Examining the intrinsic link between homelessness and health

23 November 2017

The average homeless person has a life expectancy of 47 compared with 77 for the general population,[1] at the same time 92% of homeless people in the UK are registered with a GP. [2]

The first figure if deeply troubling, is sadly, not a surprise. The second statistic however perhaps offers cause for cautious optimism. What is clear is that in order to understand the link between homelessness and health, one must analyse not only systemic issues, but also the way in which the health service itself is geared towards the needs of the homeless and those at risk of it.

On a systemic level, homeless citizens are simply more likely to suffer from poor health: 41% of homeless people live with a long term health condition, compared to 28% of the general population and 45% of homeless people suffer from mental health issues, compared to 25% of the population.[3] The reasons for such disparities are easy to understand yet much harder to address. Cold weather, poor diet, the risk of violence and substance misuse all contribute to the trend. Of course, poor health and homelessness are closely associated in that each can be the cause of, and/or exacerbated by the other. Additionally, rates of homelessness and rough sleeping are on the rise. The homelessness charity Crisis estimates that the number of people sleeping rough in England has risen by 132% since 2010,[4] with even rough sleeping numbers now standing at well over 4,000 people in England each night. In short, the NHS is challenged with producing models of care aimed at an extremely at risk, and rapidly growing population.

Having established the scale of the problem, it would be disingenuous not to praise the ongoing efforts of the NHS and its staff to improve care for the most at risk in our society. However, that is not to ignore the overwhelming need for further progress. Whilst 92% of homeless people are registered with a GP, research shows that significant numbers have (contrary to NHS guidelines) been turned away from GP services because of a lack of photo ID or proof of address. Additional barriers to accessing care include: immigration status, literacy problems which cause discomfort around form-filling, frequent moves around the country, and a lack of access to a telephone to book morning appointments. Perhaps most significantly homeless service users have reported a lack of understanding and empathy regarding their complex needs. [5]

As a result of these factors, underlying problems are often allowed to develop as homeless service users access A&E departments rather than general practice which may then result in admission to hospital. Homeless people use A&E six times more than the housed population and stay in hospital three times as long.[6] When one considers that an average GP consultation costs the health service £45, an A&E visit £113, and a hospital inpatient episode £1779, the economic case for getting primary care right becomes clear. Whilst it can be argued that the delivery of primary care could be improved throughout the general population, providing an effective hospital discharge process into the community is particularly important amongst the homeless population. A 2014 audit showed that 36% of homeless people said they had been discharged onto the streets with nowhere to go,[7] and had experienced a lack of support or information on how to better manage their condition. Importantly, many homeless patients felt that upon discharge their health issues had also not been fully addressed. Of course, this creates a damaging and costly cycle of discharge and readmission.

The health challenges facing homeless people - and healthcare providers - are therefore clear, whilst the solutions are much harder to pin down. Whilst macroeconomic conditions and the resulting cuts to government expenditure and Britain’s severe housing shortage are underlying issues, positive steps can be taken specifically within the health sector to tackle the problem. With issues both around physical and mental ill health, coupled with a high prevalence of addiction and low healthcare literacy, perhaps more than any other population group, homeless people require integrated services to address their complex needs.

Examples of such models have shown demonstrable success. The charity Pathway’s model of integrated care operates within the framework of existing health and care services, bringing together teams of NHS, local authority and voluntary sector professionals. Each team includes a specialist GP, nurses, housing professionals and, in some hospitals, Pathway Care Navigators: people who were once homeless, who have been trained to support homeless patients. The model provides such varied services as housing and benefits advice, assistance with documentation, access to addiction services and complex care planning, and discharge liaison. Early analysis of this model found a 30% reduction in inpatient bed days, and, more importantly, increased patient satisfaction as a result of higher standards of care. [8] Such models of care allow homeless patients one entry level to an often complicated healthcare system whilst reducing inappropriate discharges as part of a personalised care plan. Crucially, this multi-agency approach allows addiction services to connect with social services and housing teams to identify long term housing solutions for homeless people with health problems. Additional integrated services have enjoyed similar success. In 2013 the Department of Health invested £10 million in the Homeless Hospital Discharge Fund to improve services for people who are homeless and leaving hospital. According to the Department, 69% of homeless people had suitable accommodation to go to when discharged, but this figure rose to 93% in projects which combined NHS and housing staff. [9]

Integrated, multi-agency support teams seem to offer the offer the most effective vehicle for improving outcomes and the quality of care for homeless patients, yet currently services exist in silos. During the current period of budgetary constraints and financial uncertainty across the healthcare system, extra funding for innovative models of care is in short supply. However, given the potential long savings of integrated care models as outlined above, it would be counterproductive not to take action. With this said, improvements will be driven not by financial prudence, but a continuing desire to treat the most vulnerable in our society with the compassion and respect they deserve.

[1] NHS England (2011) Homeless die 30 years younger than average, Available at: https://www.nhs.uk/news/lifestyle-and-exercise/homeless-die-30-years-younger-than-average/ (Accessed: 20/11/2017)

[2] Crisis (2015) Health services, Available at: https://www.crisis.org.uk/ending-homelessness/health-and-wellbeing/health-services/ (Accessed: 19/11/2017).

[3] Homeless Link (2014) The unhealthy state of homelessness

[4] Suzanne Fitzpatrick, Hal Pawson, Glen Bramley, Steve Wilcox, Beth Watts (2017) The homelessness monitor: England 2017

[5] Faculty for homelessness and inclusion health, Care Quality Commission, Pathway, Health London Partnership, NHS 'Homelessness and access to General Practice, Training pack for Reception Staff

[6] The Health foundation Promoting Compassionate Healthcare for Homeless People, Available at: http://www.health.org.uk/programmes/closing-gap-through-changing-relationships/projects/promoting-compassionate-health-care (Accessed: 19/11/2017)

[7] Homeless Link (2014) The unhealthy state of homelessness

[8] The Health foundation (2015) Spreading the Pathway Model of Homeless Health, Available at: http://www.health.org.uk/newsletter/spreading-pathway-model-homeless-health (Accessed: 20/11/2017).

[9] Homeless Link (2015) Evaluation of the homeless hospital discharge fund

References

· NHS England (2011) Homeless die 30 years younger than average, Available at: https://www.nhs.uk/news/lifestyle-and-exercise/homeless-die-30-years-younger-than-average

· Crisis (2015) Health services, Available at: https://www.crisis.org.uk/ending-homelessness/health-and-wellbeing/health-services

· Homeless Link (2014) The unhealthy state of homelessness

· Homeless Link (2015) Evaluation of the homeless hospital discharge fund

· Suzanne Fitzpatrick, Hal Pawson, Glen Bramley, Steve Wilcox, Beth Watts (2017) The homelessness monitor: England 2017

· Faculty for homelessness and inclusion health, Care Quality Commission, Pathway, Health London Partnership, NHS 'Homelessness and access to General Practice, Training pack for Reception Staff

· The Health foundation Promoting Compassionate Healthcare for Homeless People, Available at: http://www.health.org.uk/programmes/closing-gap-through-changing-relationships/projects/promoting-compassionate-health-care

· Homeless Link (2014) The unhealthy state of homelessness