Redesigning Care Pathways Making Creative Use of NHS Estate Peter Molyneux Common Cause Consulting 22 nd February 2016

Mental Health, housing and Homelessness Housing problems frequently cited as a reason for being admitted to hospital Much higher rates of mental illness for people who have experienced homelessness More likely to live in rented accommodation than be an owner occupier. Twice as likely to be unhappy with their accommodation. Mental ill health frequently cited as reason for tenancy breakdown.

Five Year Forward View for Mental Health Housing is critical to the prevention of mental health problems and the promotion of recovery. Stable employment and housing are both factors in maintaining good mental health and are important outcomes for their recovery. The NHS, local authorities, housing providers and other agencies should be working together locally to increase access to supported housing for vulnerable people with mental health problems. More ‘step-down’ help should be provided from secure care, such as residential rehabilitation, supported housing and forensic or assertive outreach teams. Agencies should work to build the evidence base for specialist housing support for vulnerable people with mental health problems and explore the case for using NHS land to make more supported housing available for this group. The DWP should use the evidence to ensure the right levels of protection are in place for people with mental health problems who require specialist supported housing. NHS England should lead work on producing a Mental Health Five Year Forward View Dashboard that includes employment and settled housing outcomes.

Old Problems : New Solutions Secure and settled accommodation can reduce unplanned admission. Housing should no longer be seen as outside the traditional care pathway – or commissioned and provided by ‘others’. All too often discharge is not delayed by a lack of housing but by delays in making accommodation fit for habitation. Better access to mix of types of housing to provide for short-term crisis use, reduce delayed discharges and offer long term accommodation. Innovative use of NHS Estate could release more value by developing supported accommodation to support speedy discharge and / or step down to recovery.

Integration that works – Tile House One Housing Group and Camden & Islington NHS Foundation Trust Care Support Plus – 15 apartments Reducing admissions, length of hospital stay, and need for out of area placements Savings to NHS of £440,000 per annum £1m saving to social care over 5 years

Crisis House & Rehab Services, Tower Hamlets – Look Ahead Partnership between Look Ahead and East London NHS FT Clinical input from ELFT for both services Crisis – 28 days, alternative to in-patient care Rehab – years, OATS and Step Down

NHS Land Disposal Process Land surplus to requirements Lodge with public land registry for 50 days If NHS or other public body interested then transferred or sold at NPV. If not marketing agent instructed and sealed bids sought. Bids assessed and received by District Valuer Highest bid accepted.

How Housing Associations and NHS Trusts Can Work Together Land can be used to produce a receipt, build new in- patient facilities or support care pathway redesign Asset based partnerships lever in new resources, provide specialist services, build out S106, develop housing for sale to croos-subsidise funding of facilities. You – not Commissioners – deliver integrated care.

Rules on Assets Foundation Trusts must operate within Risk Assessment Framework. Decision may require approval from the Board and Council of Governors. NHS Trusts are entitled to keep proceeds up to £5m. Over £10m a Business Case is required. Up to £50m a Business Case for investment must receive NHS TDA approval. Over £50m DH and Treasury approval is required.

Release value of land at outset Low financial risk Raises fixed capital sum quickly – for investment in new facilities Overage partly recoups uplift from development Trust loses equity in perpetuity Trust loses control over development and development of community infrastructure is difficult Early sale may reduce income and cost control needs to be robust to limit risk of overrun.

Cross-subsidy with Single Partner Surplus land is exchanged for new mental health facilities. Financial certainty is delivered early – design certainty also needs to be delivered early. Trust is not distracted from core purpose. Financial failure of selected purchaser. Trust is very dependent on purchaser delivering on obligations.

Single flexible partner, release in phases using open supply chain Selection of right partner will share burden of optimised delivery of the whole Control maintained over timing and sequencing of the whole development and community development. Sales values maximised. JV structure could be used to incentivise the delivery of holistic best value. Income at risk from market fluctuations.

Consortium Approach to Whole of Planning Consent Financial risks and workload are shared. Opportunity to engage or involve community partners in the consortium – which can also hide / reduce value of cross subsidy. Risk share may reduce outturn value to the Trust for cross subsidy. Delivery of best value in discrete elements may not deliver best value overall.

Making an Approach Housing associations should have a clear service offer that is measurable, tradeable and marketable. Understand service transformation and CIP programmes and how they can help with them. Understand land disposal plans of local Trusts and appetite for disposals or JVs Understand proposals of Local Authorit y.

Peter Molyneux