Lambeth Living Well Network Alliance Progress Report 2022-23

Strategic Priority: Independence

Our priority outcome: To increase the number of people able to live independently.

Our approach is to support people to live in the community as independently as they are able. This means keeping down the time they are in hospital or places with full-time supervision to the minimum required, and only when they really need this much support.

Context and key challenges

We used more acute hospital beds in 2022/23 than in any other year (see chart below). This is partly because of the impact social isolation had on mental health during the pandemic. We are also seeing more patients who are homeless and/or ineligible for benefits. This makes discharge more complex and takes longer due to the time it takes to secure suitable accommodation for people to move on to. When Lambeth beds are full, patients are either found spaces outside of the borough if they’re available, or, increasingly, go to private hospitals. Private beds are our last resort as they are more expensive and likely to be outside of south-east London. 

What we offer

We’re committed to helping people with enduring mental health challenges to live independently as soon as they possibly can. We’re working together on a range of key initiatives to help achieve this: 

Community Liaison and Support Service (CLaSS)

Our Community Liaison and Support Service (CLaSS) works with our inpatient staff and peer support workers (people with lived experience) to support people in hospital wards to move on once they’re well enough. They help build confidence and find and resolve anything that may prevent people from being discharged, for example tackling issues around housing and finance or practical problems such as hoarding.  

Culturally Appropriate Peer Support and Advocacy (CAPSA)

Our pioneering Culturally Appropriate Peer Support and Advocacy (CAPSA) service gives one-to-one support from people with their own experiences of mental health challenges. Their focus is on health equality. In Lambeth this means to make it as easy and likely for people of African and/or Caribbean heritage to use our services – and get the same experience and results as if they were from a white ethnic background. 

Living Well Centre: Short-Term and Focused Support Teams

Our Living Well Centre Short Term and Focused Support Teams regularly review the people they support, to make sure they’re receiving the right level of care. 

Home Treatment Team

Our Home Treatment Team works with people to keep them out of hospital, by providing therapeutic support and medication to people in their homes and communities.

Staying Well

Our innovative Staying Well programme brings together GPs and Living Well Centre staff (clinicians and support workers) to share their knowledge, expertise, and experience. They meet at least once a month to support one another and advise on ways they can keep more people well in their communities. For example, mental health clinicians can advise GPs on specialist medication, supporting them to administer this at their practise. If a GP raises a concern about how well one of their patients is coping, a support worker may be able to offer one-to-one practical help with their issues, preventing the need for further intervention. 

Supported Accommodation

We commission a large number of ‘supported accommodation’ services. These range from a few hours a week support for someone in their own home (for example to make sure medication is taken) to 24-hour supported specialist accommodation for those with greater needs. We’ve recently refreshed and improved many of these contracts to make them more suitable for the people we care for. For example, we’ve asked contractors to supply more staff who can help people take medication in their own homes, which means they don’t need to be in specialist supported housing to do this. 

Our impact

As the chart shows, 2022/23 saw increases in long lengths of stay in acute hospital beds (more than 100 days and more than 200 days). However, both figures are still well below our first year’s numbers – 33% lower for stays over 100 days and 46% lower for stays of over 200 days.  

Our Home Treatment Team, which works with people to keep them out of hospital, supported 784 people in 2022/23, up 9% on the previous year. 

Our Focused Support Teams supported on average 797 people in 22/23 and supported 415 people to return to their communities, 52% of their average caseload.  

Our Short-Term Support Teams supported 850 people to move on in 2022/23.

People supported by the Home Treatment Team

(up 9% from 2021/22)

Average number of people supported by Focused Support Teams
People supported to return to their communities by Focused Support Teams
People helped by Short-Term Support Teams to move on in 2022/23

Our next steps

We recognise we need to reduce the number of people experiencing long-term hospital stays. We’re continuing to improve the way we work so people can have greater independence sooner by: 

  • reviewing how we make referral and discharge decisions, 
  • finding and addressing anything that may be preventing someone from being discharged sooner, 
  • improving supported accommodation services, 
  • developing and expanding our Staying Well approach, [insert link to explanation of Staying Well in section in the document]  
  • introducing new roles such as community reablement workers, mental health practitioners in GP surgeries and transitions workers for children and young people turning 18.


Case study: Blu, Staying Well

Daniel, Blu’s Staying Well support worker, visits him regularly. This supports Blu to be more independent at home, where he feels more relaxed, and with less intensive psychiatric support. They support with benefits and administrative tasks that Blu finds difficult due to the challenges he experiences understanding letters.   

Daniel also secured funding to contribute towards a new TV to provide Blu with a source of entertainment and manage his mood during his extensive periods spent indoors.  

“I don’t like to go out very much. In my spare time I like to watch films, all types depending on the mood. Sometimes I read but I prefer films. It helps me to relax. Any time I feel down, I watch comedy which helps me feel better.  

Blu spends most of his time in his flat. His social anxiety, mobility issues, joint pain, memory problems and paranoid schizophrenia mean that he finds leaving his home extremely challenging. He also needs frequent trips to the toilet, which tends to limit how far he wants to go or how long he stays out. The Staying Well team offers support that is sensitive to Blu’s needs and his desire to maintain a home of his own, while also helping him to manage his mood and the challenges he faces in interacting with the world outside his flat.’  

My support worker, Daniel, has helped me feel more confident. He helps me to find the best solutions and to get better, and I’m very grateful for this. He gets me out of the house more. Most of the time we meet at the local bakery now, which is a big improvement.  

If I didn’t get the support from Staying Well, I’d be half of what I am now, and I’d definitely be more depressed. They help me with anything to do with my health and getting the benefits I’m entitled to which means I can stay independent in my own home. To me this means a lot. What does home mean to me? Home is where the heart is.”


Can you help us?

We have a short survey that anyone who use our services will be invited to complete (online or on paper). It will take less than three minutes and will tell us how well we are doing and what we need to improve.

Complete the survey now.