DD2360 Rough Sleeping and Mental Health Pilot

During 2017/18, 7,484 people were seen sleeping rough in London, more than double the number in 2010/11. Sixty per cent were new to the street, 47 per cent were non-UK nationals and 23 per cent were from Central and Eastern Europe (CEE). Around three quarters had one or more support needs (50 per cent mental health, 43 per cent alcohol, and 40 per cent drugs).

The Mayor funds and commissions a range of pan-London rough sleeping services and other initiatives to tackle rough sleeping. A budget of £33.8 million for these services was approved (through MD1532) for the period 1 April 2016 to 31 March 2020. The Mayor has since boosted this core budget, first, by earmarking £1.25m of GLA funding for a project to help rough sleepers with mental health support needs. This was allocated through the 2018-19 budget setting process and announced in February 2018. The Mayor also allocated an additional £7m to further support people off the streets (announced in February 2019).

In addition, working with his No Nights Sleeping Rough taskforce, the Mayor secured over £4.2m of Government funding in March 2017 for additional rough sleeping services and initiatives (see MD2083). Further funding has since been secured from the Government’s Rough Sleeping initiative (RSI) fund - £3.3m in 2018 (see MD2333) and £2.99m in 2019 (MD pending approval at the time of writing). Funding of at least £400,000 has also been secured from the Government to augment the mental health pilot referenced in this decision. It is proposed that this funding is combined with the £1.25m approved by the Mayor to create a budget of at least £1.65m for the pilot. Subject to the early performance of the pilot, Government has indicated that a further £700,000 may be made available, which would increase the budget to £2.35m.

Charitable organisations which provide homelessness services in London have consistently highlighted that they often cannot access mental health treatment and support for their clients. Similarly, many mental health trusts often report they do not have the resources to enable them to provide flexible, targeted services to rough sleepers, such as street-based assessment and interventions. In 2017/18, half of all people sleeping rough in London were recorded on the Combined Homelessness and Information Network database as having mental health support needs, making it the most prevalent support need among rough sleepers. However, outreach teams report that the support and treatment people need is often not available to them. This problem is particularly acute in those areas which do not have specialist mental health provision for rough sleepers; such services are currently available in a small number of London boroughs.

Mental health trusts and homeless outreach teams have identified a need for people sleeping rough to receive better access to assessment, support and treatment from statutory services in order to improve their mental wellbeing and help them leave the streets. Greater input from mental health practitioners would have huge benefits for people sleeping rough. There are already a small number of boroughs in London which have a dedicated homeless mental health team operated by the mental health trust. In these areas, rough sleepers with mental health issues are reported to have much better access to the services and support which they need, and partnership working between the homelessness and mental health sectors is much stronger.

The £1.25m of Mayoral funding plus the £400,000 of Government funding referred to above will be used to fund a two-year pilot (running to the end of June 2021) to assist people with mental health support needs who are sleeping rough. The pilot will operate in four Mental Health Trust areas covering sixteen London boroughs. The aim is that the Pilot will demonstrate the value of providing this type of support and lead to the NHS funding similar initiatives in the future. The MD approving the operational funding for the main phase of the pilot will be completed once final proposals for the local model in each area are received.

Providers of mental health and homelessness services in the areas in which the Pilot will operate have identified that a new approach is required to improve the support provided to rough sleepers with mental health issues. The service will therefore be co-designed by statutory mental health services, homeless outreach teams, London boroughs, people with lived experience of homelessness/mental health and other key stakeholders in each local area. This approach will enable development of a service which meets local needs and builds on existing assets.

The primary aim of the Pilot will be to improve the access which people with mental health issues who are experiencing rough sleeping have to statutory mental health services, through delivering additional specialised, personalised and flexible provision which specifically meets the needs of this group. Although the model in each area will vary depending on the locally developed proposals which consider the specific needs and assets in the area, the model in all areas will include mental health professionals (exact workforce mix will vary) specifically tasked with providing assessment, support and treatment to people sleeping rough, including working in partnership with local homelessness services and conducting this work on the streets and during the night as required.

The design and implementation stage of the Pilot is currently being undertaken by Imperial College Health Partners (ICHP) under its agreement with the GLA dated 12th February 2019 at a cost of £25,000 (the “Agreement”) (see ADD2327). The next stage of the Pilot is the development of an evaluation and monitoring framework, at a cost of £4,500, and the procurement of a Programme Coordinator, at a cost of £142,000. It is proposed that the Agreement be varied to include the development of the Monitoring and Evaluation framework for the same project. As set out above, the cost of this stage will be £4,500.

Given their current involvement in the project until this point, ICHP are best placed to undertake the creation of the monitoring and evaluation framework. The second stage of work is intrinsically linked to work already undertaken by ICHP. To that end, ICHP have already completed extensive data exploration and analysis work. In so doing, they have developed in-depth knowledge of the population the local initiatives will work with and the routine data metrics already collected. They have also built strong relationships with senior managers in the relevant mental health trusts and developed a strategic understanding of the evaluation through this, including the impact the programme will need to demonstrate to help ensure long-term funding sustainability. Furthermore, it has enabled them to already commence work with mental health trusts and other stakeholders about changes which could be made to their data collection to enable outcomes to be better monitored and evaluated. ICHP have extensive experience is developing such frameworks and dedicated data analysts and health economists who will work alongside the project manager on this, ensuring that a comprehensive range of knowledge and skills is allocated to the work.

Imperial College Health Partners were chosen to provide the project management of the design phase through a competitive tender process, in line with GLA’s Contracts and Funding Code. Their bid was scored as being of the highest quality and demonstrated the best value for money. Furthermore, the work, which ICHP has completed thus far, has exceeded the requirements established for this role. Therefore, the Rough Sleeping Team at the GLA is satisfied that varying the existing agreement to include the development of the Monitoring and Evaluation Framework represents value for money and will ensure that the framework meet the needs of the Pilot.

The framework will mean that the evaluation of the programme is well-designed, incorporating metrics which accurately measure the efficacy of the local initiatives and the impacts on the people supported. It will ensure that all the necessary data required is collected from the outset, guaranteeing that the final evaluation can truly demonstrate the outcomes of the programme. This will be essential in making the case to the NHS to continue funding the initiatives after the pilot.

Separately, a competitive procurement exercise will be run to find and commission an organisation or individual to coordinate the programme. The selected organisation will:

• Provide programme-level coordination and leadership, supporting the mental health and homelessness services to successfully deliver their local initiatives;
• Provide advice and guidance, and support the local organisations to overcome any challenges which are likely to arise in the service delivery;
• Facilitate the implementation of the overarching programme principles within the local models. This includes cross-sector learning between the mental health and homelessness services and the delivery of local innovation projects;
• Be responsible for establishing a Community of Practice to help share learning at programme level and ensure that the findings from the initiatives are strategically disseminated on an ongoing basis; monitor funding recipients, to ensure they are meeting agreed outputs and objectives, and, support them to identify improvements where required;
• Ensure that all data agreed in the evaluation framework is being consistently collected and aggregate this data at a programme level; and
• Conduct an interim evaluation of the programme at the mid-way point, to identify any developments which may need to be made in the second year and indicate whether any changes need to be made to the evaluation framework and the data collected ahead of the final evaluation.

Organisations and individuals known to possess the requisite knowledge and skills will be invited to submit bids and proposals for this role. The opportunity will also be listed through Contracts Finder and circulated through existing networks to expand the pool of potential bidders. The budget allocated for this is £142,000, which is based on one FTE Band 6 (NHS) level Programme Coordinator for two years, with an additional £15,000 allocated for completion and reporting of the interim evaluation, which will require significant additional time resource and data analysis expertise. Due to the expertise required and more operational element of this role, alongside the potential of organisations who have a variety of expertise in this field to draw upon, it is prudent to commission this work, rather than employ an officer at the GLA for this function.

The monitoring and evaluation framework will ensure that once the local initiatives commence delivery, all data needed to monitor performance and later conduct a robust evaluation of the programme which demonstrates its impact, is collected from the outset. The evaluation and monitoring framework and the interim evaluation completed by the programme coordinator will have the following outcomes:

• Local initiatives will deliver on agreed outcomes and objectives;
• Areas for improvement will be swiftly identified and remedied; and
• A robust evaluation will provide a strong evidence base for future funding for the local initiatives, and similar approaches in other areas, increasing their long-term sustainability.

The Programme Coordinator will ensure the programme successfully delivers on its aim of improving mental health provision for people sleeping rough in London and creates a strong evidence base, thus increasing the long-term sustainability of this work. Through improving access to statutory mental health services and collaboration between the mental health and rough sleeping sectors, the programme will have the following outcomes in the areas in which it works:

• Ill-health does not contribute to rough sleeping;
• Rough sleeping does not prevent people from accessing health services of equal quality to others, and the impact of rough sleeping on health is minimized; and
• Ill-health does not prevent people moving off the streets or sustaining a settled lifestyle.

The local initiatives included in the pilot programme will be delivered in four mental health trust areas, covering a total of 16 boroughs. It is envisaged that the programme will have the following annual impact across London:

• Engage and complete work around mental health with 700 people
• 350 people leave rough sleeping;
• 450 people engaged with a community mental health service for the first time; and
• 300 people connected with primary care services.

Under section 149 of the Equality Act 2010, as public authorities, the Mayor and GLA are subject to a public sector equality duty and must have ‘due regard’ to the need to (i) eliminate unlawful discrimination, harassment and victimisation; (ii) advance equality of opportunity between people who share a relevant protected characteristic and those who do not; and (iii) foster good relations between people who share a relevant protected characteristic and those who do not. Relevant protected characteristics under section 149 of the Equality Act are age, disability, gender re-assignment, pregnancy and maternity, race, religion or belief, sex, and sexual orientation.

Of those seen rough sleeping in 2017/18:

• 46 per cent were non-UK nationals;
• 50 per cent had a mental health need;
• 15 per cent were women;
• most of those seen rough sleeping (56 per cent) were in the 26-45 age group;
• eight per cent were under 26 years old;
• 11 per cent were over 55; and
• eleven people were under 18.

As rough sleepers are over-represented among those with the protected characteristics of race and disability, the proposals in this paper are likely to have positive impacts on these groups. Given that this project is focused on improving mental health support for those on the streets it will have a positive impact on this group.

Key risks and issues

Links to Mayoral strategies and priorities

1. The objectives of the proposals are in line with the pan-London Rough Sleeping Commissioning Framework priority 8 and priority 9, as well as the Mayor’s London Housing Strategy which includes a commitment to ‘fund and commission a range of pan-London services and other initiatives. These will focus on identifying rough sleepers and intervening rapidly to support them off the streets, providing specialist support for particular groups, and helping rough sleepers stay off the streets.’

1. The objectives of the proposals are also in line with key aim 2 in the Mayor’s London Health Inequalities Strategy that ‘All Londoners to share in a city with the best mental health in the world’, so that there ‘is an end to the stigma people face due to mental health problems.’

1. The project is also in line with the Mayor’s priorities, outlined in Chapter 4 of his Rough Sleeping Plan of Action (“The support people need to rebuild their lives”)

Impact assessments and consultations

1. The pan-Rough Sleeping Commissioning Framework was made available for consultation with key stakeholders and partners and was subject to a full equalities impact assessment. The London Housing Strategy has been subject to a full-integrated impact assessment and statutory consultation with the public was recently undertaken. The Mayor’s Rough Sleeping Plan of Action was based on a robust data and feedback gathering exercise from a wide range of sources and parties.

This decision requests approval for revenue expenditure of £146,500:

a) £4,500 to fund ICHP to develop an evaluation and monitoring framework
b) £142,000 for the procurement of a Programme Coordinator (£63.500 per year for two years – NHS staff) and Evaluator (£15,000).

The above expenditure will be funded from within the £400,000 receipts from the Ministry for Housing, Communities and Local Government (MHCLG) and £1.25m funding allocated to this initiative by the Mayor. The breakdown of expenditure by year is as follows:

• 2019/20: £68,000 (MHCLG funding)
• 2020/21: £78,500 (Mayoral allocation).

The foregoing sections of this report indicate that the decisions requested of the director fall within the statutory powers of the Authority to promote and/or to do anything which is facilitative of or conducive or incidental to social development within Greater London and in formulating the proposals in respect of which a decision is sought officers have complied with the Authority’s related statutory duties to:

(a) pay due regard to the principle that there should be equality of opportunity for all people;
(b) consider how the proposals will promote the improvement of health of persons, health inequalities between persons and to contribute towards the achievement of sustainable development in the United Kingdom; and
(c) consult with appropriate bodies.

In taking the decisions requested of him, the director must have due regard to the Public Sector Equality Duty; namely the need to eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Equality Act 2010, and to advance equality of opportunity between persons who share a relevant protected characteristic (race, disability, gender, age, sexual orientation, religion or belief, pregnancy and maternity and gender reassignment) and persons who do not share it and foster good relations between persons who share a relevant protected characteristic and persons who do not share it (section 149 of the Equality Act 2010). To this end, the director should have particular regard to section 4 (above) of this report.

As set out in paragraph 1.9 above, the officers propose to vary the Authority’s existing agreement with the ICHP dated 12 February 2019, which relates to the Mental Health Pilot (the “Contract”). Furthermore, the proposed £4,500 worth of services relate directly to the said pilot. Section 10.1 of the Authority’s Contracts and Funding Code allows for an exemption from the requirement to run a competitive procurement in circumstances where the existing work cannot be separated from the new work. As the officers have noted, the proposed services cannot be easily separated from the previous work, which the ICHP has undertaken. Moreover, ICHP was appointed to perform the Contract following a competitive tender. In light of the above, the executive director may approve the exemption, if he be so minded.

The officers are reminded that a written variation must be put in place between the Authority and the ICHP, before ICHP proceed with the additional services.

As set out in paragraph 2 above, the officers propose to carry out a competitive tender in order to procure a project coordinator and evaluator for the Mental Health Pilot. The officers are reminded to ensure that a written agreement be put in place between the Authority and the ultimate service provider prior to the commencement of the services.

The Rough Sleeping team will maintain oversight of this Pilot and this position through regular contract monitoring.

The logic model and evaluation framework will require 12 to 14 weeks’ work, to commence 13 May 2019 and be completed in August 2019.