HSHAWB48 Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg | Cwm Taf Morgannwg University Health Board  

Senedd Cymru | Welsh Parliament

Ymateb gan: Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg | Evidence from: Cwm Taf Morgannwg University Health Board  

Cwm Taf Morgannwg University Health Board (CTMUHB) appreciates both the social and ethical imperatives in making the lived experience of homelessness and housing insecurity rare, brief and unrepeated. The health system is acutely aware of both the physical and mental health implications for individuals and families living in unstable, often unsuitable, temporary accommodation. From detriments to sleep, impacts on children’s education, privacy and security. These are likely to produce both short/medium term stressors, affecting emotional well-being as well as the unknown long-term impacts of such experiences.

CTMUHB believe services should be designed to work with the individual or family who present as homeless. It is not appropriate to fit people's needs into system constraints, for example, pursuing temporary accommodation placements that provide an unsuitable or unsafe environment for either the individual or family. Services should indeed be trauma informed and person centred with particular attention paid to vulnerable groups.

Long-term housing is dependent on sufficient supply and this is a structural issue that will not be quickly resolved. Social Housing Grant is not sufficient to build the number of affordable homes required. The aim must be to utilise prevention strategies to keep people in stable accommodation and this requires a multi-agency approach, particularly for health inclusion groups. CTMUHB are not confident this approach forms part of the Bill. Responsibility remains heavily weighted to Local Authority Housing Teams.

CTMUHB wholly supports the preventative, upstream approach to homelessness. Identification of, and awareness of housing insecurity at the earliest point enables early intervention, keeping families in a current and secure home.  It is a concern that success rates for prevention have remained unchanged over the last 10 years, albeit this has occurred in a time of increased demand, with the supply of affordable housing not keeping pace.

CTMUHB would like to see greater regional co-ordination of Housing Support Grant, which at present, remains focussed on commissioning within individual Local Authority areas. For example, evidence from the CTM Regional HSG Collaborative Group suggests there are greater respective numbers of those considered complex and in need of ‘high-level’ support (and thus higher costs) in one of our local areas than others, whilst this area receives the smallest HSG contribution (based on population size). There remains persistent numbers of individuals with either long-term or repeat use of temporary and supported accommodation who, when studied by the CTM Regional HSG Collaborative Group, do not fit a continuing model of supported living, despite clear evidence these individuals are extremely unlikely to sustain an independent tenancy and pose a very high risk of returning to street homelessness and revolving once again through the system. More innovative models of supported living or graduated, stepped down pathways, inclusive of support, are required to avert this situation long-term.

CTMUHB fully support the opportunity that healthcare system interactions with patients and the public provide for recognition of homelessness or homeless risk. CTM’s Substance Use Housing Outreach Multi-Disciplinary Team have an operationlised multi-agency approach which seeks to keep those within the homelessness system and with complex health issues, from requiring acute medical care. The team stabilise individuals’ circumstances, making it more likely they will go on to sustain accommodation. This is prevention in action for a complex and often hard to reach population. At present, this is a service unique to CTM, but the model could be replicated across Wales.

With regards preventing homelessness being the responsibility across the Welsh public service, Identification can be built into CTMUHB processes across district general hospitals, community hospitals, community-based teams and mental health in-patient provision. This needs to come with effective training and awareness programmes for relevant staff and prevention must be backed up by an increase in Housing Support Grant aimed at keeping people in their home. With regards aligning the duty to Ask and Act with NHS discharge processes (D2RA), it is anticipated that CTMUHB’s discharge policy will include provision for patient’s housing situations to be considered at the earliest point, this should be discharge planning at point of admission. This provides additional time for identification, referral and preventative action on potential homelessness. 

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It is disappointing that the current Duty to Ask & Act omits NHS Wales Primary Care. This is where conversations about an individuals’ housing situation and social circumstances are most likely to take place.

Time pressures and capacity of clinical staff to Ask & Act will be limited, as will the capacity to train and maintain training for staff. It would be useful if such training is aligned with Statutory & Mandatory Training around domestic abuse and safeguarding. These issues are also opportunities to recognise a risk of homelessness.

At present there is not a national approach in Wales which focusses on Health Inclusion groups. These represent some of the most vulnerable in our population and those whom are likely to require the intervention of multiple services and whom are at high risk of homelessness. There are good practice examples within Cardiff and Vale Health Board from which learning should be taken. Getting an understanding of regional populations and approaches to health inclusion across Wales would be of value to understand the current resource implications of supporting this population and how they may be better served under the Act.

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To use a bath tub analogy - we can work very hard to stop the water from flowing from the tap by focussing on early identification and prevention of homelessness, however, there is an urgent need to reduce the numbers of people within the homelessness system and those who are repeat users of the system. These represent the ever-rising bathwater. At present, there is little evidence that appropriate housing or supported accommodation will be available to enable a strategy of rapid re-housing with sustained, long-term tenancies. Therefore, we are unable to remove the bath plug.

Evidence also suggests that the system is re-housing those from priority homeless lists without the adequate support to sustain tenancies, even within social housing. If this is to be built into the Bill, it could be suggested it will simply push the problem to another part of the system.  Social housing providers are left to do the hard work on preventing homelessness and taking the burden of risk.

And whilst we train health board staff in how and why they need to Ask & Act, there is a potential this will increase the numbers of those owed a homeless duty, increasing not only the workload of Local authority Housing Teams to assess and work with those who are homeless, but also place greater pressure on HSG and costs of temporary accommodation. In effect, the Act risks creating even more flow via the intention of prevention.

CTMUHB commend the projected cost benefits associated with improved health by reducing the experience of homelessness across the first 10 years of implementation of the Act. It is important to understand the wider net societal benefits predicted from the Act  and the predicted reduction in spend related to health services in the medium term.