Health workers are involved in a joint team with other agencies to help rough sleepers off the streets. Family doctor Nigel Hewett describes its impact on 72 clients over six months

Rough sleepers often present a complex mixture of mental and physical health problems, compounded by difficulties with benefits, rent arrears and exclusion from hostels. Many different agencies will be working with the same clients, but collaboration is often difficult in a rapidly changing situation.

This is a classic example of a 'joined up problem requiring a joined up solution'.1 In Leicester awareness of the need for joint working has resulted in the development of a rough sleepers multidisciplinary team, which has come together for weekly case management meetings since January 1998.

There are representatives from local authority hostels, housing advice, the voluntary sector, primary health and mental health care - it is a truly multi-agency and multidisciplinary team.

A collaborative venture like this, developed without new funding, depends on a history of contact and confidence-building between the various agencies concerned, at managerial level and between frontline workers.

Leicester has benefited from an eight-year history of outreach mental health nursing for homeless people. This service provides regular visits to hostels and a daily presence at a drop-in centre to offer open access mental health assessment and referral without the need for formal appointments. A twice-weekly GP surgery for homeless clients has been funded by the health authority at the voluntary-sector Y advice and support centre (YASC), which runs a daily drop-in.

For the past year, four new outreach and resettlement workers have been funded by the government's rough sleepers initiative (RSI) and managed by YASC. This history of outreach work has meant that frontline workers regularly come into contact with each other and build up trusting relationships.

At a managerial level the Leicester City Council housing department has taken a lead role over many years in building links between the housing department, health authority, social services and voluntary sector. As well as regular personal contact over particular issues, this has involved participation in joint planning forums on homelessness issues and the development of an inter-agency rough sleepers commissioning group which put together the successful bid for RSI funding.

For the past two years minds have been focused by the Jock Moon lecture, an annual conference on homelessness in Leicester, which invites key agencies to report on their services to homeless people.

The chance to form this team arose from several factors: the new RSI outreach and resettlement team presented an opportunity for more intensive work with homeless clients; the housing department appreciated the need for closer inter-agency work and was willing to provide a room and secretarial support; and the sessional GP for the homeless was able to give more time as a result of study leave.2

At each meeting team members bring their different professional perspectives to bear on a client's multiple needs in order to agree goals and make and act on plans.

Each organisation represented aims to take co-ordinated and collaborative action to ease the smooth transition of clients into suitable and more permanent accommodation.

The RSMDT works with people with a history of sleeping rough and those who appear at significant risk of rough sleeping, including people with a history of failed tenancies or licenses. The team concentrates on difficult cases that may benefit from the multidisciplinary approach

The team meets weekly for about an hour. Meetings are chaired by the GP of the Leicester homeless service. The worker who has made first contact presents new clients to the team. After discussing the case, any necessary action and the person responsible for taking that action is identified and minuted. Information on existing clients is updated, with decisions again recorded. Through this shared record (which complements individual records) the care package evolves in line with the client's wishes and responses.

As they stabilise, clients are removed from the active discussion list - as they are if they move away or decline the team's support.

Once a month senior managers from each agency join the meeting. This group oversees the team's work and tackles policy issues identified as hampering its efforts to help rough sleepers. The commitment of managers with the authority to address the specific problems of rough sleepers is a major contribution.

Confidentiality can be a difficult issue. Each agency has a confidentiality policy in place or is bound by professional ethics. The client's permission will always be sought before any confidential information is divulged, although much of the information discussed has not been confidentially obtained but is the result of observation of the client's situation or behaviour.

The clients presented are not simply rough sleepers in Leicester but selected people who were proving difficult to help. Minutes of the first 24 meetings over six months from January to July 1998 have been analysed, and show 391 entries were made about 72 people. On average, each person was discussed five times, and at each meeting 16 different clients were discussed. There were 15 women and 57 men. Their average age was 35, with a range of 14-72 years. Each client's status has been compared between the time they were first discussed and the time they were removed from the discussion list.

The essential aim of the team is to improve accommodation status. One means of evaluating progress is to consider a progression from the streets. The usual first step for a rough sleeper is to go into the night shelter or to become of no fixed abode (that is, off the streets but in insecure and unsuitable accommodation such as a friend's floor). The next step is often into a long-stay hostel, and then into supported accommodation and ultimately independent living in their own flat.

Of course some people may go straight from rough sleeping to their own flat and many go back to the streets from their own accommodation, especially if support mechanisms break down.

Of the 72, 35 had positive accommodation moves, 30 made no progress and seven were in a worse situation at the end of the team's involvement. Virtually all the clients have a recent history of rough sleeping, although the outreach workers often succeed in arranging a night shelter bed or hostel place before the team discusses a client. While 17 of the 72 clients were still sleeping rough when first discussed by the team, only six were rough sleeping at the end of contact.

A major contributing factor to rough sleeping is rent arrears - 33 clients had rent arrears. During the course of the team's involvement 16 had co- operated with repayment plans and 17 made no progress.

The most frequently encountered health problems among this group were related to drug and alcohol abuse. A relatively small improvement can make a real difference to quality of life. Contact with a drug or alcohol outreach worker may be significant. There may be evidence of positive changes in behaviour, for example from daily, chaotic uncontrolled drinking with self-neglect to steady drinking with regular meals and improved personal hygiene. Similarly a change from chaotic drug use to steady use with some funds devoted to accommodation and food is progress.

Twenty four clients had a problem with alcohol consumption. Eight showed some improvement and 16 showed no change. None was worse off at the end of the team's involvement.

For the 22 clients with drug problems, four showed some progress, 17 showed no change and one deteriorated.

Co-ordinated working with other agencies involved with the client but not part of the team is also important. For 42 per cent of the clients, there was significant liaison with another agency such as social services, probation or a housing provider.

As well as direct benefits to the clients from quicker and co-ordinated working, team members have also benefited. They have had to learn to respect one anothers' competencies and speak one anothers' professional languages. There is now a greater understanding of the scope and limitations of other professionals, and perhaps most significantly, a feeling of support for individual workers who previously felt isolated and unsupported while working with challenging clients. Evaluation of our work should help with the targeting of resources and planning developments.

Positive inter-agency collaboration provides a platform on which further developments can be built. So far time pressures prevented social services from committing a representative to the team, but we hope that joint finance may in the future provide a social services link worker. We also hope that funding will become available in the future for better general nursing provision for homeless people and more GP provision, perhaps through of a second wave primary care act pilot project.