Multi-agency partnerships and the transformation of domestic abuse support

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Domestic abuse has been rising up the political agenda in the past few years. 2019 saw the appointment of the UK’s first Domestic Abuse Commissioner, and last month, the updated Domestic Abuse Bill was introduced to the UK Parliament (expecting to see Royal Assent in April 2021). But domestic abuse is still a widespread and endemic problem across the UK, with figures suggesting incidents across all areas of the country and across multiple demographic groups.

Often people who experience domestic abuse are difficult to identify and can struggle to engage directly with domestic violence support services. However, there is a growing recognition that knowledge sharing, and partnership working between statutory services, like housing or health teams, is vital to identifying and supporting victims and survivors in a timely and effective way.

Increasingly, the criminal justice system, health sector, social housing providers, charities, and local government have been attempting to work together to ensure that they are all able to respond effectively and provide the necessary support to domestic abuse victims and survivors.

The impact of lockdown

The most recent Crime Survey for England and Wales released by the Office for National Statistics (ONS) showed that an estimated 2.3 million adults aged 16 to 74 years experienced domestic abuse in the last year (1.6 million women and 757,000 men). Research published by the London School of Economics (LSE) after the first lockdown found that in London domestic abuse calls to the police increased by 11.4% on average, compared with the same weeks in 2019. The increase was, in a large part, due to an increase in calls from third parties not directly witnessing the incident, including neighbours or family members.

Similarly a report from Women’s Aid found that those delivering services needed to grapple not only with increased demand for support, but also with the challenge of delivering effective support in a different way as many services were only able to be accessed virtually.

Coordinated community responses transforming support for survivors

Organisations are becoming increasingly aware of the roles they can play in supporting people who experience domestic abuse and in the early identification of people at risk. Research also suggests that if someone is experiencing abuse, there is a high likelihood that they will also be experiencing other “needs”, which may cause them to come into contact with multiple services at once. Co-ordinating the response between services encourages organisations to share information to ensure consistency of care and experience; it can also help identify any gaps in support and allow for appropriate signposting and places the onus on the organisations, rather than on the person experiencing abuse.

Coordinated community response (CCR) approaches encompass the broadest possible response to domestic abuse; CCR addresses prevention, early intervention, dealing with crisis, risk fluctuation, and long-term recovery and safety, working with a wide range of services, pathways, agencies, and systems.

The fundamental premise of the CCR is that no single agency or individual can see the complete picture of the life of a family or individual within that family, but all may have insights and can provide interventions that are crucial to their safety and wellbeing. The CCR enables a whole system response to the whole person. It shifts responsibility for safety away from individual survivors to the community and services existing to support them.

The CCR is made up of 12 components: survivor voice; intersectionality; shared objective; structure and governance; strategy and leadership; specialist services; representation; resources; co-ordination; training; data; policies and processes. Taking a CCR approach provides communities with method for coordinating a response to domestic abuse. It places survivors at the heart of decision making and is an approach many frontline services can and do take when designing and implementing support services for people who have experienced domestic abuse.

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A pilot roll out for wrap around housing support

The Whole Housing Approach (WHA) to domestic abuse was first conceptualised in 2018 by the Domestic Abuse Housing Alliance (DAHA) in collaboration with the National Housing and Domestic Abuse Policy and Practice Group This approach aims: “to improve the housing options and outcomes for people experiencing domestic abuse so that they can achieve stable housing, live safely and overcome their experiences of abuse.”

The approach enhances how people who have experienced domestic abuse have control over their own lives, considers what they want to achieve and change, and offers interventions based on this. The key principles of the WHA are outlined as: safety; inclusivity; empowerment; accountability; and prevention, with 12 additional key components which make up the practical application of WHA programmes.

The initial WHA pilot project was delivered in three areas from October 2018 to the end of March 2020. Six specialist domestic abuse organisations, as well as a civil society organisation, have been working with 10 local authority areas, including in London, Stockton and Cambridgeshire to establish comprehensive and consistent housing practices and deliver a WHA.

A whole housing approach toolkit has been published which contains more information on the pilots, evaluations and analysis of the programme. The toolkit includes a dedicated section for each of the twelve components of the WHA. Each section can be read as a standalone toolkit that outlines key initiatives to help survivors achieve safety and stable housing. It offers practical guidance and resources to local areas to deliver a consistent WHA to domestic abuse.

Image Via DAHA

Final thoughts

While the landscape of domestic violence support is varied and is delivered in different ways by different agencies, there is a growing understanding of the practical steps which should be taken to ensure that partnership working and effective coordinated responses between services are offered to survivors of domestic abuse. It is clear that there is an appetite among those who work within frontline services to improve the availability of support. The ultimate aim of a coordinated response and a wraparound service to survivors of domestic abuse is achievable if current best practice and effective pilot schemes can be built upon, with additional funding and wider roll outs.


If you enjoyed this article you might like to read:

Domestic violence during quarantine: the hidden crime of lockdown

Safeguarding in social isolation: how social care teams are adapting to the new normal

A home for life? Developing lifetime neighbourhoods to support ageing well in place

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Devolving health and social care in England: an opportunity to transform how we approach health and care?

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In recent years, the Department of Health and Social Care (DHSC) has increasingly encouraged the transfer of powers over health and social care in England away from central government and towards city regions. These bodies, DHSC argues, are uniquely placed to understand the challenges faced by their local populations, the capacities and expertise of their local NHS and to develop plans for the future. This should enable them to approach health at a local level, promoting increased delivery of care in the community, and a greater integration between health and care services.

Putting local places at the centre of “Build back better”

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, like taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

The NHS Long Term Plan has also outlined a new direction for the NHS based on the principle of collaboration rather than competition, and the introduction of new structures such as Integrated Care Systems, Integrated Care Providers and Primary Care Networks. These partnerships bring health and social care commissioners together to plan and deliver integrated and person-centred care.

In the context of “building back better”, awareness of how our external experiences and contexts impact our health and wellbeing (for example the impact of poverty, deprivation, housing, and unemployment) is increasingly important.

Beyond the immediate recovery from the pandemic, health devolution could be one way of opening up the possibility of integrating not just disparate services within the NHS – or even NHS and social care services in a locality – but bringing together in a combined strategy and structure all of the services, systems and partners in a community that have an impact upon the health of a local population, and the care services to better meet their health needs.

“It doesn’t have to be a battle”- partnerships and balance are the key to effective devolution

The move away from centralised processes and organisations towards more local ones can sometimes be portrayed as a rejection or an attempt to “break free” from central government. However, practitioners have been increasingly stressing that devolution does not mean complete independence, and that while improved local decision making will improve outcomes for local people, that does not mean that the need for some centralised decision making is completely removed.

On the contrary, some decisions should and will be taken at a national level, but the ability to distribute power, decision making and accountability to a local level will have significant positive impacts for improving “citizen voice”, transparency and co-production in decision making.

This is where the Health Devolution Commission argues that balance, communication, and partnership between the local and national infrastructure needs to be aligned so that devolution can be successful and sustainable. Integrated planning and management of long-term health care strategies is important, as is the ability to bring citizens and local decision makers into discussions about national health policy.

The Voluntary, Community and Social Enterprise (VCSE) sector, including patient voice and carers organisations, also plays an important role in linking together services and communities. As well as partnering to deliver services, these organisations also often offer vital bridges between statutory systems and those communities which can often be excluded from engagement with services or who can find it harder to access them. The commission also emphasised the importance of bringing these bodies into the conversation on devolution going forwards as they will be invaluable partners in the process.

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DevoManc providing the blueprint?

In 2016, as part of a pilot, control of the health and social care budget for Greater Manchester was transferred to a partnership team in the area comprising local authorities, clinical commissioning groups, NHS foundation trusts and NHS England.

The combined authority identified that the health of its population was one of the key obstacles to its economic growth. By relating the concept of regional economic prosperity with health, they began to see health in a completely different way – as part of a wider plan and an investment for growth, not a burden.

“It’s better to have decisions made locally, because local people understand what local problems are and what Greater Manchester needs. We need to work together.”

Lord Peter Smith, Chair of Greater Manchester Health and Care Board

The Greater Manchester Health and Social Care Partnership are working in partnership with other sectors including education and housing to support everything from good eating habits and exercise to education and everyone’s ability to earn a decent living. The partnership is taking action to give children the start they need, support independence in old age, tackle illness earlier on and even prevent it altogether by improving the lifestyles of local people.

Other areas of England are also currently undertaking their own health devolution journeys, including London, West Yorkshire and Harrogate, as well as some other combined authority areas. However, one of the big challenges is that currently, while we can learn from the experiences of those already on their devolution journey, there is no common, consistent or comprehensive understanding of what good heath devolution looks like, full evaluations of the benefits it brings or overarching strategies on how it should be developed.

This is something that will need to be addressed if health devolution is to be successfully rolled out across England.

Final thoughts

Devolution of health to a more local level provides an opportunity to tackle the big public health challenges of our time at source, and to create a better, more joined up community health ecosystem. It also provides the chance to share and collaborate, learning from best practice and delivering improved health and social care services at a regional and national level.

It has been suggested that the coronavirus pandemic, while traumatic in more ways than one for the NHS and its staff, may provide the re-setting point needed to implement some of the changes proposed in relation to greater health devolution. Proponents of this view argue that improved funding to support effective and high quality care, improved integration between health and social care, and greater positioning of health and assessment of the impact of decisions on health across all policy areas, should be among the top priorities as the country looks to recover from the pandemic.

As the Health Devolution Commission underlines:

The pandemic has shown we cannot go back to the way things were. We need a ‘new normal’ and we believe that comprehensive health devolution is the only viable solution to the challenges the country now faces.”


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Healthy ageing: how health inequality can be tackled at the local level

Image: Peter Kindersley via Centre for Ageing Better

Older people make up a significant portion of our population, and projections show the proportion of people over the age of 60 within the global population is set to rise even further over the coming years. ONS data shows by 2066 there will be a further 8.6 million projected UK residents aged 65 years and over, taking the total number in this group to 20.4 million and making up 26% of the total population.

Supporting people to age well, and age healthily is something which both local and national policymakers will have to take account of in order to not only ensure good quality of life for their ageing populations but also ensure that services are not overwhelmed.

Studies show the higher levels of deprivation people face in their earlier years, the more likely they are to enter older age in poor health and die younger compared with people who experience lower levels of deprivation. This highlights the need to tackle inequality across the life course, with the preventative action having a positive knock on impact on health inequalities in later life.

Some of the main drivers of inequalities include: social exclusion and isolation; access to and awareness of health and other community services; financial difficulties including fuel poverty and housing issues; insecure or low paid employment, with reduced opportunity to save or enrol in a formal pension to prepare for retirement; a lack of transport and distance from services; low levels of physical activity; and mobility or existing poor health, often characterised by long term chronic health issues.

These inequalities often combine and overlap to create even more challenging situations as people move into older life. More recent research has shown that the Covid-19 pandemic has only exacerbated these inequalities further.

Tackling inequalities at the local level

Alongside the national discussions around ageing, local demographic change has received comparatively less attention, despite place-based policies and concepts like “ageing well in place” being used in public health conversations for a number of years.

Research from the Resolution Foundation explores the intersection between demography and place, and its implications for politics and policy while further research is looking increasingly at local level case studies to highlight pockets of best practice which could help to inform the national approach.

A review from Public Health England looked at the specific experiences of older people in coastal and rural areas and the specific challenges they face in comparison to people living urban areas, exploring local level interventions and interventions which adopt a place- based approach, responding to the specific needs of people living in the area.

Other research in this area stresses that councils have a clear leadership role in supporting an ageing society and that they are uniquely placed to create strategies which reflect the needs of their populations. Through local engagement of older people systematically and regularly, and through co-production and co-design in the production of local policies and services, councils are in a position to underpin a more positive outlook on ageing, ensuring that older people are regarded as full citizens, rather than objects of charity or pity.

Approaches to poverty reduction in Greater Manchester

In Greater Manchester, healthy ageing and age inequalities have been made mayoral priorities and the Greater Manchester Combined Authority set up the Greater Manchester Ageing Hub to respond to what policymakers there see as the opportunities and challenges of an ageing population.

In 2018 the city published an “Age Friendly Strategy” to promote increased social inclusion within the city by trying to tackle the barriers to inclusion created by poverty and inequality, including creating age friendly places which allow older people to participate within their local communities, and promoting healthy ageing through strategies like GM Active Ageing, a partnership with Sport England.

Image: Peter Kindersley via Centre for Ageing Better

Creating a consensus on healthy ageing

The Centre for Ageing Better and Public Health England established 5 principles for healthy ageing which they are urging government and other policy actors to adopt to support future healthy ageing the five principles are:

  1. Prevention
  2. Opportunities
  3. Good homes and neighbourhoods
  4. Narrowing inequalities
  5. Tackling ageism

These principles can be used as building blocks to help organisations create strategies and policies which accurately reflect the core needs of people as they age. One thing which continues to be a challenge, however, is integrating intersectionality into both research and strategies or frameworks on ageing.

Not treating “older people” as one homogenous group, but taking account of the individual experiences of specific groups and how this may impact on their experience of inequalities: this is something researchers are making efforts to resolve in their work, and while there are limited studies which look specifically at BAME or LGBT groups, in the future taking account of intersectionality in ageing and inequalities will become more commonplace.

The future of ageing

We are living longer than ever before. Taking steps to reduce inequalities and support healthy ageing will ensure that those extra years are fulfilling, both for the individual and for society.

Helping people to continue to contribute to society, to really live into old age, embrace and enjoy it and not just exist in old age should be a priority for everyone, Reducing inequalities to support people to age well will be a major contributor to ensuring this happens.


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A home for life? Developing lifetime neighbourhoods to support ageing well in place

“Same storm, different boats”: addressing covid-19 inequalities and the ‘long term challenge’

Inclusive streets: from low expectations to big dreams

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Why are we still talking about healthy places?

In recent years, there has been a wide ranging debate across the housing, planning, health and infrastructure sectors about the development of healthy places in both regeneration and newly approved projects.

In 2016, Town and Country Planning Journal published an article on building health and wellbeing into the built environment (Town and Country Planning, Vol 85 No 11 Nov 2016, Knowledge Exchange customers can login to view the article here) In 2017 and 2018 the talk was all about healthy towns initiatives, and a Design Council report in 2018 looked at the relationship between healthy placemaking and the impact on our communities. In 2019 the Town & Country Planning Association (TCPA) called on members to “reunite” health and planning

It is clear that everyone involved in placemaking agrees building places that promote health and wellbeing for all is of vital importance to our communities, The Covid-19 pandemic brought this into sharp focus, and the idea remains at the forefront of design policy, particularly in urban city contexts. But, over four years after the initial conversations and thought pieces, why are we still talking about it, and what actions still need to be taken to integrate the idea of a healthy place into planning to the extent that it just becomes the norm in the planning and design of our places?

Preventing avoidable disease

The phrase ‘healthy placemaking’ has been defined by Design Council as: “Tackling preventable disease by shaping the built environment so that healthy activities and experiences are integral to people’s everyday lives”.

Public Health England defined healthy placemaking as: “Placemaking that takes into consideration neighbourhood design (such as increasing walking and cycling), improved quality of housing, access to healthier food, conservation of, and access to natural and sustainable environments, and improved transport and connectivity”

Research has shown preventable diseases linked to lifestyle and environment are among the most significant threats to public health. Lifestyle-related conditions like heart disease and cancer, as well as being health problems in their own right, can also contribute to the development of other chronic conditions, exacerbate symptoms and create complications with care which are costly to the NHS.

Creating healthy spaces is not just about encouraging people to live more active lifestyles by facilitating active travel and improving the environment around buildings, although this is a significant part of it. “Healthy places” include approaches to improve air quality, reduce loneliness, allow people to age well in place, promote mental as well as physical wellbeing, reduce deprivation and inequality through projects like housing, infrastructure development, and high street regeneration.

Healthy places also have a preventative role to play in public health management, not just a health improvement role; such interventions are essential to help avert the onset of disease, improve people’s quality of life and reduce health inequalities. And evidence shows the return on investment from public health interventions is high and creates value of different kinds – economic, social and personal.

In short people who live in healthy places, tend to live healthier lives, place less strain on services and “contribute” more to society, both economically through work or spending and socially through community engagement.

Victoria Park, Belfast. Image: Fiona Ann Paterson

Enabling planning practitioners to think about creating healthy places

Research published in 2020 by the Royal Town Planning Institute (RTPI) explored local, national and international planning practices that enable the creation and delivery of healthy places. While a lot of research draws attention to the barriers to building healthy places – including a lack of funding, different requirements from developers and conflicting policy priorities – the RTPI report instead sought to identify important challenges faced by planners who try to integrate healthy placemaking principles in their decisions and then offer potential solutions to these in practice. Key themes emerging from the report include a need to improve collaboration, knowledge sharing and the skills of planners.

The report provides case studies looking at: the place standard tool; the livewell development accreditation; connecting communities in Tower Hamlets; health planning in South Worcestershire; and train station district rejuvenation in Grasse, France. It also identifies seven steps to plan for healthier environments

Across the sector there have been calls for planners to be allowed to be innovative, creative and take a “visionary” approach to planning to help make places healthier in order to address the convergence of challenges around public health, the climate emergency, and economic recovery from Covid-19.

How has the coronavirus pandemic changed how we think about healthy spaces?

The lockdowns  imposed as a result of the coronavirus pandemic have thrown the importance of quality space into sharp focus. Places that facilitate health and wellbeing among the people who live there, and places where the indoor living quality is as important as the outdoor space have become incredibly important.

The pandemic has highlighted what it really means to have a healthy space. It has also demonstrated how wider socioeconomic deprivation and inequality – linked to living conditions as well as other factors – is having an impact on infection and hospital admission rates, with those groups who live in more deprived areas being found to be at a higher risk of becoming seriously ill or being admitted to hospital with Covid-19. 

The 2018 Design council report found in its survey of practitioners that focus was given far more to outdoor space than to indoors, as it was easier and more cost effective to make changes that could produce demonstrable impacts (an increase in cycling, for example). But the pandemic and the increased time we have been forced to spend indoors has encouraged designers and urban planners to think even more creatively about quality space in their developments.

Where now?

Public Health England (PHE) which for many years was a strong voice in the conversations around healthy placemaking has been disbanded and will be replaced by a National Institute of Health Protection. It remains to be seen how, or if this new organisation will fit into the conversation going forward. But reflecting on recent reports on the significant public health crisis facing the UK in the long term, it is clear that the work must continue, driven collectively by those in planning, urban design and public health.


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Virtual reality: a game changer for mental health treatment?

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Demand for mental health treatment in the UK far outstrips supply. And the outbreak of COVID-19 has forced many primary care services to think creatively not only about demand and supply, which has increased further during the pandemic, but also about delivery. GPs and community mental health teams in particular are thinking about more innovative ways to deliver remote support to people with mental health conditions, including the use of Telehealth and virtual reality (VR) platforms.

People are probably most familiar with VR in a digital gaming context, with devices like Oculus headsets offering immersive gaming experiences where players can place themselves “in the game”, but it has been suggested that integrating VR, alongside other telehealth options like apps and videoconferencing into mental health consultation and treatment could make counselling and alternative treatment options more accessible to those living and working remotely. Early research suggests that while discussions about investigating the benefits of this type of delivery of care have been accelerated by the coronavirus pandemic, researchers and practitioners were already beginning to explore how VR and Telehealth could be a tool that could be utilised more regularly in the treatment and engagement of people with mental health conditions, not just during periods where face to face contact is a challenge.

Blended treatments to help improve outcomes

Telehealth encompasses a number of different approaches and techniques, including using platforms like skype for mobile conferencing, or mobile apps to help people manage conditions and to help deliver some treatment options. It has previously been used in other areas of medicine, for example to help those with chronic conditions self-manage, with various levels of success and uptake.

One foundation embracing remote mental health support, even before the arrival of coronavirus, is Greater Manchester mental health foundation trust who use a mobile app called ClinTouch, to support people recovering from psychosis, schizophrenia and bipolar disorder. Although patients will typically see a care co-ordinator monthly, symptoms of a relapse can appear within days; with the app, users are asked how they feel a few times a day, and an alert is generated if a relapse looks likely.  Some NHS organisations have also adopted telepsychiatry – videoconferencing therapy sessions. 

Using VR for remote therapy almost takes telehealth a step further, and involves using a complete virtual environment, with the potential for this to be integrated into treatment plans, so clinicians can, for example, create a setting which looks like the inside of their office, or use virtual environments to model external scenarios that may cause anxiety to help patients practice coping techniques like breathing exercises.

One of the potential extended uses for VR and telehealth in a clinical mental health treatment setting which has emerged is its application for rural populations, or for people who are isolating because of exposure to coronavirus. However, this has raised some additional questions about the potential barriers to uptake exacerbated by digital illiteracy and poor access to digital devices, as well as the problem of poor or slow internet connections, something which will need to be considered by health boards if they decide to offer these treatment options.

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More research is needed, and is being done

While recent research has shown face-to-face therapy remains the optimal treatment method in mental health care, VR-based therapy has been found to be more effective than Skype-based or phone only counselling. The research also suggests VR-based Telehealth sessions could improve engagement, compared to phone only sessions and greatly reduce dropout rates for clients which in turn can support positive clinical outcomes. It appears the general consensus is that self-service, VR and automated technology, in the form of apps and notifications could support and augment healthcare professionals and help support the delivery of more traditional approaches.

The virtual reality lab at the NIHR-Wellcome Trust-King’s Clinical Research facility aims to improve the understanding of the mechanisms that play a role in the onset and maintenance of mental health problems. They use virtual reality environments to assess and develop treatments to improve the well-being of people with mental health problems.

Research is also being done on the specific reaction to young people of engaging with digitally driven treatment options. There are some suggestions that the delivery of digital interventions to support young people with mental health problems may help them to engage more, in part because they are more familiar with digital platforms and may feel more comfortable using them day-to-day, however there is also a suggestion that young people also prefer the feeling of “distance” and “impersonality” that a digital platform provides which can lead to some feeling more able to express how they are really feeling, compared to a face to face meeting with a clinician which can sometimes be a stressful and intimidating experience.

Where next?

So far in clinical psychology and psychiatry, the primary focus of VR has been its role in treating anxiety and stress-related disordersspecific phobiaspanic disorder, and post-traumatic stress disorder. However the disruption to face to face mental health treatments caused by the coronavirus pandemic has led to clinicians thinking even more creatively about the applications of VR and telehealth options to help support the treatment of people with a wider range of mental health conditions.

While it is clear that virtual treatments should not replace the face to face consultation in mental health treatment entirely, research suggests there is a growing role for VR and Telehealth options in augmenting face to face treatment options and that they could be offered as an option for those who are unable to attend face to face sessions. Telehealth and remote treatments are something which will continue to be explored beyond the coronavirus pandemic and could soon be integrated into practice as part of the standard delivery of mental health care and treatment.


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The Covid-19 knock-on: public health and the impact of delays in non-urgent treatment and diagnosis

Since the beginning of the pandemic, concerns have been raised about the wider public health impacts of coronavirus. In addition to strains on acute NHS care services on the frontline, there are warnings about the additional public health impacts of delays to preventative healthcare measures like screening and routine medical care in the form of pre-planned operations for long-term chronic and non-urgent conditions.

At the outbreak of the pandemic many hospitals took the decision to delay or stop entirely routine pre-planned surgeries and preventative screening and diagnostics. Some even suspended treatment for more urgent care like cancer treatment on a short term basis. While many of these services have resumed since the beginning of the pandemic, albeit with a backlog of patients now to be seen, significant strain on the NHS as we come into the winter months because of  coronavirus is still anticipated. As a result, many hospitals are not working at full capacity in order to prepare for potential increases in admissions due to coronavirus or staff shortages over the winter.

In many areas this has led to a backlog of care, both for those patients already in the system awaiting routine surgeries, as well as those who are yet to be diagnosed but would have been through preventative screening programmes run by the NHS.

Delays in healthcare and routine screening programmes 

Even before the coronavirus pandemic took hold, many NHS hospital trusts were under criticism because of the significant length of waiting times for people who required routine operations, which in some parts of the UK can be as long as three years. Doctors across the UK are now warning that these delays could be increased further unless the NHS receives additional support to increase capacity across all areas of care  not just urgent care in the coming months.

Data released by NHS England in October 2020 showed the numbers waiting over a year for hospital treatment have hit a 12-year high, with almost 2 million patients waiting more than the target time of 18 weeks for routine care.

It has been suggested that delays in diagnosis and routine treatments could lead to an increased number of hospitalisations further down the line, requiring higher levels of care, longer lengths of stay, and increased hospital readmissions.

A reluctance to visit hospitals and use primary care services

Government messages to ‘protect the NHS’ may have had the unintended consequence of discouraging people from seeking urgent medical care when it was required for fear of using services unnecessarily or for fear of contracting the virus when attending hospital or primary care settings.

Research from the Health Foundation found that there had been a significant reduction in the number of GP consultations since the start of the pandemic which has led to concerns about the care of non-covid patients, patients with long term health conditions and also the potential for delayed diagnosis. Primary care consultations also reduced and have remained low consistently since the beginning of lockdown.

Figures have also shown a reduction in the number of referrals, medical tests, new prescriptions and immunisations. While some of these reductions are the result of advice to delay routine referrals to free up capacity for hospitals to deal with the potentially large number of cases of Covid-19, routine referrals have still not recovered to pre-lockdown levels.

 

A potential future crisis for the NHS and a ticking time bomb for public health

Doctors are now warning that the treatment backlog which has been caused by the coronavirus pandemic, in addition to diagnostic delays and screening programmes, may lead to a future crisis of care or significant delays in care for people waiting to receive more routine treatment.

Delays in care have not only been reported in cases of physical health. There have also been significant delays in referrals for those seeking treatment for a mental health condition, an area of the NHS which was already facing significant delays in referral and transfer of care even before the pandemic. Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this. People with mental health conditions may have been unable to access appropriate support through primary care pathways, which could potentially impact on their long term health and care.

Finally, concerns have been raised about the wider social determinants of health such as employment and poverty. Public Health England (PHE) published a monitoring tool which looks at the wider impacts of the Covid-19 pandemic on population health, and it is likely that the knock-on impact of the virus could have far reaching consequences for public health in the future as the health implications of lockdown, lack of social interaction and rising unemployment could be significant. 

Where next?

While the challenges of the coronavirus pandemic for the NHS will not be going away anytime soon, it is clear that it will be necessary for the NHS and other supporting services to act now to prevent a longer term public health crisis. It is critical that we not only focus on the acute care of Covid-19 patients, but also proactively manage patients without Covid-19, particularly those with time-sensitive, complex and long term conditions who are postponing their care. We must also consider the knock-on impacts of delayed diagnosis for those people who missed out on routine screening or who were unable or too afraid to visit their GP or hospital. This is important not only to sustain health and life, but to preserve hospital and NHS capacity in the future.


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Domestic violence during quarantine: the hidden crime of lockdown

Domestic violence is often described as a “hidden epidemic” within the UK. Even before Coronavirus forced the country into lockdown, support services faced funding and resourcing challenges, and many people fleeing domestic abuse already faced barriers to accessing support,  but as social distancing has become the dominant policy response to suppress Covid-19, it is clear there have been unintended consequences for domestic abuse victims which have exacerbated the challenges in providing and accessing support.

An increase in reporting of domestic violence

Figures show that calls to domestic abuse services have increased significantly worldwide during the Coronavirus pandemic. Calls and online enquiries to the UK’s National Domestic Abuse line increased by 25% after the UK entered lockdown in March 2020. More than 40,000 calls and contacts were made to the National Domestic Abuse Helpline during the first three months of lockdown; in June, calls and contacts were nearly 80% higher than usual, according to the charity Refuge, who runs the service.

An investigation by the BBC’s Panorama found that three-quarters of victims told them that lockdown had made it harder for them to escape their abusers and in many cases had intensified the abuse they received and research by a team at LSE showed that while the overall level of domestic abuse crimes (not calls) have remained stable when compared with the long-term trend, calls to the Metropolitan Police between March and July which related to reports of domestic abuse increased by 11% compared with the same period in 2019.

This same research from LSE also noted some changes in the characteristics of the cases being reported, with calls more likely to be made by “third parties”, such as neighbours, and that while abuse by ex-partners fell by 9.4%, abuse by current partners and family members increased significantly – by 8.5% and 16.4% respectively.

In early May, the government announced a £76m package to support the “most vulnerable in our society”, including victims of domestic violence and modern slavery, rough sleepers and vulnerable children. However, with many charities which support victims of domestic abuse struggling with the financial fallout from the COVID-19 pandemic and facing a significant rise in demand for their services, concerns are being raised that the availability of specialist support could be reduced, meaning people exposed to domestic abuse may not be able to access the help they need.

Local level support for vulnerable people fleeing violence

Lockdown offered an opportunity for local authorities to think about the support offered to vulnerable people, including those who were homeless due to fleeing violence.

In Greater Manchester GMCA formed partnerships early on to secure accommodation for women fleeing violence to ensure they would have a safe space. The accommodation was intended for women who are homeless or facing homelessness, including rough sleeping or in shared supported accommodation where the service was unable to meet public health guidelines regarding Covid-19. This included women experiencing domestic abuse, trauma, or contact with the justice system as well as other multiple disadvantages. The service delivery model was designed to be a Trauma Responsive Service Model in order to create a safe and secure environment for each resident and to avoid further traumatisation. The process marked a departure from how cases of female homelessness due to domestic abuse would typically have been handled pre lockdown.

Halls of residence at the University of Cambridge were also offered to homeless women and their children after students vacated them early due to the pandemic. St Catherine’s College formed a partnership with Cambridge Women’s Aid to provide over 1000 nights of secure supported accommodation during the lockdown period.

In both instances the partnerships allowed for practical and quick solutions to provide support to vulnerable women, filling the support gap some traditional routes like refuge shelters were unable to fill because Covid 19- restrictions on the mixing of households meant that homeless and refuge centres were operating with a limited capacity.

Final thoughts

People fleeing domestic violence already faced significant barriers to finding the safety offered by refuge services, even before the lockdown imposed by the Coronavirus pandemic. But we know now that the pandemic has made it harder for survivors to leave an abuser or to seek help, that their experiences of abuse were made worse by the conditions imposed by lockdown and that the circumstances gave abusers more control than ever. When the pandemic is over the majority of local services expect to see a spike in people looking to access their life-saving support, but at the same time the pandemic has threatened the sustainability of the network of services which makes up this support, many of whom were already experiencing a funding struggle.

The work being done to help support vulnerable people fleeing abuse and people facing barriers to accessing refuge is more important now than it has ever been, and continuing support from government and effective partnership working will be vital to ensuring these services continue in the future.


If you need help or support in the UK, call the national domestic abuse helpline on 0808 2000 247, or visit Women’s Aid online.

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How the COVID-19 homelessness response shows opportunities for future progress

Before the UK entered lockdown in March 2020, there were already discussions around how the spread of COVID-19 would impact some of the most vulnerable people in our society. There was an acute awareness not only of the significant levels of homelessness in our towns and cities but that the number of people who needed support was growing at an alarming rate. Strategies for prevention and outreach programmes to help break the cycle of homelessness through a network of support systems for homeless people were helping to a certain extent in some areas, but the problem was (is) chronic and the concern among people who worked in, and had experience of, the sector in relation to the potential impact of COVID-19 was growing.

Homelessness during the COVID-19 pandemic

Surprisingly though, in many areas the response to support the UK’s homeless populations was swift, definitive and all encompassing. Partnerships were formed with local hotel chains – the GLA partnership with multiple hotel groups as part of the Pan London Placement scheme is probably the best publicised but individual arrangements have sprung up across the country and people were moved from the street into accommodation which was self-contained and would allow them to effectively isolate if they showed any symptoms of COVID-19.

In March, minister Robert Jennick announced £3.2 million of funding for councils to help them protect local rough sleepers from the pandemic and MHCLG, councils, the voluntary sector and those who work within homelessness outreach specifically have all mobilised to form an effective network of support for many people who had previously been sleeping on the streets.

The response to moving those who were sleeping rough off the streets has been unprecedented, as is the volume of people who have been helped. Many people have been accommodated regardless of their “local connection” or their “recourse to public funds”, something which previously was a significant barrier to many people being housed in temporary accommodation by their local authority.

A new wave of homelessness?

However despite the significant progress made, there are growing concerns about a “second wave of homelessness”- people who become homeless off the back of the stagnation and collapse of some areas of the economy, particularly those in low paid and precarious work i.e. hospitality and retail sector. Additionally, there are signs that some especially vulnerable groups have not engaged with the process or that some people have became homeless after the initial offer of support was rolled out. These include people from migrant backgrounds, and people with acute and severe mental ill health.

Things can’t go back to the way they were

One thing is clear, according to professionals, things can’t be allowed to return to the way they were. In some instances this is for practical reasons, and in other instances because we have been able to see what it is possible to achieve when people co-operate and there is a collective will to progress.

The use of communal shelters, one of the main ways of delivering emergency accommodation for many years may have to stop, or at least be re-organised to avoid multiple people sharing facilities like bathrooms or sleeping in rooms with multiple beds. A move towards more “pod style” contained living may be a way forward, but it will take a shift in design to accommodate people safely in the future.

The response has shown that it is vital to develop links between housing and health, and that the integration of services with public health to create wrap-around care (which is something which is currently being co-ordinated in response to the pandemic) should be maintained going forward.

The pandemic response has also shown that multiple organisations can work well effectively together and that the red tape, perceived layers of bureaucracy and challenges of different ways of working can be overcome if there is collective understanding and will. These barriers can be overcome to create really effective and much needed services and support for some of our most vulnerable citizens.

Concerns have been raised around future funding, and in particular the risks of funding being stopped abruptly or the supply being removed at short notice, for example if hotels re-open and councils then struggle to identify appropriate accommodation for people to transition into. The sector has stressed that councils should be planning for this transition phase to prevent people returning to the streets and dis-engaging with services.

Opportunities to learn lessons

At an online event hosted by the Centre for London, which brought together professionals from within the sector in London to reflect on the response to COVID-19, somewhat surprisingly, the atmosphere was one of optimism that this could be the start of a new way of working. There is hope that a “can do” and “get things done attitude” which had been catalysed by the need for urgency because of the spread of COVID-19 can be harnessed and that this mindset should be embedded into practice going forward.

One of the main questions that appears to be raised is, if we can do it now, with such urgency, why couldn’t we do it before, and what steps need to be taken to ensure that the collective will and the government support doesn’t disappear post COVID-19? This is something local authorities, homeless outreach groups and other partners will have to grapple with over the coming weeks and months.

The response to the pandemic has been unprecedented. It has shown that with understanding, flexibility and effective partnership working to deliver coordinated services (as well as appropriate supply and funding) that tackling homelessness, or at least offering more to our homeless communities in terms of effective long term support, can be achieved.

There is a collective sense within the sector that the steps forward taken as a result of this pandemic should not be allowed to regress in the future, but should be strengthened and built upon to provide more effective support going forward for homeless communities across the UK.


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Read some of our other blogs on housing and homelessness:

Digital infrastructure supporting health care during the COVID-19 pandemic

Healthcare is a key frontline service in the response to the COVID-19 outbreak. The NHS has had to react at pace to plan and deliver services in new and innovative ways.

Digital healthcare solutions are at the fore of ensuring not only the delivery of acute care for those patients suffering from COVID-19 but are also supporting the successful continuity of care and the day to day running of a health service which still needs to maintain “normal service” as well as its pandemic response. Digital infrastructure is helping the NHS and other partners to adapt and to meet the demand for health and care in a number of ways.

Supporting the delivery of care

In many ways, the NHS and frontline care in particular were already making inroads towards transitioning to digital and online platforms before the pandemic emerged. Many GP surgeries allow online appointment booking, and where appropriate, monitoring of those with long term conditions can be done remotely through at-home testing facilities, such as home heart monitors or monitors to help people monitor their diabetes.

Many care providers also already offer telehealth solutions for clients, and patient records are now stored online. However, in many ways the COVID-19 pandemic has catalysed uptake of digital solutions to healthcare diagnosis and delivery, with an increase in online consultations, greater use of the NHS Digital and NHS24 online and app platforms and a rise in the development of digital solutions to better support care in the community.

Support and training for frontline staff

In addition to supporting the direct delivery of care to patients, digital health infrastructure is also being adapted and used to deliver training and support to staff on the frontline. Blogs and online forums, including social media groups are enabling people to share experiences and best practice, and to create a sense of community among healthcare workers. In addition, virtual and e-learning opportunities are being developed to enable staff to access educational activities remotely. These include supporting the rapid education of the healthcare workforce in how best to manage the respiratory conditions encountered, as well as providing education to staff who may have been redeployed to other departments or settings as a result of the pandemic response. Online learning has also been used to help train volunteers and help the public to keep up to date with the latest developments across the health service.

Beyond healthcare to support the response to the pandemic

Artificial intelligence and data analytics also have a vital role to play in helping prevent the spread of coronavirus and other infectious diseases as digital solutions look to be developed to help beyond acute healthcare responses.

Predictive analytics and scenario modelling can be used to help identify those populations who are at risk of spreading the virus and of falling most severely ill to help support shielding campaigns and protect vulnerable groups as lockdown measures ease.

A project run by UK firm Biobank is looking to use samples collected by volunteers to map genetic sequencing in order to identify whether certain genetic characteristics make people more predisposed to become seriously ill, or more likely to contract the virus in the first place. This may help in the development of a vaccine and can also help identify those groups who will be most vulnerable when lockdown conditions are lifted so that they can be monitored more effectively.

Modelling and analytics can also be used to try and project any potential “second waves”. It is hoped that AI, analytics and machine learning will be able to help organisations learn from events such as the SARS epidemic, as well as quickly creating new knowledge from the millions of data points being generated in this outbreak.

Final thoughts

The significant humanitarian response to this global pandemic is being underpinned by a digital infrastructure, the extent of which we have never had at our disposal before. This digital support, of care delivery, communication, analytics, and modelling is being used in conjunction with insight from health and scientific specialists to try and help us find a path through this pandemic, deliver care, aid recovery and prevent re-emergence.

Making best use of the data and digital capacity we have throughout our health and care infrastructure will be a key part in preparing and meeting the needs and challenges that communities are facing.


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Further reading: articles on COVID-19 from The Knowledge Exchange blog

Living life in full colour: exploring the relationship between colour, design, behaviour and emotion

Seeing red…. green with jealousy….. feeling blue. Associating colours with emotions is not new, but increasingly, psychologists are being asked to explore the relationship between colour, emotion and its impact in a number of different settings, including learning in classroom settings, the design of the built environment, including work spaces and travel hubs, and improving wellbeing as a result.

Colour is a powerful tool. It can be used to get attention, enhance clarity, establish a code, label and differentiate items, as well as to influence behaviour or learning outcomes. For example in schools we are often told to use blue or black ink. Red ink is supposed to be used by teachers to correct assignments, notebooks, and class work. This is a deliberate tool to draw our attention to the mistake we make, designed to help enhance our learning outcomes, in the sense that by drawing attention to the mistake we will remember not to repeat the points highlighted.

“Bad” and “good” colours

Studies have disagreed on how exactly our association between colour and emotions develops. Some have suggested it is an instinctive reaction, something primal which suggests to us that things that are red in colour are dangerous or negative, while blues and yellows signal happier less aggressive colours.

However, others have suggested that the connotations we associate with colour are learned, albeit from a very young age. We associate some colours as being “good” and others as “bad” and this impacts how we interact around them in spaces like classrooms and workspaces. The meaning of colours is culturally-specific and differs around the world in different societies and groups.

However, a third view is that colour theory is much more complex than simply yellow = happy and blue = sad. Colours can have several meanings, and can encourage an audience to feel or act in certain ways depending on when and how they are used, and in some instances depending on personal experiences which people link to specific colours. This is the reason why the literature on colour is so contested; in many instances it blurs the boundary between our instinctive associations of colours and those associations we create ourselves through experiences.

Image “Harvey_Nash_13″ by K2 Space is licensed under CC BY 2.0

How colours are impacting on the design of our spaces

Knowing how colour can affect behaviours is informative for designers and psychologists in a number of environments, including in schools, offices or hospitals. In a learning context, such as in a school using “engaging” hues (warm colours such as red, orange, and yellow) to prevent learners from getting bored, and passive hues (cold colours such as green and blue) to keep learners calm can help with learning, but getting this balance right is important.

A number of studies have looked at the impact of classroom design, including use of colour on the learning and behavioural outcomes of both neurodiverse, and neurotypical children, with many emphasising that overstimulation, particularly of young children through excessive use of bright colour can create a disruptive classroom environment and make it difficult to encourage concentration and staying on task. However, some colour in specific areas of the classroom is good to help with engagement and stimulation.

Similarly, colours have been used by architects and designers in their choice of building material or building design to help encourage feelings of calm or reflection. This is particularly the case in transport hubs like airports and in hospitals or care facilities. Using fresh and calming colours which relate strongly to nature is also a technique used by office designers to help create the feeling of open calm and fresh spaces to help improve working environments and improve productivity.

The design of the built environment and how “green” and “blue” features which incorporate natural materials (green spaces and water have a positive impact on mental and physical wellbeing) has been widely discussed by planners and architects. The evidence generally supports the view that the inclusion of green spaces, promotes health and wellbeing across the life course. This combination of colour and the integration of nature into spaces is being used increasingly in the design of buildings and  in master planning for large urban projects.

Final thoughts

Colour and emotion both play important roles in our capacity to learn and be productive. The association between colour and our emotions and actions is complex and a source of disagreement for some psychologists. Colour has been found to affect how people feel both psychologically and physically. Understanding how colour and emotion relate and how colour can be used to change environments to encourage particular feelings of calmness or concentration, particularly in schools and workplaces is something that will be further explored by designers.

Colour should be understood as part of a wider “toolkit” used by designers and architects to ensure that we are building better places that create environments which support and promote wellbeing, encourage positive emotions and create more effective spaces for us to work, learn and interact in.


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