We all need somewhere to live where we feel safe and comfortable. Given this simple fact, it is unfortunate that for far too long, housing has been seen as at the periphery of the concerns of most mental health professionals, service providers, and researchers. While the importance of adequate housing may be recognized in principle, little research has been done to identify staffing and management practices associated with high quality care, or to improve outcomes. Meanwhile, people with severe mental health problems continue to live in substandard accommodation and struggle to gain access to decent and affordable housing (Kirby and Keon, 2006). This chapter explores these issues. We will describe the historical and policy background, review current issues, and bring together the available research to make practical, evidence-based suggestions for improving the quality of residential care. The context is the ‘mixed economy’ of care that now characterizes housing provision for people with mental health problems in the United Kingdom and in most of northern Europe, Australasia, and North America. This has grown up as we have moved away from long-term care in hospital. The ‘total institution’ has thus disappeared, but we now have many smaller ‘institutions’, with different management authorities, cultures, and values. How have we arrived at this point?
Historical and policy background
In England, the central theme in the development of residential care for people with mental health problems over the last 50 years has been the move from National Health Service (NHS)-funded hospital care to a multiplicity of independent ‘for-profit’—and ‘not-for-profit’—community providers. Similar developments have taken place in most other developed countries. Thus, long-stay hospital beds in England and Wales reduced from 155,000 in 1955 to less than 3000 today (O’Brien, 2010). The policy background that drove this dramatic change was signalled in the NHS ‘Hospital Plan’ almost 50 years ago (Ministry of Health, 1962) which announced an intention to move towards a more community-based system of care. Care in the Community (DHSS, 1981) then shifted the responsibility for managing residential care from Regional Health Authorities towards Local Authorities (local government) and in 1990 the NHS and Community Care Act (Department of Health, 1990) enabled agencies other than the NHS and Local Authorities to become involved in providing these facilities. Subsequently Partnerships in Action (Department of Health, 1998a) emphasized the importance of joint working between statutory and independent sector agencies and, more recently, Supporting People (ODPM, 2002) set out explicitly to co-ordinate all housing support for vulnerable people, including those with mental health problems.
During these changes a tension has emerged between the aims of ‘community care’ for most people and the needs of a relatively small group of highly disabled patients who require some kind of specialist, ‘institutional’ provision—albeit resembling community facilities as much as possible. Despite the successes of community care, patients continue to present to services with multiple and complex needs of such severity that care in non-specialist facilities does not seem feasible. Up to now, their needs have also been included in policy. For example, the National Service Framework for Mental Health (Department of Health, 1999) recommended a small number of intensive, high dependency places in specialist residential facilities which would provide high quality medical and nursing care for the most disabled. These were called’24-hour nursed care’ or ‘hospital hostels’ (Shepherd, 1995). At the time of writing, a new mental health policy document to replace the NSF has just been published (New Horizons; Department of Health, 2009). Its vision is for improved prevention of mental health problems, through early intervention and ‘social inclusion’ and the successful challenging of inequality and stigma. But, it says little about those with the greatest and most complex needs. There is therefore a danger that the needs of this group will be overlooked as policy moves towards more ‘preventative’ and ‘public health’ models (Mountain et al., 2009).
Another important policy theme which has emerged as the hospitals have been run down, has been the most appropriate mechanisms for regulation and quality inspection in a new, multiple provider, environment. In England and Wales a range of monitoring frameworks have been established by different bodies to set standards and attempt to shape practice (e.g. Department of Health, 2003, 2007; ODPM, 2005; Royal College of Psychiatrists, 2010). There has also been a succession of regulatory bodies (in England, three in the last 10 years) to oversee arrangements for the inspection of standards. The latest, the ‘Care Quality Commission’ (CQC), was set up in 2009 to regulate all adult heath and social care services. It will use a system of registration, together with a familiar combination of standards, self-assessment and emergency inspections (much as its predecessors the Commission for Health Improvement and the Healthcare Commission). The threat to ‘deregister’ individual providers for conspicuously poor standards of care suggests that it may have more impact than previous regulatory bodies; whether it will be any more effective in raising general standards waits to be seen. Previous experience suggests not (Walshe, 2003). Improving the quality of local care is essentially a local matter and this has not changed in the last 200 years.
A new area of policy development that is now beginning to impact across mental health services, including residential care, is that associated with the principles of ‘recovery’ (Shepherd et al., 2008; Slade, 2009a,b). These aim to make services more supportive of individual’s recovery ‘journeys’, recognizing the centrality of life goals as opposed to symptom management, the importance of a sense of being ‘in control’ rather than continually directed by others, and of personal hopes and ambitions as opposed to the often reduced expectations of professionals. These ideas now underpin public mental health policy in several countries and we will examine their specific implications for residential care later. Before doing that, let us try to clarify terms.
Table 20.1 The spectrum of residential care (modified from Lelliott et al., 1996)
Usual number of places
Ratio of staff: residents
% staff with care qualification
Staffed care home
Dedicated supported housing schemes
Individual flats/small houses up to 4 places
Available in complex
Outreach support in individual tenancy
Usually individual flats
0.5 up to 3
This classificatory scheme suggests that the different forms of supported accommodation can be arranged on a dimension of staffing levels from acute inpatient wards with constant staffing and relatively high numbers of staff; through high staffed hostels, low staffed hostels; staffed care homes with sleeping night staff; and group homes without staff on the premises, but regular visiting. The problem of this kind of classification for modern residential services is that the changes in the pattern of care over the past 50 years towards a more mixed model of providers have also been associated with a move towards more ‘supported housing’, where the care is delivered to the person in their home by peripatetic staff teams, rather than by fixed staffing associated with a single facility (hence, these options need to be added). This means that levels of care are much more flexible and the person can live as independently as possible most of the time. It also reflects the consistent research findings that service users generally favour more autonomy and wish to avoid shared housing options that seem too like the institutions they were set up to replace (see ‘Quality of care’ and ‘quality of life’ section). At the same time it opens up the possibility of using a much greater range of ‘ordinary housing’ options in a more cost efficient way and accords with current thinking on the importance of ‘social inclusion’.
One of the major practical reasons for wishing to develop agreed and consistent definitions of sheltered and supported housing is so that these can be used to inform planning for the range of different kinds of accommodation required to meet the needs of a specific, local population. For the reasons given above, this has become increasingly difficult as planning has come to depend more and more on the simple availability of general housing stock. Nevertheless, there are some interesting examples in the literature of attempts to do this and these are summarized in Table 20.2.
Table 20.2 Examples of attempts to estimate local housing needs through survey methods
Census of acute bed usage in a nationally representative sample
Highlighted the need for specialist rehabilitation placements or 24-hour, ‘nursed care’ units
Large-scale, systematic assessment of local needs
Community living skills, social skills and problem behaviour were the primary characteristics affecting adjustment to residential settings
Survey of in-patients
Five levels of care developed, only 10% of current inpatients needed to remain in hospital, 60% could live independently in the community with appropriate support
Analysis of 730 acute admissions
Many patients might have benefited from alternative, community-based services. A quarter could have been supported effectively in the community in specialist accommodation if available.
Survey of all State and non-governmental high support housing services
State and non-government services useful, but significant numbers of unmet social and psychological needs in residents
Survey of acute in-patients
Almost 20% of acute beds occupied by patients for more than 6 months. ‘By far the majority’ required 24-hour nursed care, need to improve access to this provision.
Despite these kinds of studies, there is still no generally agreed system of local needs assessment for residential care and no recognized instrument to assess housing need at an individual level (Strathdee and Jenkins, 1996). In practice, the development of local provisions appears to be largely determined by history and factors such as demography, transport, unemployment, ethnic composition, funding priorities, attitudes of primary care, effectiveness of specialist mental health services, etc. Some of these can be partially taken into account by sophisticated quantitative modelling (e.g. Glover, 1996), but at the heart of such algorithms remain guesses—albeit sensible and well-informed guesses—about what numbers of different kinds of provisions a given pattern of local morbidity implies.
The problem of accurately estimating demand is further complicated by the fact that one kind of housing or accommodation can often ‘substitute’ for another. Thus, high support hostels may substitute for inpatient beds; flexible community teams may substitute for sheltered housing (or hospital beds); family care with intensive professional support may substitute for professional support or specialist housing; and so on. Housing needs assessments therefore cannot be separated from the functioning and dynamics of the total service ‘system’ and the confidence limits surrounding any estimates of need for different kinds of accommodation remain large (Johnson et al., 1996).
For all these reasons, it is probably more sensible to begin a local planning process by conducting a simple inventory of local housing availability to see who is currently accommodated (i.e. survey of levels of disability and case-mix in existing provision). If one then adds in information on who is currently excluded (e.g. homeless) and these figures are combined with local information about the availability of general housing stock, then this should give a starting point in terms of development priorities. On the basis of national information, shortages in high dependency housing and flexible, intensive community support are likely to be the areas of greatest deficiencies (Audit Commission, 1998; Department of Health, 1998b).
The impact of service developments
In England, the National Service Framework for Mental Health (Department of Health, 1999) prompted the development of a range of new specialist community based teams, focusing on patients with specific needs (crisis and home treatment; assertive outreach; and early intervention). This new pattern of services led, in turn, to a significant reappraisal of traditional concepts of the limits of ‘community care’. Thus, it is now clear that many service users who would previously have been in hospital for long periods, or in the ‘revolving door’ of repeated admissions, can now be successfully supported in the community with well-functioning, specialist teams. However, the success of these specialist teams has resulted in a further reduction in acute beds and this has put pressure on the community teams in terms of their ability to support people with severe and complex problems living in facilities that are run by largely non-statutory providers.
Whether this constitutes a process of ‘reinstitutionalization’ depends on what you count as an ‘institution’. In England, the majority of the residential alternatives that have been developed in the community show few of the common features of institutional care (large size, impersonal routines, lack of contact with the community). Indeed, it is their lack of ‘institutionalization’ that seems to account for the higher rates of satisfaction reported by patients resettled from the large hospitals (Leff et al., 1994; Thornicroft et al., 1995). Of course, this is not necessarily the same in countries where larger, more ‘institutional’ units are common.
In all cases, tensions have emerged around the problems of ‘partnership working’ between mental health services and housing providers in the new system. For example, there is often a perception on the part of clinical teams that housing providers can choose who they will accept and, not surprisingly, tend to choose the apparently ‘easier’ clients. Conversely, many independent sector providers believe that statutory services simply want to ‘dump’ difficult problems on to them and then fail to give adequate support and follow-up. Both views reflect stereotypes, but both also contain a degree of truth. These attitudes underline the need for statutory and non-statutory agencies to work closely together (e.g. through joint training). But, given its importance as an everyday, practical problem, the problems of improving joint working has received surprisingly little attention as a research topic.
As indicated above, in England the process of ‘de-institutionalization’ is now effectively complete and there are only a few remaining long-stay in-patient units, providing mainly medium stay (i.e. 1 to 2 years), 24-hour nursed care for ‘new’ long-stay patients (Killaspy et al., 2005). A study of changes in services across nine European countries by Priebe et al. (2008) showed a similar picture.
In addition to the increase in placements in sheltered and supported housing, what other changes in services have occurred? There has certainly been a growth in forensic beds and prison places which cannot be explained by changes in prevalence or patterns of morbidity among patients with severe mental illness (Priebe et al., 2008). For example, between 1994 and 2003 the number of NHS secure beds rose from 1080 to 2560 and detained admissions increased from 600 to 1400/year (of which one in five were treated in private or independent sector facilities). Similarly, in England and Wales the number of prison places increased by 32,500 (66%) from 1995 to 2009 (Ministry of Justice, 2009). However, when one considers the case mix of residents in these different facilities it is clear that while there is some overlap between patients in secure and semi-secure beds and those who might have been in ‘mainstream’ hospitals, the diagnostic profile of those with mental illness in the prison system is quite different—less than 10% with psychosis, high rates of personality disorder, low levels of literacy, and frequent drug and alcohol abuse (Singleton, Meltzer and Gatward, 1998). Thus, while it is possible that there may have been some ‘reinstitutionalization’ of people with mental health problems from ‘open’ hospitals to secure and semi-secure provisions, it is unlikely that there has been much ‘reinstitutionalization’ back to prison.
Perhaps more importantly, there have been changes in public perceptions regarding the risks posed by people with mental illness in the community. These were exacerbated, in the early days of the run-down of the mental hospitals in England, by cases like that of Christopher Clunis, a man with schizophrenia who was well-known to local services, but who had fallen out of follow-up and eventually murdered a member of the public in an Underground station in London (Coid, 1994). Not surprisingly, these kinds of events attracted substantial media attention and, despite the lack of evidence of any actual increase in homicides committed by people with mental illness (Shaw et al., 1999), they contributed to a shift in attitudes—public and professional—towards the need for greater use of secure provisions.
Changes in the pattern of residential provisions have also been driven directly by an increasing emphasis on a ‘market philosophy’, where private providers are encouraged to try to increase their ‘market share’ in competition with traditional state provisions. This has also happened across Europe (Priebe et al., 2005) and, as indicated, has been ‘successful’ in that new providers have been encouraged into the ‘market’. However, it has led to concerns regarding the costs and quality of care provided. Secure services are often remote from the geographical area where the patient originated and this makes it difficult to maintain contact with local community services. It can also lead to difficulties in monitoring progress and unnecessarily protracted lengths of stay. The separation of vulnerable patients from their families and friends then makes successful resettlement more difficult (Ryan et al., 2006). Finally, physical and organizational isolation has repeatedly been shown to be a common factor in hospital abuse scandals (Martin, 1984) and these same factors can operate within residential units if they become similarly isolated. It is therefore welcome that the new regulator in England (CQC) will include private and independent sector provisions within its remit.
Staffing and staff training
As indicated above, one of the biggest challenges resulting from the growth of non-statutory providers is that many more staff are now involved who do not have formal mental health training or qualifications (Phelan and Strathdee, 1994). In some ways this is an advantage since they are less likely to have traditional, ‘institutional’ attitudes but, as we noted earlier, staff untrained to deal with difficult clinical problems are more likely to be reluctant to accept such individuals into their care. In terms of the development and evaluation of training programmes for residential care staff, the evidence is limited and mixed. It is summarized in Table 20.3.
Table 20.3 Training and quality of care
Survey of staff in 15 residential care homes
Association between staff critical comments and resident subjective quality of life. Staff high EE associated with illness severity, suggesting a complex interaction between attitudes and levels of morbidity
State hospital staff trained workers in community care facilities caring for people with severe mental illness
After a 17-week programme community staff reported high satisfaction and the overall quality of the service was reported to improve, with reduced staff turnover
Survey of residential care
Patients with the highest levels of disability tended to receive the least interaction and more negative interactions when they did occur
Survey as part of the TAPS study
Almost a quarter of reprovision schemes offered no training at all, not even in the management of violence or risk
Psychoeducational programme for staff in community residences
Staff liked the networking and mental health component. Service users also became more active and had fewer admissions
Part of the reason for the failure to develop and evaluate training programmes for residential care staff is that it has not been clear exactly what skills they require. The application of ‘expressed emotion’ (EE) models from the research with family carers (Ball et al., 1992) is one model that seems intuitively plausible. Regarding recruitment and selection of staff, while it is recognized that staff characteristics are important, almost no attention has been given to developing more reliable and valid selection criteria. Again, the ‘low EE’ model may have applicability as a framework for staff selection (e.g. select staff who are low on blame and criticism) but has not been empirically tested. The involvement of service users (consumers) as part of the selection process also appears to be widely used but, to our knowledge, has not been formally evaluated.
The qualities of effective leaders in residential care teams and how best to develop and support them have also received little specific attention. In other areas of teamwork, successful leaders seem to able to combine good ‘task’ skills (analysing problems, setting clear goals, agreeing responsibilities) with good ‘socioemotional’ skills (involving colleagues, recognizing their strengths, inviting collaborative decision-making, etc.), see Alimo-Metcalfe and Alban-Metcalf (2006). There is no reason why this same mix of positive qualities should not apply to leaders in residential staff teams but, again, this has not been investigated within an evaluative framework.
‘Quality of care’ and ‘quality of life’
Before discussing more of the research literature, we should clarify what we mean by the terms ‘quality of care’ and ‘quality of life’. ‘Quality of care’ implies evaluation from an external perspective (e.g. as reflected in positive changes in functioning) whereas ‘quality of life’ refers to subjective satisfaction by residents with the care delivered and the physical environment.
In terms of quality of care, the most important factor appears to be the effectiveness of individually-centred, targeted programmes of care. The strongest evidence for this comes from studies of ‘hospital hostels’ where there is 24-hour professional care (Fakhoury et al., 2002). Service users going through these units tend to show positive improvements in functioning—including some reductions in violence—compared with controls and this seems to be associated with the delivery of highly individualized, ‘user-centred’ programmes (Shepherd et al., 1996; Trieman and Leff, 1996). Such programmes combine structure and support, in the context of frequent, high-quality (‘low EE’) staff–resident interactions.
Quality of the physical environment may also affect quality of care. For example, Baker and Douglas (1990) studied the effect of the quality of the housing environment on community adjustment over a nine month period in a large sample (n = 729) of clients in community support programmes in upstate New York. Clients who were resident in housing rated ‘good’ or ‘fair’ showed significant improvements in functioning and no increases in maladaptive behaviour compared with those in housing rated as ‘poor’. In a large-scale systematic review of the quality of institutional care for people with longer-term mental health problems, Taylor et al. (2009) found eight domains of institutional care that were key to recovery: living conditions, interventions for schizophrenia, physical health, restraint and seclusion, staff training and support, therapeutic relationships, autonomy, and service-user involvement. Evidence was strongest for specific interventions for schizophrenia, but this may have been due to the mixed quality of the available research evidence.
Among the most important factors in determining quality of life as perceived by the service user are choice (including choice over which setting in which to live) and the absence of unnecessary rules and restrictions (Owen et al., 1996). In relation to choice, as indicated earlier, it is a consistent finding that service users tend to express a preference for more independent living, in ordinary housing, with flexible, domiciliary support, rather than living with staff (Hogberg et al., 2006; Owen et al., 1996; Tanzman, 1993). In addition, if these choices are followed then there is good evidence that satisfaction will increase (Keck, 1990; Nelson et al., 2007; Srebnick et al., 1995).
However, the literature also contains several examples where staff or family perceptions conflict with service users’ preferences. Minsky and colleagues (1995) found that the choice of 80 long-term inpatients was overwhelmingly to live alone, with family, or chosen room mate: only 4% preferring options with live-in staff. By contrast, 61% of staff felt this to be the best option. Massey and Wu (1993) surveyed service users in a Florida mental health centre and found similarly that service users prioritized personal choice, location and (interestingly) proximity to mental health services more often than staff. A Canadian study by Piat et al. (2008) found that mental health case managers tended to prefer supported accommodation with structure, i.e. staffing ‘built-in’ to the accommodation, whereas service users preferred their own apartments. Friedrichs et al. (1999) found that for service users living independently, they and their families reported isolation to be a significant problem and family members tended to prefer housing which provided support and structure. The research therefore suggests that staff—and family members—tend to opt for more ‘safe’ housing options, with staff on site; while service users value independence and privacy.
Regarding the importance of minimizing ‘unnecessary rules and restrictions’, in the TAPS study (see ‘Outcomes’ section) it is striking how much change there was in measures of ‘restrictiveness’ when patients moved from hospital to community settings (Leff, 1997). These changes were often small (e.g. being able to access the kitchen at 9.00 p.m. and make a cup of tea; having the choice over what to eat and who to eat with) but these small choices made a big difference to the quality of peoples’ lives (Borge et al., 1999). The increased satisfaction (‘quality of life’) consistently associated with the move from hospital to community seems to be largely a direct reflection of the value of these small increments in perceived autonomy (Shepherd et al., 1996).
Another important consequence of moving care from hospital to community is that it becomes necessary to deal directly with public attitudes, specifically stigma. In England, public attitudes towards people with mental health problems living in the community have generally softened in recent years. For example, in 2010, 66% agreed with the statement, ‘Residents have nothing to fear from people coming into their neighbourhoods to obtain mental health services’, this compares with 62% in 2009 (TNS UK, 2010). However, while the public may have become generally less fearful, they are still likely to have specific fears about actual developments in their neighbourhood. Hence, the study by Wolff et al. (1996) is still relevant. They evaluated the effectiveness of a community education programme aimed at preparing a local neighbourhood for a new supported housing scheme. Targeting approximately 150 people, providing information sheets, a video, a public meeting with a ‘question-and-answer’ session, a barbecue and other social events. Common stereotypes of dangerousness were addressed and the public were reassured that residents would not be simply ‘dumped’ and left to fend for themselves. The study found a small increase in knowledge concerning mental illness, but a significant reduction in fearful and rejecting attitudes. This confirms several different antistigma programmes and shows that they can make a difference providing they are clearly targeted and involve direct contact, in controlled conditions, between those holding the prejudice and those who are the object of it (Thornicroft et al., 2007).
As indicated earlier, there is currently considerable interest in the concept of ‘recovery’ in residential care (e.g. Dinniss et al., 2007). However, there is also still confusion concerning the meaning of ‘recovery’ and what evidence is available to support the approach (Shepherd et al., 2008; Warner, 2009). In residential care, recovery is mainly about the style and quality of care, in particular the extent to which attempts are made to empower the person to take their own decisions and pursue their own priorities, rather than those of professionals. Hence, it relates closely to the key dimensions of ‘choice’ and ‘control’ mentioned above. A new method of improving the quality of recovery-oriented services has recently been proposed by Shepherd et al. (2010) and is to be tested in an empirical study over the next few years.
In England, the move towards a ‘recovery-orientation’ has been encouraged by attempts to increase the ‘personalization’ of care (Department of Health, 2008). Recently, this has included attempts to provide patients with individual ‘budgets’, where they are given direct funding and helped to make their own choices about residential (and day care) options. This approach is still controversial and uptake has been slow (SCIE, 2009). The central problem is providing appropriate help and support to individuals who find it difficult to express their views and difficult to manage their own care. There are also obvious dangers of exploitation and abuse. Nevertheless, this approach is becoming more common in relation to residential options for people over 65 and, with increasing pressures on budgets, it is likely to become more widely used for adults of all ages in the future.
Finally, we come to the question of outcomes. Predictably, due to ethical, logistical, and conceptual problems, the evaluation of different forms of residential care is not an area where there are many randomized controlled trials (RCTs). However, there are many other ways of assessing outcomes and we will consider attempts to assess housing initiatives at the whole service level, individual housing schemes, and also narrative approaches, which give rich, qualitative information from an individual perspective.
The research on ‘deinstitutionalization’ has consistently demonstrated that the functioning of long-stay patients resettled in the community is generally improved and they are more satisfied compared with those remaining in hospital. The TAPS study examined the progress of more than 700 patients leaving Friern and Claybury hospitals in north London over a period of more than 5 years (Leff, 1997). Following resettlement, service users showed reduced negative symptoms, increased social networks and functioning, and reported higher levels of satisfaction with their living situation compared with the matched controls. There were no differences regarding the severity of positive symptoms or the rates of suicide or crime. Forty per cent of the 72 patients who were initially ‘difficult to place’ went on to be resettled from hospital over the next 5 years, suggesting that even the most disabled people could manage in less institutional settings, providing appropriate support is available. There were some concerns regarding fragmentation and the possible inadequacy of community services, but overall the results are generally viewed as demonstrating that properly funded, planned resettlement of long-stay patients from asylums results in significant social benefits and increased quality of life without any increased risk of harmful outcomes. If all costs were taken into account, care was slightly less expensive for the community group, but increased with increasing levels of disability (Beecham et al., 1997).
Uncontrolled, prospective follow-up studies of community resettlement in several different countries show a very similar picture. Studies in Australia (Andrews et al., 1990), California (Segal and Kotler, 1993), Northern Ireland (Donnelly et al., 1996), Norway (Borge et al., 1999) and Italy (Barbato et al., 2004) have all generally found improved satisfaction for people moving to the community, stable levels of symptomatology (no increase or decrease) and relatively few subsequent long-term readmissions.
Turning now to specific types of residential care, the one which has probably been most studied is ‘24-hour nursed care’ (‘hospital hostels’). The outcome evidence for these kinds of units was reviewed by Macpherson and Jerrom (1999). The data from one random controlled trial and a number of matched controlled trials and uncontrolled follow-up studies suggest that they are effective in improving the functioning of up to 40% of residents sufficiently for them to be resettled into the community after an average of 2 to 3 years. Residents generally made more progress than controls regarding their social functioning; they showed increased contact with the community; and higher levels of satisfaction. Overall, costs were generally less than acute beds.
The outcome evidence for other forms of accommodation is very limited. In their review, Fakhoury et al. (2002) found 28 largely descriptive studies from the United States, Canada, and Europe. They noted that the research was of variable quality and problems of definition, design, and methodology made it difficult to draw firm conclusions regarding the clinical and cost-effectiveness of differing forms of supported accommodation. Similarly, Chilvers et al. (2002) attempted a Cochrane review of studies of supported flats within designated housing schemes (staffed ‘core and cluster’ facilities) compared with dispersed, ‘ordinary housing’, outreach support. They found no randomized controlled studies and highlighted the need for more—and better—research. Kyle and Dunn (2008) systematically reviewed 29 studies, using a method to allocate levels of evidence according to the robustness of the research method. They found good evidence that housing interventions impact positively on hospital use in the homeless, but weak evidence for similar effects with people with severe mental illness who were not homeless. There was generally weak, or very weak, evidence of a beneficial effect of supported housing on psychiatric symptoms and, at best, medium evidence of an association between housing and quality of life. These reviews illustrate the wide variety of study methods used and the complex, and at times conflicting, results of studies in this area. A selection of studies that are worth considering in more detail are summarized in Table 20.4.
Table 20.4 Reasonable quality outcome studies
Comparison of 61 inpatients in Montreal placed into designated supported apartments with 51 individuals on the waiting list
No differences in service use after 2 years, but control group showed significantly more thought disorder from 12 months attributed to the stress of living closely with other mentally ill individuals in a poorly supervised setting
Study of the quality of care provided in a variety of care settings
Number of living companions, housing concerns and having a private room predicted ‘community adaptation’ (measured by scales rating emotional well-being and personal empowerment).
RCT, followed-up homeless people with severe mental illness for 18 months after random allocation to independent apartments or to group homes
Neuropsychological functioning improved significantly for both groups, but executive functioning decreased significantly for the group living in independent apartments. Authors suggest that living alone may result in a lack of social interaction leading to deleterious effects on cognitive functioning
Random allocation of 208 participants with severe mental illness and substance misuse to a housing programme which offered immediate housing without expectation of psychiatric treatment compliance or abstinence from substance use, compared with transitional housing which required compliance and sobriety.
No differences in psychiatric symptoms or substance abuse. Results challenge the common practice of linking access to housing with a requirement to accept treatment and sobriety
Turning now to the qualitative studies, Chesters et al. (2005) reported on the narratives of 15 residents of supported housing programme in Australia. These highlighted the importance of supported housing as an integral part of recovery focused services. The participants reported that people with mental health problems found it difficult to get effective care and treatment (other than education) in the community. The authors concluded that people need the benefits of decent public housing and ongoing support. They also warned that not all communities are welcoming and that friendships can be even less easy to secure than housing and support. In a study using interviews with supported housing residents in Ontario, Walker and Seasons (2002) found that four themes emerged: loneliness, poor quality of housing, a desire for greater understanding, and social inclusion. Forchuk et al. (2006), again working in Canada, used a focus group methodology to study the housing experiences of people with severe mental illness living in the community. They likened the devastating impact of loss through mental illness to the effects of a tornado, with periods of losing ground, struggling to survive, and then eventually gaining stability. From a professional perspective, Hogberg and colleagues (2006) carried out a qualitative analysis of interviews with nine nurses in Sweden. They noted a central theme of respect for the service user’s self-determination, but also saw a key role for the professional in providing a link between the service user and their local neighbourhood.
These qualitative studies give insights into the lives of people living with serious mental illness in the community. However, they are most useful when it is possible to relate peoples’ subjective experience to quantitative data regarding ‘quality of care’—staffing levels, quality of interaction, leadership, management regimes, etc. Thus, it is not just the case that ‘more research’ would be useful, but more ‘mixed method’ research is most likely to help us improve the quality of resident’s experience.
Summary and conclusions
1 In terms of planning and estimating needs, any definitions of residential alternatives must be multidimensional and should include a consideration of the whole system of supported accommodation, including all the available private, charitable, and statutory services. They should also reflect the established value and attraction to service users, of flexible, ‘supported housing’ models, rather than traditional group homes and hostels with fixed staffing. Local planning should be built on locally collected information about who the housing network is serving (and who it is not). It should not rely on ‘norms’. Any planning process must not neglect the needs of those requiring the highest levels of support and a range of models of specialist residential provision, including’24-hour nursed care’ should be available in each locality.
2 In terms of housing developments, new projects are increasingly likely to be managed by independent sector providers. To improve ‘partnership working’ between statutory and non-statutory agencies there needs to be a mutual respect and understanding regarding their respective roles and responsibilities. Support for providers through education and joint working with community mental health teams is necessary and should be seen as an integral part of the work of both agencies.
4 In terms of staffing and interventions, more attention needs to be given to the development and evaluation of joint training initiatives, aimed at improving the knowledge and skills of residential care workers. Attention should also be given to staff selection processes in order to identify those who will be most effective in their interactions with residents. Particularly careful consideration should be given to the desirable attributes of project leaders and to mechanisms for supporting and helping them develop their leadership skills. Housing regimes which maximize choice and independence are likely to be most highly valued by residents.
5 The adoption of a ‘recovery orientation’ in mental health services will challenge those working in residential care to provide good quality accommodation of the type service users want and maintain a focus on the individual and the importance of choice and control. This may conflict with aspects of a ‘business’ model where there is an emphasis on ‘throughput’ and cost efficiency.
6 In terms of outcomes, in general those resettled from long-stay hospitals show few advantages in terms of clinical symptoms but function better socially, are happier, and cost less than their counterparts remaining in hospital. The evidence in favour of transitional 24-hour nursed care for the ‘new’ long stay is generally positive, however it may be unattractive to some service users. Other ‘high-support’ options may therefore need to be developed. Regarding the differential effectiveness of other types of provision, the evidence is limited and, once again, user preferences should probably predominate as these are most reliably associated with good outcomes.
7 There is a need for better quality, carefully designed, quantitative research which investigates the relationship between ‘quality of care’ variables and objective improvements in clinical and/or social functioning. There is also a need for better quality, carefully designed, qualitative research which explores the experience of service users and staff in residential care settings and investigates the relationship between ‘quality of care’ variables and ‘quality of life’ (satisfaction). Both methods should be combined for maximum effect.
Housing should be at the centre of community psychiatry. In order to achieve meaningful improvements in housing provision, we need to adopt a whole-systems, multiagency, collaborative approach. Services have evolved rapidly since the closure of the psychiatric institutions and further changes in response to various ideological and policy developments are inevitable. The challenges for professionals working with people who need supported accommodation are as much to do with promoting social inclusion and challenging stigma, as they are about providing the right clinical support and treatment. Residential care is certainly an area where ‘more research is needed’, but we would also be able to make considerable progress now if we were simply to implement what we already know.
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