vanessa Heaslip (Salford University), Jess Harris, Elisabeth Biswell and Joanne Coombes, Janet Robinson (King’s College London), Stan Burridge (Expert Focus)
Countries: England
Keywords: Homelessness, evaluation, implementation, out-of-hospital care, intermediate care, economics, discrete choice experiments
Contact: Michela Tinelli (m.tinelli@lse.ac.uk)