Getting streets ahead: improving the health of the homeless

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The government’s recent announcement of “a vision to end rough sleeping”, which included a national commitment to help homeless people access healthcare, is a positive step, but a lot more needs to happen at a local level if this commitment is to be met, says Homeless Link director Jacqui McClusky.

People who are homeless experience some of the poorest health in our communities. The bleak statistics, about the prevalence and impact of these needs, speak for themselves: tuberculosis affects rough sleepers at a rate 200 times greater than that of the general population; the average age of death of a rough sleeper is estimated to be 40-44 years old; and up to three quarters of rough sleepers have mental health disorders – such as anxiety, depression and psychosis.

Over the past two years Homeless Link has collated data from over 1,000 homeless individuals about their health as part of a national project. The information they shared makes a compelling case for change. The majority reported multiple mental and physical health problems; repeated use of A&E and extended stays in hospital.

In a case not untypical of those we heard, one client had been to A&E five times in six months: despite a range of health problems he had no GP registration and was not receiving any treatment for his mental health needs. The Department of Health estimates that the high use of hospital services by homeless people represents a cost to the NHS eight times as much as the general population.

It’s easy to get lost in statistics, but what these figures and the individual stories that lie behind them show is that the NHS has failed to improve the health of homeless people. Many services, traditionally set up to deal with “one need at a time”, remain ill-equipped to meet the complex health problems that homeless people experience.

We hear from many homeless people about their continued exclusion from mainstream services, including health services; our research found nearly one in ten homeless people have been refused access to a GP or dentist, with many more feeling that they have been discriminated against in other ways. In addition, as a group which can easily become overlooked, they are often not included in routine needs assessments, leaving them less visible to commissioners.

In their recent report, the Homeless People’s Commission - a committee of current and former homeless people - called for greater recognition of the complexity of needs homeless people have and recommended the commissioning of more multidisciplinary health teams who can address these problems. This is a strong message which is reflected in the wider experience of our members.

Indeed, we believe that services need to provide a more personalised approach which takes into account the particular needs of a homeless person. We need more advocacy schemes to help clients gain the confidence to navigate what can be complex and intimidating health systems. And importantly we need to make sure competition doesn’t work against those individuals whose health outcomes might be harder to achieve.

Strong partnerships between health services and housing providers are key – poor health is rarely solved only by clinical interventions. For those with multiple needs we require a wider perspective which takes into account an individuals housing, welfare and wider wellbeing. From the people with experience of homelessness that we spoke to, we know this can make the difference.

All this seems timely as the government re-imagines the role of the NHS and in particular overhauls many of the structures responsible for commissioning services in this country. Throughout the debate, we and others in the sector have made clear the case for improving the health of homeless people.

Without improving health for this group, we cannot achieve the vision for the “fair and equitable” NHS. Without improving the health of the most excluded, we cannot reduce health inequalities and we cannot reduce the significant financial costs currently incurred because homeless people’s health problems aren’t been prevented or addressed early enough.

Part of the solution lies in strengthening local accountability for the health of the most disadvantaged. After calls from the sector, the government have announced that health and wellbeing boards to ensure that the needs of vulnerable groups are better reflected in joint strategic needs assessments.

But we need to go further, local consortia must also actively work with homelessness organisations, public health teams and their local authorities to ensure they fully understand these needs and develop the right responses to them. These must be included in and reported in all commissioning plans so that we can identify where progress is still needed.

We are encouraged that in their recommendations to the government, the NHS Future Forum called for stronger mechanisms to provide greater accountability for reducing health inequalities, and as the Health and Social Care Bill is recommitted to Parliament, we will be calling for this to happen.

However, we still face the reality of a health service under immense financial pressure. We know that homeless people are not the main priority when allocating local resources - housing related support services have already been hit by disproportionate cuts in many local authorities.

Already we are seeing the impact this is having on homeless people’s health: 46 per cent of homelessness organisations have reported reductions to mental health services. This is why it is so critical health services focus action on homeless people: if we provide accessible, high quality services for the most excluded, then we are probably getting it right for everybody else too.

Improving the health of homeless people must be a shared goal. Homelessness services must continue to build links with local health structures and local government to drive forward change. But we urge health services to take the lead too and help make our NHS which truly meets the needs of everybody in our communities.