In 2010 Look Ahead and the East London NHS Foundation Trust opened the doors to the Tower Hamlets Crisis House. Our vision was to achieve a better patient experience of the mental health acute care pathway. The service provides an alternative to in-patient admissions and integrates housing and social care expertise with clinical practice in a safe and welcoming community setting. A recent longitudinal study undertaken by Contact Consulting found that this partnership had enabled a safe and effective service, demonstrated preventative impact, and created significant cost efficiencies, an increasingly specialised range of service offers and a better patient experience.
The financial opportunities and service user benefits resulting from housing, social care and health integration are well documented, yet examples remain relatively rare.
The obstacles that housing associations face to working with health partners are recognisable and typically include;
• A relative lack of evidence-based practice,
• Distinct operational languages,
• A lack of ‘qualified’ expertise, and
• Service offers poorly defined in a health context.
In my time as operational lead for Look Ahead’s integrated mental health services I observed many of these challenges to integration in action. One thing I would add to the list above are clinical governance arrangements.
“If someone dies in a hostel it’s a tragedy. If someone dies in a crisis house it’s an enquiry.” Whilst risking seeming flippant I’ve made this statement more than once before, it highlights the distinct governance challenges faced when commissioned by or partnering with health services. Aligning practice along the NHS’s Clinical governance themes is an essential consideration for housing associations that are serious about working with the NHS. Doing so also works to address challenges such as adopting a shared language, credibility issues, it also fosters innovation and enables shared management of clinical risk.
Following the opening of the Crisis House, we went on to develop several more integrated services including other in-patient alternatives, high risk forensic and complex care services and medication outreach support.
“Clinical governance is a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish” (Scally and Donaldson).
Clinical governance consists of five key theme areas;
• Patient Focus,
• Information Focus,
• Quality Improvement,
• Staff Focus, and
In practice clinical governance is a clear structure of accountability that runs from the frontline to the board. It is also the process for ensuring that practice changes are embedded and consistent across an organisation.
Housing associations do not typically employ clinicians but they do employ expert professionals in housing, support and social care. As a housing and support professional ‘practice governance’ has been the term I have found fits and translates well with health partners.
By adopting clear approaches to practice governance housing associations have an opportunity to ‘professionalise’ their service and partnership offers and qualify their expertise in terms that more keenly resonate with health partners.
In my experience housing associations should consider the following;
• Adopting the five clinical governance themes within practice, incident and quality reviews,
• Articulating how the five key themes inform operations across their departments,
• Revising governance structures to more closely mirror those in health and enable joint risk management; eg defining ‘avoidable incidents’ and ‘never events’, how these are investigated and how recommendations are signed off at respective senior levels.
Examples of the five key themes in practice:
Patient / Service User focus
Peer support, paid service user representatives and models for ‘co-production’ are increasingly common place within NHS services and housing associations alike; they are amongst many routes to a broader and deeper service user focus.
Good information and data management enables more evidence-based reviews and approaches.
Housing associations must strive to keep up as the NHS increasingly digitises information and improves access to records. It may be appropriate to appoint a Caldicott Guardian equivalent.
Most NHS Trusts will be guided by the principles of delivering safe, effective, patient-centred, timely, efficient and equitable services. Seeking to align practice along clinical governance themes acts as a vehicle for defining how these principles apply to housing and social care services.
Measures for achieving both responsive and proactive quality improvement are key to good practice governance.
Competency-led role descriptions and staff development strategies provide a route to an expertise offer that is more clearly defined and able to support partnerships with health.
Health partners will expect clear approaches to valuing and supporting staff expertise. On a local level I have observed several partnerships start out as clinical input into case reviews or reflective practice.
Structures that include clear lines for reporting, oversight, review and accountability are critical for credible practice governance. As much as at the frontline, middle and senior leadership levels may require investment to be confident and well equipped to work well with NHS partners.
In my experience housing associations already possess strengths in many of these theme areas. Building on these will provide an effective route to greater resonance with clinical partners and more ready access to health commissioning.
Peter Airey acted as a senior operations manager overseeing many of Look Ahead’s specialist mental health services before recently becoming a free-lance consultant specialising in governance and change management in housing, social care and health. He can be contacted at (firstname.lastname@example.org).