Introduction and overview

The following report was produced by an expert sub-group of the London Mental and Homelessness Steering Group, coordinated by the Transformation Partners in Health and Care (TPHC) Co-Occurring Conditions Programme.  

The London Co-occurring Conditions Programme works with London partners to develop services and systems that have “no wrong door” for people experiencing homelessness with co-occurring substance use, mental health conditions, learning disabilities, or autism. The programme has been funded since 2022 by the Rough Sleeping Drug and Alcohol Treatment Grant overseen by the London Office for Health Improvement and Disparities (OHID).  

The sub-group was formed to examine the area of “workforce development”, which was identified as one of three priority areas for the London Mental and Homelessness Steering Group.

Initially, membership of the sub-group was from the people within the wider steering group, including stakeholders within the homelessness and health sectors. There was a commitment to broaden this to include more representation from non-homeless specific mental health services. It was identified that engaging this wider section of the workforce was a priority, as they were less likely to have ready access to resources, support and knowledge regarding working with people experiencing multiple exclusion homelessness.

Over a period of 12 months, the group met monthly and identified three key stages of workforce development for review by the subgroup:

The aim of this document

This document shares suggestions and examples of good practice, in relation to the mental health workforce when working with people experiencing homelessness across the following domains.

• Recruitment.
• Upskilling the workforce.
• Retention of staff.

Who should read this report?

This document will be of value to anyone who has responsibility for the development of the mental health professional workforce. It also suggests further actions that could be taken to improve the ability of services to meet the needs of those experiencing homelessness with multiple disadvantages.

WFD Stages	Purpose	Curriculum	Expected outcome
Recruitment	– To influence the recruitment of the Mental Health & Adult Social Care workforce so staff are able to address the needs of people experiencing homelessness. – To develop the non-homeless specialist statutory mental health workforce.	– A workforce that is aware of the needs of the homeless population across London. – What is the existing staff’s knowledge of mental health needs for people experiencing multiple disadvantages of homelessness, mental health and substance use? i.e. community mental health teams, Adult Social Care, nursing etc.	– A more inclusive and empowered workforce to work with people experiencing homelessness.
Upskilling	– To improve the competency, knowledge & skills of the mental health workforce to work effectively with people experiencing multiple disadvantages.	– A review of available resources and opportunities vs required resources and opportunities to enhance engagement with the client group.	– Increased skills and awareness of the needs of people experiencing multiple disadvantages. – Additional skills to work with a broader client group. – Enhanced clients experience (e.g. better communication, reduced stigma).
Retention	– To retain and support staff to develop in their roles. – To sustain psychological safety of the workforce.	– Reflective practices. – Explore career progression opportunities for the workforce.	– A sustained workforce to support continuity of care for people experiencing multiple disadvantages of homelessness.

Lived experience: One of the key themes which emerges throughout this report is the importance of incorporating the perspective of people with lived experience into how these tasks are undertaken. This group itself greatly benefitted from such expertise which, in itself, might be seen as one of the more significant achievements of this piece of work.

Terms of Reference

The subgroup was guided by Terms of Reference developed by the host, Transformation Partners in Health and Care (TPHC) with membership comprising of cross-sectoral stakeholders and experts by experience across London.  Please see Appendix 1 for the Terms of Reference and list of members.

Methodology of developing the Workforce Analysis (from Lived Experience Member, Mark)

Selection Process: Unknown. Another member and I were recruited from Groundswell’s volunteers.

Input/ Involvement of meetings: My own input was weighed in exactly the same manner that other paid staff were afforded and given equal measure with my opinions and suggestions.

Remuneration: For each one-hour meeting, I was paid with Amazon vouchers for the sum of £40.

Frequency of meetings: Approximately six meetings over the course of eight months.

Further work/ reading requests: I was asked to write a short report of my own experiences of homelessness/ medical/ subsequent housing).

Activities undertaken and recommendations for action

WFD stages	Actions taken by the subgroup	Outputs from the subgroup	Recommendations
Recruitment	– Presentations relating to and discussions around supporting mental health workforce to be more inclusive and representative of people with lived experiences. – Ways of facilitating career development of homeless sector workforce in mental health.	– Example of a recruitment toolkit by Pathway to support health trusts in recruitment. – Examples of incorporating lived experiences in recruitment e.g interview panels, interview questions’ setting by Groundswell/ Shelter. – Ways of supporting the homeless sector workforce to train professional mental health practitioners.	– A role to campaign and facilitate the adoption of these practices by all NHS Mental Health Trusts workforce.
Upskilling	– Map out good practices for MH professionals in training and personal professional development relating to multiple exclusion homelessness. – Discussions of online resources with the Faculty. – Exploration of recovery college as a resource for mobilise.	– Publication/presentation of these – with commentary from the sub-group. – Promotion of research by Kings College London around addressing homelessness in social work education and any related case studies of good practices.	– Systematically engaging training leads and professional bodies with Recovery Colleges across London. – More systematic reviews of resources.
Retention	– Explored areas of reflective practices and staff resilience.	– Find some case examples of where homeless sector has effectively communicated their commitment to Trauma-informed models to MH Trusts.	– Find ways of engaging mental health workforce in understanding steps taken within homeless sector. – Funded time.

Good Practice Examples

Recruitment

Examples of Good Practice:

• Recruitment toolkit by Pathway to support health trusts in recruitment of people with lived experience– Recruiting people with experience of homelessness toolkit | NHS Employers. This short video profiles the benefits to the individuals recruited. The Pathway toolkit https://www.nhsemployers.org/toolkits/recruiting-people-experience-homelessness-toolkit.
• Incorporating lived experience of homelessness into recruitment practice: The development of the “Rough Sleeping and Mental Health Programme” (RAMHP): People with lived experience were involved in all stages of the recruitment process, including membership of interview panels and interview question setting. Further information can be found here: “Rough Sleeping and Mental Health Programme” (RAMHP): https://www.london.gov.uk/sites/default/files/2023-10/UCLP%20Final%20RAMHP%20Pilot%20Evaluation%20-%20October%202022%283%29.pdf.
• Examples of embedding lived experiences into recruitment practice: Groundswell. Groundswell is a homelessness health charity, over 70% of its staff team and all of their volunteers have experienced homelessness at some point in their lives. As part of the process for recruiting new employees the relevant line manager will establish a recruitment panel, on which at least one panel member will have previous experience of homelessness. The panel is involved in all aspects of recruitment including shortlisting, interviews and final decisions. For senior leader roles all candidates are interviewed by two panels, one of which is a panel of senior leaders and Trustees and one which is a peer panel of staff and volunteers. All Groundswell volunteers have experienced homelessness which ensures lived experience participation is embedded in the recruitment process. The two panels meet following interviews to reflect and share feedback, all of which is taken into consideration as part of the decision-making process, creating opportunities and removing barriers to employment for people with lived experience. More information can be found via https://www.career-matters.org/lived-experience-charter/.
• Mental health professional work placements: A number of organisations working with people experiencing homelessness offer practice placements to those training to become mental health professionals. Examples include: Occupational Therapy placements created by partnership work between the St Mungo’s Homelessness charity and the Enabling Assessment Service (EASL) London who provide professional supervision. Social work placements are offered by several homelessness organisations, including Thames Reach, St Mungo’s  and Hestia.
• Formal clinical placements: Many larger NHS inclusion health services offer supervised placements to health practitioner students (although there are challenges regarding the capacity to undertake this work, due to the number of qualified assessors available and/or workloads).  The Pathway charity will attempt to find placements for elective students if / when they get contacted by members of the Faculty of Homeless and Inclusion Health and are generally successful in securing placements.  

Upskilling

Examples of Good Practice:

• Networks and shared learning spaces: The examples listed below reflect spaces where specialist homelessness health professionals engage with and draw attention to the needs of people experiencing homelessness. A number of third sector organisations also provide free access to newsletters, clinical networking meetings, training opportunities and conferences. A recent example is the work of the London Network of Nurses and Midwives Homelessness Group which has had a  focus on the workforce development needs relating to safeguarding in a homelessness context. This has resulted in Masterclasses and conferences focused on the issues of self-neglect and organisational neglect. Pathway also has a Mental Health Subgroup which meets bimonthly and has around 300 members. Additional examples of specialist networks are:
  • Faculty of Homeless and Inclusion Health
  • Queen’s Nursing Institute Homeless Health Programme
  • London Network of Nurses and Midwives Homelessness Group
  • Frontline Network
  • Asylum Support Advice Network

• Awareness raising films: Use of the following short films in team meetings, away days etc to increase awareness of the challenges of homelessness and the challenges of accessing health care when you are homeless in a variety of settings:
  • Less film
  • Clarissa film
  • Tina film

• Approved Mental Health Professionals Training: Enabling Assessment Service London deliver training sessions on ‘Mental Health Act Assessments and Homelessness’ as part of the core training course for people training to become Approved Mental Health Professionals at London Metropolitan University. EASL also provide similar sessions to specific Local Authorities as part of their AMHP refresher training.
• Social work training: Report: ‘Current approaches to addressing Multiple Exclusion Homelessness in social work education: Harris, J. & Mason, K., (2024) https://www.kcl.ac.uk/research/addressing-multiple-exclusion-homelessness-in-social-work-education.
• Online learning resources: Several online sites exist to enable practitioners and students to gain further knowledge and experience regarding homelessness and mental health, either free or at low cost. However sometimes these resources can be hard to find (this is an issue that is dealt with in the next section):

Key sites are:

• Aneemo
• Fairhealth
• E-Learning for Healthcare

• Pre and post registration health care practitioner courses: Many inclusion health services and individual practitioners provide lectures on pre-reg and post-reg health care practitioner courses at universities pan-London. However, it is important to note that this is currently an ad hoc practice, and is not consistent across all relevant courses.

Useful Learning Resources

The sub-group was not resourced to undertake a systematic literature review of the resources that might be helpful but the resources below were identified as being particularly helpful:

• Aneemo “Improving Access to Services for Clients Experiencing Multiple Disadvantage & Co-occurring Conditions”: https://academy.aneemo.com/p/improving-access-to-services-for-clients/?utm_campaign=purchase_notification_with_tax_details&utm_medium=email&utm_source=student_mailer 
• Homeless Link and EASL’s Homeless Guidance for Mental Health Professionals: https://homelesslink-1b54.kxcdn.com/media/documents/Homelessness_guidance_for_mental_health_professionals_June18.pdf
• Westminster CC, Resources for Autism, National Autistic Society, Homeless Link and St Mungo’s “Autism and Homelessness Toolkit”: https://resourcesforautism.org.uk/wp-content/uploads/2019/04/Autism_Homelessness_Toolkit.pdf 
• Pathway et. al “Mental Health Service assessments for Rough Sleepers Tools and Guidance”, (particularly the MCA related elements.): https://www.pathway.org.uk/resources/mental-health-service-interventions-for-people-sleeping-rough/
• LGA and ADASS “Care and support and homelessness: Top tips on the role of adult social care”: https://www.local.gov.uk/sites/default/files/documents/25.207%20Care%20and%20Support%20and%20Homelessness%20AA%20WEB.pdf

Retention

Despite its importance, this area, unfortunately, lay largely beyond the scope of the sub-group to address. Nevertheless, these was recognition that, in recent years the issue of staff psychological safety has been increasingly recognised within the homelessness sector. A number of services have started the process of developing Trauma Informed approaches, including recognizing the importance of reflective practice, although there is still a lack of consistent models across the sector.

There are examples of good practice where local statutory services and the homelessness sector have formed alliances to support this approach. Examples of this are the Lambeth Together Network (with the involvement of SLAM and Thames Reach amongst others) and the Camden Trauma Informed network.

There is a recognised value of participation and coproduction in supporting retention of staff and general job satisfaction – this is references in the NHSE document ‘Working in Partnership with People and Communities@ https://www.england.nhs.uk/publication/working-in-partnership-with-people-and-communities-statutory-guidance/.

Examples of Good Practice:

• Pathway has recently run a targeted job satisfaction and burnout survey of all staff in Pathway teams and regularly reviews all exit interviews with all staff in team support roles to promote learning.

Co-production participation

Mark and Tracy are members of the Workforce Development Sub-group whose personal experience was used to inform and shape the recommendations made in the report. One of the recommendations was to explore the apprenticeship pathway to develop the future of the workforce.

From your experience, how did the gaps in workforce skills impact on your treatment and/or recovery journey and what are your recommendations for an inclusive workforce”?. Please feel free to share any good practice examples and anything else, we trust your expertise.

A Lived Experience Member of the Panel’s Journey from Unstable Homelessness and Ill Mental Health to a Stable Home and Stable Mental Health.

The workforce regarding my own experiences of homelessness, health and substance management in my own experiences were very good.

The homeless support (between November 2002 – May 2003) mostly involved living in a homeless single men’s hostel, specifically for “vulnerable adults”, as in those with severe physical and mental health challenges. It allowed cannabis smoking and alcohol drinking in public areas and there were some aspects of class A substance misuse, but that was very secretive from the staff and the majority of the hostel residents.

I lived there for approximately eight months and was provided a residential support worker.

However, it should be noted that the staff rota was very flexible as frequent locum staff and indeed, one support worker took his own life during the Christmas season.

It should also be noted that adjacent to the hostel was a wet hostel and I believe there were frequent drugs transactions between both.

The aspect of frequent locum staff caused some concern with the residents given the level of their vulnerabilities. Some residents recently became homeless upon discharge of hospital admissions as well as penal services and were visibly unstable in their behaviour.

Upon my own support at the end of my tenure with the hostel and offer of a Housing Association flat, I was given a floating support worker who afforded me support with my DLA application, connections with utilities and medical services.

Two years later, I was assigned a dual-diagnosis worker who was trained as a social worker. She was very charismatic and upon meeting with her, I refrained from using illegal substances save one day of relapse and have not used street drugs since February 2008.

Throughout the process of my own treatment history, given my immediate abstinence from all street drugs and overall success of the process over the course of around a year, I was given some additional responsibilities. Including:

• Co delivered Pan London Dual Diagnosis training to mental health professionals across the SLaM services.
• I wrote my recovery journey as part of an NHS NICE paper which has been widely read across the mental health services, discussing the successes of my dual diagnosis process.
• I was also signposted to volunteer with a stimulant drugs project in Brixton which I volunteered for over 18 months.
• I was recruited by Lewisham Service Users’ Council which tasked me with developing a social club on Friday nights for vulnerable adults. Of which I turned into a social enterprise (Ltd) which supported over 1000 visitors a year over two sites every week for seven years.

Over the course of my dual diagnosis counselling sessions, we agreed various goals of which included to get a full time paid job and get married. I achieved those within a few years of the completion of my sessions, of which, within five years, I was made redundant and divorced. From that point, I have been establishing a career in the homeless sector and in various ways, such as a support worker in a large homeless hostel, various volunteering, set up an unconstituted gardening charity and various consultancy work which had some successes.

Recommendations

• Peer Support would be a hugely beneficial part of successful recovery. Groundswell has demonstrated this very effectively as well as Royal Borough of Kensington and Chelsea in the 20^th Century as that established the CDP drug services effectively. From my own experiences, setting up the social club and gardening charity helped virtually everyone who came through our doors. That included me, who ran it, the volunteers and the patrons who we supported. It should be noted that my own project had backroom support from NHS and Lewisham Council professionals, but I was allowed to get on with the projects. The peer aspects of my work flattened the hierarchy and overall had a very warm and welcoming environment. As long as “ego” was absent from the management, overall the morale of the volunteers and the projects themselves would be high and the personal outcomes for each person involved would be successful.
• Consultation involvement of Lived Experience members from all homeless/ vulnerable services will be vital going forward. Given they have experienced their journeys, their input will be vital in future productions.
• Co-production seems to be the new by-word for almost all new projects which support vulnerable people. Given the newness of this process, it is yet to see if it works, but in my own opinion, I think co-production will be vital for any new service designs at whatever level of the “co-production ladder” is incorporated.
• There are some financial successes which have been garnered from co-produced projects such as Crisis’s Expert by Experience co-production of their warm mailouts of which one campaign increased their annual income (2023) by more than £250,000 by virtue of the authenticity of the work carried out (by the experts).

Reflection from Tracy

I was homeless and a heroin and crack cocaine addict for 18 years, I was approached by an Outreach team from Thames Reach in 2008. They took a year to convince me they could help me, because having being on the streets for 18 years it was my way of life, so when I did take their help and built a good friendship with my outreach worker Mark, he helped. I remember asking Mark how would I fit in with all the workers as I didn’t know how to use a computer etc and he said I had 18 years of experience that they never had.

Over the next 2 years I learnt so much, and gained so much confidence, and when my manager spoke to my caseload of clients they were all happy with my work, some would even say I was the best worker because I had been through what they were going through.

I then applied for an traineeship with Thames Reach which I really enjoyed and learnt so much. I learnt that I was worthy to be there because even though I didn’t have a college or uni degree I had experience and had worked hard to get where I was. The traineeship was a good opportunity to work in a chaotic hostel environment which I really enjoyed, I personally think that all charities should offer Traineeships because you see how people can grow and become amazing Support Workers. I then applied for a role as an Activities/Support Worker with Thames Reach and got it and worked there for another 5 years. I ended up leaving cause the sector was changing, i used to enjoy working with clients and seeing them grow, just like my Outreach Worker had done with me but then funding was cut and it was all about ticking boxes, and personally you can’t put everyone down as the same, everyone’s recovery journey is different, so I made the choice to step away.

It took me a couple of years to start volunteering again, and so I did with St Mungo’s and did this for a few years and yet again the funding was cut and I had to stop. I just find it frustrating that there’s not enough funding to back homeless charities or organisations.

How can apprenticeship programmes help the workforce? 

It can help by giving people a chance at gaining employment, gaining self-confidence, and learning to team bond.

Recommendations:

• The recommendations I had was having a staff mentor who I met with every 3 weeks and we discussed my workload and clients cases etc, also online and face to face training I found that very beneficial.
• Also a big one for me was meeting with other apprentices maybe after work and just being able to offload with each other.
• also I can’t remember the name but meeting with a psychologist every 3 months and just being able to debrief about how I was feeling and how I felt I was coping knowing it’s all confidential.
• Also I feel having a good manager who’s always checking in with you makes you feel like your doing a good job. Cause it can be intimidating starting a job knowing that staff know that your an ex-homeless or addict but knowing that you can talk to your manager if you did feel any awkwardness luckily I didn’t but I know a colleague who did.

Further Recommendations from the group

Further Recommendations from the group

Recruitment recommendations

• A role to campaign and facilitate the adoption of these practices by all NHS Mental Health Trusts workforce.

Upskilling recommendations

• Systematically engaging training leads and professional bodies with Recovery Colleges across London to enable all the learning, and networking and training opportunities that already exist to be effectively disseminated.

• A systematic review of resources that are relevant for mental health professionals and mental health professionals in training to take place e.g. – Inclusion Health Education Mapping and Review – Pathway. This review which took place in relation to wider health and homelessness resources, and could be replicated for mental health.

Retention recommendations

• Find ways of engaging MH service work force in understanding steps taken within homeless sector in relation to TI approaches.
• Funded time?

A role to campaign and facilitate the adoption of these practices by all NHS Mental Health Trusts workforce:

Inclusion Health Education Mapping and Review – Pathway

Clinical Networks:

Apprenticeships:

1. Apprenticeships | OneHousing changing or starting new career – property services/care and support.

2. Apprenticeships | St Mungo’s (mungos.org) for people who experienced homelessness. St. Mungo’s take student social workers and nurses on placement generally for about 70 days. They also run a volunteer scheme. St. Mungo’s has an employment specialist team in Sutton and have an Employment Specialist with knowledge of all services within the Borough and externally, the run training/apprenticeships/work placements.

3. Salvation Army apprenticeships.

4. Thames Reach ‘traineeship’.

5. Apprenticeship search tool by postcode – https://www.apprenticeships.gov.uk/apprentices/browse-apprenticeships select area of interest as ‘care services’, add postcode and all relevant apprenticeships available will show up.

Conclusion

Since the early 1990s, there have been mental health programs and services that have specialised in working with people experiencing homelessness. These have generally focussed on people sleeping rough (rather than experiencing other forms of homelessness) and been located in areas with the highest number of people in this population.

Over recent years and especially with the publication of the NICE guidance 2022 there has been focus and investment in specialist services as well as in specialist posts. Evaluations of such specialist services and feedback from the people with lived experience of them has in large part been positive. However, even in the areas where these services operate, and clearly in the areas where they don’t, most contact between people experiencing homelessness with mental health services will not be with specialist homeless mental health services.

 It is this fact that has led this group to focus on examples of good practices and resources that can improve the ability of the mental health workforce not involved in specialist homeless services to better understand and respond to the needs of people experiencing homelessness.  We hope that this document will support employers and bodies involved in the training and development of mental health professionals in this endeavour – we also hope that where there is particular knowledge and expertise in relation to homelessness and mental health this is mobilised in a way that maximises its impact – this should include development of all staff involved in mental health.

Appendices

Appendix 1

Membership

No	Name	Organisation	Post
1	Barney Wells	Enabling Assessment Service London (EASL)	Director
2	Samantha Dorney-Smith	Pathway UK	Senior Nursing Fellow and Nursing Practice Lead
3	Sophie Koehne	Pathway UK	Mental Health Lead and OT Lead
4	Joanna Mark-Richards	Thames Reach	Director of People, People Team
5	Bill Tidnam	Thames Reach	Chief Executive
6	lona Brown	St Mungos	Pan London Navigator Team
7	Robin Swan Brown	St Mungos	Pan London Navigator Team
8	Melissa Ellison	West London NHS Trust	Service Manager
9	Emma Cassey	Groundswell	Peer Coordinator
10	Mark Banham	Groundswell	Lived Experience Practitioner
11	Tracy Isted	Groundswell	Lived Experience Practitioner
12	Michelle Butterly	Camden Trauma Network	Trauma Practice and Educator Lead
13	Jasmin Malik	Transformation Partners in Health and Care (TPH)	NCL Integrated Care Board GP Lead
14	Alison Bearn	Transformation Partners in Health and Care (TPH)	London Co-occurring Conditions Programme Manager
15	Jurgita Mikelsonaite	Transformation Partners in Health and Care (TPH)	SWL Project Officer, London Co-occurring Conditions Programme
16	Abisoye Okutubo	Transformation Partners in Health and Care (TPH)	NCL Project Officer, London Co-occurring Conditions Programme