by Dr Gerry Mitchell (a social policy researcher)
“I came here so broken and uncertain, and the beginning of this journey started in room 9. I am leaving with so much hope and determination for the next chapter.”
In two bungalows set back in a quiet road of the city, an intermediate care service comprised of a ten bedded residential home called Milestone (MICU), was created, at pace, in response to increased pressure for Edinburgh’s hospitals to make effective use of beds during the pandemic. The Waverley Care staff who run Milestone , and their partners, have supported over 80 people experiencing homelessness or at risk of experiencing it, since the crisis began. It has enabled them to isolate, recover from acute interventions and access the multi-disciplinary support that will enhance recovery and enable a successful discharge to safe and appropriate accommodation.
The service has since established itself within the system of local care, support and housing and has a track record of achieving remarkable outcomes. Last year, EVOC was commissioned to write a business case to keep Milestone open and I was recruited to work on it. Many hours of interviews and meetings followed: time and input generously provided by Maria Arnold, EVOC Senior Development Officer, the Milestone steering group, and staff from Waverley Care, Edinburgh Access Practice, the Cyrenians, The Royal Infirmary, NHS Lothian Public Health and Harm Reduction Team and others.
Reflecting on my experience of the evaluation, four aspects stand out:
1. People using MICU experience the most extreme health inequalities and barriers to health intervention in our society.
GP John Budd was one of the first steering group members I spoke with. He had been instrumental in getting the service started. As a GP at Edinburgh Access Practice, a specialist surgery for patients experiencing homelessness, with a one stop shop of services including welfare rights workers, community health workers and addictions care, John talked me through an audit of his patients in 2018, who had similar profiles to those people who had stayed at Milestone. The statistics are shocking. The average age of death was 46.5 years for men and 41 years for women. Their health profile was comparable to that of a general population cohort in their 80s. Equally shocking was that many causes of death among people experiencing homelessness are reported to be from treatable conditions (Field et al, 2019).
Interviewing John and others instrumental in setting the service up, such as Claire Mackintosh, Consultant in the Royal Infirmary’s Infectious Diseases Unit, it was clear that individuals experiencing homelessness experience a range of barriers to receiving timely, effective healthcare intervention. They often need to negotiate numerous and complex referrals systems. While they may be seen by a number of different services, there may be duplication and unmet needs/gaps. They experience higher acute hospital admission rates than the most deprived cohort of the population (Waugh et al, 2018), with twice the Accident and Emergency attendance rates. They may also stay in hospital three times longer than the most deprived cohort, reflecting ongoing and unaddressed care and housing needs (Homeless Link, 2014). Shockingly again, one study found that 70% of people experiencing homelessness were being discharged from hospital back to the streets without having their housing or ongoing care needs properly addressed (St Mungo’s, 2017).
2. Specialist intermediate care units reduce secondary health care costs (and are likely to do the same for housing costs)
When step-down intermediate care services are introduced, they result in lower A&E visits, more effective planned discharges and reduce the average length of inpatient admissions. Between April 2020 and April 2021, 43 step-down referrals to MICU were patients from NHS Lothian acute sites who, without Milestone, would have stayed in hospital. This was a saving to NHS Lothian of 240 occupied acute hospital bed days, a total of £156,720.
Patients with experience of homelessness have 60% more outpatient appointments when compared to a most deprived cohort but are estimated to miss 28% of them. However, with ongoing contact with a hospital in-reach service, one large-scale study found that they attended twice as many appointments. This leads to engagement with, for example, follow-up endoscopies, procedures, and treatment such as surgery or cancer therapy (Field et al., 2019.)
Managing the transfer of care and planned discharge into sustained accommodation is also key, not just the exit from the acute sector (Cornes et al 2021). On admission to MICU, 50 out of the 80 people who have stayed there, had no fixed abode or were in temporary housing, while eight could not return to their tenancy. On planned discharge from MICU, 83% moved into sustainable accommodation. The MICU is therefore likely to provide significant savings to City of Edinburgh housing services associated with the reduction in temporary housing costs.
3. Barriers created by the NHS and other services may reinforce the trauma
Rachael Kenyon, at Cyrenians, manages the MICU hospital in-reach team at the Royal Infirmary. She and her colleagues make the initial contact with potential residents of Milestone while they are still in-patients there. They manage the patient’s referral and also support them throughout their time in the MICU and on into sustainable accommodation. Development of trusted relationships with people using the service is a vital element of facilitating successful engagement with a range of health and social care services. Rachael explained the adverse consequences of stigma in a clinical setting. Patients may be discharged rather than having their transfer delayed or pain medication may be withheld due to judgements about substance use. Changing the cultural attitude to patients both with an addiction to drugs and/or alcohol and who are experiencing homelessness or at risk of homelessness, is an explicit objective of the service. And Rachael and her colleagues’ roles include modelling trauma-informed practice to their colleagues in clinical settings.
4. Trauma-informed multi-disciplinary practice delivers successful outcomes
The staff I met during my time working with Milestone are committed to its work. They approached the evaluation from a desire to improve their own practice in order to further support the people they work with. Central to that is to acknowledge the barriers present in their own organisational cultures and processes and address them through multi-disciplinary working, training and other reform.
During the interviews with MICU partners, I gathered some remarkable lifechanging success stories of those who had been supported at Milestone. Some were the result of some very effective short-term interventions but, more often than not, they were the result of people knowing that, on discharge, they could return to Milestone if needed. That it was there for them longer-term. And, equally, they knew that if they did return, they would continue to receive consistent, trauma-informed support. The evidence compiled for the Milestone Intermediate Care unit business case has demonstrated that an overreliance on short-term performance indicators and viewing individuals as inputs and outputs to a system doesn’t work with this complex and marginalised group of people.
And this is confirmed by evidence elsewhere. For example, Cornes et al. (2021).
You can read the full evaluation on the impact of Milestone here