Can the NHS help end homelessness?

In its election manifesto, the Labour Party promised a “cross-government strategy to put Britain back on track to ending homelessness”. Buoyed by this promise, Pathway has campaigned on two, linked fronts since the general election: first, to persuade the new leadership in the Department of Health and Social Care and the NHS that homelessness is a significant challenge to health services that the NHS can do much to resolve; and second, to ensure that the homelessness strategy, as a cross-government endeavour, contains genuine commitments to evidence-based, NHS-led actions that align the resources of our health system with the national plan to end homelessness.

Without comprehensive NHS involvement in both ending and preventing homelessness, long-term progress will be difficult and wider government ambitions to reduce health inequalities will be (literally) fatally flawed (as Danny Beales MP said in October).

In his report to the secretary of state in autumn 2024, Lord Darzi quoted Pathway’s evidence submission to describe homelessness as “a health catastrophe”. Since the Darzi review, new research using the lens of frailty assessments has shown in further stark detail that harm from homelessness starts shockingly early, is rapidly cumulative and impacts every domain of human health.

The study found that 25 per cent of people experiencing homelessness were clinically frail before the age of 30 and had rates of multimorbidity similar to 80-year-olds in the general population. While shocking, the picture is surely no surprise - we have known since at least the end of the 19^th century that degrading, unsafe, unhygienic, insecure and insanitary living conditions, coupled with extreme poverty, make people sick.

In December, the government launched its somewhat delayed cross-government “National Plan to End Homelessness”. Looked at alongside the 10-Year Health Plan published in July, how optimistic should we be that the government is now “on track” to meet its manifesto pledge?

The new homeless action plan contains an array of policies relating to NHS services and care. I was delighted to see a specific commitment that no one should be discharged from hospital to the street, backed up by a promise to implement existing guidance about more collaborative working between hospital discharge teams and local housing departments.

To help deliver this commitment, the plan also recommends that local systems should use the Better Care Fund, alongside homeless funding pots, to commission specialist intermediate care beds for homeless patients leaving the hospital.

Overall Pathway’s long-held ambition that the NHS finally “gets” the comprehensive role it must play in preventing and ending homelessness still waits to be realised

More generally, it commits investment to specialist supported housing and describes how substance misuse budgets and mental health services should be more closely aligned.

In a chapter on upstream prevention, it references the 10-Year Health Plan, the role of mental health services (and the NHS Mental Health Rough Sleeping programme), and £473m capital investment in mental health services, which, among other things, will encourage the development of neighbourhood mental health centres and mental health emergency departments.

New neighbourhood health centres should become “hubs for multidisciplinary teams delivering holistic, trauma-informed services”, and “transform both healthcare and homelessness systems to be preventive with tailored and integrated health services, particularly for disadvantaged and deprived communities”.

There is to be a review of key parts of the Care Act 2014 and safeguarding practice, something Pathway called for in one of our 10-Year Health Plan policy papers last January.

The commitment to end street discharges, coupled with direct encouragement for systems to use the Better Care Fund to commission the specialist intermediate care facilities essential to achieving this laudable objective, is a major step forward in policy terms. The Homeless Action Plan says DHSC will lead national work on implementation, although no specific additional funding is identified.

On the downside, integrated care boards get only two mentions in the whole document, and NHS bodies do not feature at all in the chapter on delivery. The Action Plan has a strong and welcome focus throughout on prevention, but misses the opportunity to make any major links with the prevention “shift” in the 10-Year Health Plan.

The section on “specialist services” talks about mental health and substance misuse services, but makes no mention of the many amazing, specialist primary care, street outreach, infectious disease or NHS hospital homelessness services.

In November, Pathway published the annual review of our own national partnership programme through which we support a network of specialist clinically-led hospital in-reach teams across the country.

We called that report “Beacons in the Storm”, referencing the everyday battles our hospital teams face as they work to persuade other services to put the right support in place for their patients. Our hope was that the new Action Plan, with the 10-Year Health Plan, might have set a clear path out of the storm.

However, given the truly extreme risks our patients face trying to survive in homelessness, their experiences of poor care or direct exclusion from services, and the high rates of burnout we see among NHS staff in specialist services, I think the best we can say is that there is some light on the horizon. Overall Pathway’s long-held ambition that the NHS finally “gets” the comprehensive role it must play in preventing and ending homelessness still waits to be realised.