"If we don't look at the whole person and think about them in terms of what's best for them and what they want, what their needs are, we're never going to make good decisions."
Claire Terrington speaks these words with passion, with certainty.
She is an occupational therapist in the Birmingham and Solihull Mental Health NHS Foundation Trust. She is also the unofficial lead for personalised care in the trust.
She says about herself that the day she does not care about her patients anymore, is the day she will stop coming into work entirely.
An investigation into the available housing support for mental health patients has revealed that over 10,000 people were experiencing homelessness at the end of January 2021.
Occupational therapist and head of personal care
Asking Claire what is needed to support those patients, she has clear ideas.
One of them is a focus on personalised care and looking at what the patient wants to make better choices — also in regard to their housing situation.
Personalised care means looking at the person as a whole individual and thinking about what's needed from their point of view.
"As an occupational therapist our job is about promoting independence, keeping people out of hospital, keeping them well in the community and engaged in things that are important to them", Claire explains.
"We always start with the question of 'what's important to you? What do you want to achieve? Tell me your story.'"
When in hospital
Asking patients what they want becomes especially important when they are admitted to hospital.
In their housing report Brick by Brick, the charity Mind says that a mental health crisis and a hospital admission can lead to someone losing their home.
"Admission and discharge from hospital are key housing transitions for people experiencing mental health problems. The period after hospital discharge is high risk for a first or recurrent period of homelessness."Mind, Brick by Brick
If someone is in hospital and does not have housing, they need support in finding a home.
For Claire Terrington, offering the best possible support to patients involves asking them what they want — instead of assuming they know what's best for them.
"The conversation now is very much about when you're discharged from hospital, what is it that will work for you?"
In the old days, the decision was often made by the ward staff — based on what they thought was right for that person, Claire says.
Simply asking — and listening — what someone wants and needs yields better results.
"If it was me, I'd want someone to ask me what's important to me rather than assuming they know what's best for me."
Claire sees the conversation slowly shifting. The very subtle difference, Claire describes, is giving the patient some control over the discharge process.
But, finding the right solution for the patient can be a lengthy process.
Asking from day one of the admission
To start with, it can be difficult to work out if going home is the right decision for the patient.
"Initially we need to focus on the symptom management and ensure that they're mentally better before they can make sensible choices about going home."
Still, Claire emphasises the benefits of asking from day one of the admission. If the patient is not well enough to make a decision yet, there are other people who can give their view.
"But if you asked from day one, if you ask people that know that person best, be it a friend, a carer, a family member, a staff member, whoever, you could probably start making sensible choices earlier in the discharge process, which would at least give you some kind of inking."It's highly unlikely you won't know what that person needs when they are going home if I'm honest if you piece it all together quite well."
Finding accommodation
After finding out what the patient wants, the next step is to find the right, suitable and available place for them to live in.
A lack of accommodation limits the available choices. "Accommodation is massively important, but there is a huge gap", says Claire.
"We don't have enough housing for people regardless of needs. We are overrun by people."
Additionally, it can be hard to find reliable places that are going to be suitable for the patients. "That's because people that are going to hospital may have done quite risky things", says Claire — which then often excludes them from accommodation.
Because of the difficulties finding the right accommodation, a patient might stay in hospital longer than necessary for the treatment of their illness. This is called a delayed discharge.
In January 2021, there were 17,512 days of delayed discharge. Every day on average 565 patients spent additional time in a mental health hospital.
Delayed discharges occur for a number of different reasons.
Awaiting accommodation was the second common reason of delayed discharges.
But it could also be that the funding isn't in place in time.
"If you're waiting for new placements, you have to go through quite a lengthy process to get someone placed anywhere and if it needs funding then that takes even longer."
It can happen that while waiting for funding to secure accommodation, the place is given to another patient who did not have to wait for the funding to be approved.
"I was working with a guy for years. He was really quite difficult to place just because he was so acutely unwell all of the time even when he was in the community. But we found him somewhere very suitable and they gave the last bed away because our funding took too long to get organised."
Claire has also experienced that the person is initially accepted, but — after more information comes to light — is rejected.
Again she emphasises the the lack of accommodation as the overshadowing problem.
"If I filled in a form today, sent it off, got the money, there is no guarantee that I would still find somewhere for that person to live because there's no spaces for people to go into."
Mental and practical effects of not having housing
Experiencing or facing homelessness, being in the process of finding accommodation and support — all of it has huge effects on the patient's mental health, Claire says.
"Even without mental health problems, we all want somewhere safe to live."There is something about needing to feel safe and secure that is really important and that itself has a knock-on effect on your mental well-being."
But, not having an address also has very practical implications.
It starts with the fact that you need an address to apply for benefits or register for housing — which those who are homeless don't have.
"You can't apply for anything without an address in the UK and it has to be a permanent residence."
The consequence: a seemingly never-ending spiral.
"To claim benefits, you need an ID and you can't get an ID without having an address."If you don't have your benefits, you haven't got any money, so you can't look after yourself. You can't buy food, you can't buy things for your children, you can't get petrol for your car, whatever it might be. You can't do anything like that."
Often, because of their mental health, the patients can't function at a level they need to so that they are able to sort these things out.
"And it spirals out of control almost and becomes too much for people to deal with."
This is where the right support needs to come in to help the patients navigating the systems, finding them a place to stay.
Varying levels of support
The support a patient receives from mental health services depends on the trust and team they are under.
Only a third of trusts have dedicated housing professionals in their inpatient teams. Out of 38 NHS trusts with mental health wards that replied to the request, only 13 employ one or more housing support workers in their inpatient settings.
Trusts often said that "all staff would support a patient with a housing need" or "housing support is seen as a generic role and needs are met by the care coordination or other specialist mental health staff".
When there isn't enough support available, it ultimately comes down to the patient to find the right support, Claire says.
"If you're under the community mental health team, you sometimes have a care coordinator who is usually a nurse. Sometimes you don't, sometimes you just see a doctor every so many months. So it really is up to you as an individual to try and find support when it comes to housing."However, when you go into the community, that support isn't there either sometimes."
Claire remembers a time when there were neighbourhood offices in Birmingham — offices where anyone could just drop in for advice. But many of them got shut down because of funding cuts in adult social care.
Everything is online — but not everyone is
Now a lot of the housing support is online, Claire says — but many don't have the resources to access this support.
"People are struggling to find money to buy food and then they need a laptop to bid for a property."
However, Claire thinks the focus should not solely lie on filling the gap by providing the resources. Instead, there should be more community resources such as neighbourhood offices where those who have housing problems can access support.
"It gives it more power if you can sit across from somebody and have a conversation and really explain your story and they can see that you're a real-life person with a real-life problem. It's much more meaningful than having an email sent to you."If someone is coming for accommodation appointments at a neighbourhood office, you can see if something isn't right for that person. You can do something about it rather than letting it spiral out of control almost."