"It's a huge issue", says Claire Terrington. Patients need support finding a home.
How this support looks, varies depending on the patient's mental health team.
When Claire Terrington was working in Assertive Outreach Services — a specialist team supporting adults with mental illness who have particularly complex needs — her team had a dedicated housing officer.
He knew everything there was to know about housing issues, housing laws, and the rights of patients.
"We found it really useful because when we had multidisciplinary meetings about a patient and we were talking about their housing situation, then he knew if something would work or not."
However, accommodation officers are a rarity in mental health services, data obtained through Freedom of Information requests reveals.
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".
The lack of dedicated housing support can create anxiety around being discharged from hospital, says Deborah Stephenson from Rethink Mental Illness.
"It may inspire a lack of confidence around what level of support people feel they can rely on. People often don't know what housing support is available to them, and the risk of facing homelessness or trying to work through the system on their own can result in relapses."
Caroline Bernard is the Head of Communications and Advocacy at Homeless Link, the national membership charity for frontline homelessness services. She says that appropriately funded discharge schemes provide an important opportunity to engage and support people who may otherwise fall through the gaps in services.
"Key to the success of these schemes is strong partnership working between health, homelessness, housing and related services, offering individuals a range of support options, and ensuring the discharge process itself is handled sensitively, with good communication between the hospital and the patient."
Without accommodation officers or similar dedicated housing staff, the nurses on the ward are responsible for identifying housing issues on admission. They should work with the community care coordinator, local authority or housing department to secure housing.
The quality of the support then depends on how good the patient's team is at finding accommodation. Besides housing support, they also need to take care of the patients' other needs.
The more experience someone has with finding accommodation, the better are the outcomes, finds Claire Terrington. Over the years, she has been able to build up a network with housing providers in Birmingham.
"If you're clever and you've been around a bit like me you keep a list of places that are really good and you keep on contacting those people and you keep them on your good side. So if they got a vacancy, they'll phone you and say they've got a vacancy."
When different teams have to work together to secure housing for a patient, the outcome also depends on how well they communicate with each other.
Before Emma's discharge, her team in the hospital has tried to arrange a meeting with her community team back home. But her community team has either cancelled meetings or just did not show up. In the end, they had to drive to the city one hour and a half away.
"We literally had to turn up and say, 'you need to meet about this service user that's about to come back to your area'. It was really difficult", Emma remembers. "The two sides communicating was impossible."
Because of the communication problems, Emma's team wasn't fully aware that she was facing homelessness.
"But if they would have listened, if they would have communicated with us, then they would have known and would have had more time to help me out."
Lack of suitable accommodation
Having lost a home, it is hard to find a new one. Risk and a lack of accommodation limit available choices.
"Accommodation is massively important, but there is a huge gap. There aren't enough one-bedroom flats and there isn't enough supported accommodation either", Claire Terrington says.
"We don't have enough housing for people regardless of needs. We are overrun by people."
When Emma is looking for accommodation, she is often told that waiting lists are long and that there is nothing else to be done.
Less range also means less suitable accommodation that meets the patient's needs.
"There's a dearth of accommodation out there and that makes it less likely that any particular place is going to be good enough for an individual", says consultant psychiatrist Nuwan Dissanayaka.
Because of this, there is a huge competition for actually available and suitable housing.
And those who have a level of risk associated with their illness are often excluded from accommodation because of it, says Nuwan Dissanayaka.
Claire Terrington has made similar experiences with her patients: "Some people engage in really risky things before they are brought into hospital. And once that gets put on paper it's really hard to find them somewhere to live."
Housing issues are delaying discharges
Not having housing in place after discharge can sometimes lead to patients staying in hospital longer than they need to for the treatment of their illness. This is called a delayed discharge.
Claire Terrington knows that services try not to send anyone home without having suitable accommodation. "This is why we end up with people in hospital for longer. It's a real lengthy process to find anywhere — if we can find anywhere", she says.
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.
Mental health hospitals under extreme bed pressures
Delayed discharges negatively impact the finances and performance of the health and care system, according to the King's Fund.
When patients are staying in hospital for longer than they medically need to, the bed cannot be given to a new patient. This is especially critical when mental health units across England are already experiencing extreme bed pressures — not only since the Covid-19 pandemic.
Years of reducing the number of available beds has led to increasing bed occupancy rates. In 1988, there were over 67,000 beds for mental health patients available. Today, only around 18,000 of those are left.
To maintain patient safety standards, bed occupancy should not exceed 85 per cent. A higher bed occupancy leads to regular bed shortages. These are impacting patient care as directing patients to the bed most suitable for their care is less likely to be possible.
Between April 2019 and March 2020, every day on average 89 per cent of hospital beds were occupied by mental health patients.
Nuwan Dissanayaka says that there can be a pressure to discharge patients into the community when they no longer need to be in hospital for the treatment of their illness. Although they might not have housing in place yet, they could still be discharged.
"I think it is a very difficult decision, most difficult for the patient at the centre of it but those decisions are made sometimes because I guess services don't feel they have any other option but to do that."
Finding suitable accommodation for patients earlier on could decrease delayed discharges and consequently relieve some of the bed pressures.
From hospital to hostel
When Lily* was 20, she was discharged into a hostel.
After staying in an acute ward for seven weeks, she was deemed well enough to go home — only that she did not have a place to go back to.
"There was no real option about where to house me at that point", she says. Before her admission, she became estranged from her family and friends. Living with them wasn't possible.
"And then there was an idea that if I declared myself as homeless and stayed in a hostel that I would have quicker access to community housing. It was sold to me as the best and quickest way of alerting people to my homelessness and the severity of my situation."
Before Lily went to hospital, she slept rough for a few weeks, was often around people who were struggling with their mental health and substance misuse. Facing a similar environment again, frightened her.
According to Mind's report Brick by Brick, hostels are there to provide essential, emergency accommodation for people who are homeless. They should come with key workers and referral routes to some form of psychological support. But the report also says: "High demand and funding pressures limit the support options available."
Claire Terrington knows what staying in a hostel is like since some of her patients have been placed there. There were times where she got back in her car and cried about the thought of leaving the patient in this environment.
"The next day, we've spent all day to find another place for that person because it just isn't right for them.
"They're not pleasant places. They are often full of people who are drunk, using substances, noisy at night. You wouldn't feel safe and secure there at all."
Lily describes the hostel environment as frightening, having a substantial impact on her mental health.
She says: "It was troubling to be there."
After staying in the hostel for a week, Lily was readmitted to hospital. Fortunately not for long. Instead of going back to the hostel, she could stay with an extended family member.
Six weeks after declaring herself homeless, Lily was given a council property.
Today Lily looks back at it. And although the hostel was the quickest way of accessing social housing, she wouldn't have done it if there would have been other options.