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This publication is available at https://www.gov.uk/government/publications/homelessness-applying-all-our-health/homelessness-applying-all-our-health
Ill health can be both a cause and consequence of homelessness, although it is not always identified as the trigger of homelessness. For example, ill health may contribute to job loss or relationship breakdown, which in turn can result in homelessness.
The health and wellbeing of people who experience homelessness are poorer than that of the general population. They often experience the most significant health inequalities. The longer a person experiences homelessness, particularly from young adulthood, the more likely their health and wellbeing will be at risk.
Co-morbidity (2 or more diseases or disorders occurring in the same person) among the longer-term homeless population is not uncommon. The average age of death of a single homeless person is 30 years lower than the general population at 47 years, and even lower for homeless women, at just 43 years.
The legal definition of homelessness is that a household has no home in the UK or anywhere else in the world available and reasonable to occupy. Homelessness does not just refer to people who are sleeping rough, and is not just a problem found in high-value housing markets such as London and the South East.
The following housing circumstances are examples of homelessness:
- rooflessness (without a shelter of any kind, sleeping rough)
- houselessness (with a place to sleep but temporary, in institutions or a shelter)
- living in insecure housing (threatened with severe exclusion due to insecure tenancies, eviction, domestic violence, or staying with family and friends – ‘sofa surfing’)
- living in inadequate housing (in caravans on illegal campsites, in unfit housing, in extreme overcrowding)
The causes of homelessness are typically described as either structural or individual and can be interrelated and reinforced by one another. Causes and their relationship vary across the life course.
Structural factors include:
- housing supply and affordability
- unemployment or insecure employment
- access to social security
Individual factors include:
- poor physical health
- mental health problems including the consequences of adverse childhood experiences
- experience of violence, abuse, neglect, harassment or hate crime
- drug and alcohol problems, including when co-occurring with mental health problems
- relationship breakdown
- experience of care or prison
For most people who are at risk of, or experiencing, homelessness and rough sleeping there isn’t a single intervention that can tackle this on its own, at population, or at an individual level. Action is required to support better-integrated health and social care, and to help people to access and navigate the range of physical and mental health and substance misuse services they require in order to sustain stable accommodation.
Healthcare professionals play an important role, working alongside other professionals to:
- identify the risk of homelessness among people who have poor health, and prevent this
- minimise the impact on health from homelessness among people who are already experiencing it
- enable improved health outcomes for people experiencing homelessness so that their poor health is not a barrier to moving on to a home of their own
There needs to be clear local action, partnership working (across the local authority, clinical commissioning group and other local organisations) and understanding and alignment of commissioning decisions to prevent and respond to homelessness across the life course. This can include:
- reducing the risk of homelessness to children and young people to strengthen their life chances
- enabling working-age adults to enjoy social, economic and cultural participation in society
- breaking the cycle of homelessness or unstable housing by addressing mental health problems, or drug and alcohol use, or experience of the criminal justice system
This requires strong local leadership and prioritisation to identify unmet need, funding and actions to address gaps in provision.
St. Mungo’s Broadway and Homeless Link carried out an audit in 2014 of Joint Strategic Needs Assessments, Health and Wellbeing Strategies and Clinical Commissioning Groups’ commissioning plans in 50 upper tier local authorities. They found that whilst there are some good examples, more needed to be done to ensure that homelessness is consistently addressed through local authority and clinical commissioning group planning.
Facts about homelessness
The scale and nature of homelessness and rough sleeping is difficult to understand. Official homelessness statistics have historically not presented a complete picture and have reflected only those households seeking assistance from the local housing authority. Rough sleeping official statistics reflect the number of people identified as sleeping rough on the night of the national count.
What is clear however is that homelessness and rough sleeping has been increasing substantially since a low point between 2009 and 2010.
Statutory homelessness statistics reported that from 2016 to 2017 there were just over 59,000 households owed the main homelessness duty to accommodate by the local authority in England. This is a 48% increase on the 40,020 reported in 2009 to 2010.
A further 215,210 cases of homelessness prevention and relief were reported by local authorities in the same year; an increase of 30% on the 165,200 from 2009 to 2010.
Statistics have also shown:
- the number of couples with dependent children accepted as owed a main homelessness duty has risen from a low of 7,410 households in 2009 to 2010 to 11,200 households in 2017 to 2018, up by 51%. This number was higher in 2016 to 2017, at 12,760 households
- the number of lone parents with dependent children owed a main homelessness duty has risen from a low in 2009/2010 of 19,440 households to 28,910 households in 2017 to 2018, up by 49%. This number was also higher in 2016 to 2017, at 29,940 households
- the number of working age applicants owed the main duty has risen from a low in 2009/2010 of 39,300 households to 55,070 households in 2017 to 2018, up by 40%. This was also higher in 2016 to 2017, at 57,590 households
- the number of applicants owed the main duty aged over 64 has risen from a low in 2009 to 2010 of 720 households to 1,510 households in 2017 to 2018, up by 110%. From 2016 to 2017, this number has fallen by less than 1%
Although official statistics among 16 to 24-year-olds reports a decrease in statutory homelessness, Young and homeless reported this population is considered hidden and difficult to quantify. In practice, homelessness experienced by this population is felt by the sector to be broadly stable.
Alongside an increase in homelessness is an increase in the use of temporary accommodation, including bed and breakfast. There has also been a 306% increase in the number of homeless households who have been temporarily accommodated out of area (in another local authority area) since the low point at the end of March 2010.
Rough sleeping is at the extreme end of homelessness. Officially estimated numbers of people who sleep rough have increased by 169% since 2010 to 4,751. The Greater London Authority’s Combined Homelessness and Information Network (CHAIN) system - managed by St. Mungo’s - separately monitors the numbers of people who sleep rough in London. From 2017 to 2018 around 7,484 people were seen sleeping rough in London by outreach workers over the course of that year. The CHAIN data reports that rough sleeping has almost doubled in the capital since 2010 (up 88%).
Preventing homelessness could improve health and save money.
A 2010 government study of the use of health care by single homeless people reported that they are 3.2 times more likely than the general population to be an inpatient admission, at an average cost 1.5 times higher.
This implies a gross cost of £76.2m per year, rising to £85.6m when outpatient usage and accident and emergency attendances are added. The net cost (the costs over and above the costs for the same number of the general population) is estimated at £64m year. This is considered conservative given the health issues experienced by this population.
A 2012 government review of the evidence identified estimates of the annual costs to government from studies ranging from £24,000 - £30,000 (gross) per person, anything up to circa £1bn (gross) annually. The net cost is likely to be lower.
The 2015 research by Crisis drawing on large studies on homelessness across Britain, suggests that tackling homelessness early could save the government between £3,000 and £18,000 for every person helped.
Policy and legislation
The Homelessness Reduction Act (2017) marks a significant change in homelessness legislation in England. It places statutory duties on local authorities to intervene earlier to prevent homelessness, and to provide help to all eligible homeless applicants irrespective of ‘priority need’ or ‘intentional homelessness’.
Under the new duties in the Act, local housing authorities (LHAs) will now offer individuals who are homeless or threatened with homelessness a greater package of advice and support. This includes a needs-lead personalised housing plan which should contain the steps to be taken to prevent or relieve the applicant’s homelessness.
The Act moves away from the previous statutory homelessness system that excluded many single homeless people from support on the basis that they were not defined as being in priority need.
The Act has introduced a new ‘duty to refer’, from October 2018, requiring specified public authorities in England to notify LHAs of individuals they think may be homeless or threatened with becoming homeless in 56 days, with the person’s consent.
The health services that the new duty applies to are:
- accident and emergency services provided in a hospital
- urgent treatment centres
- hospital-based in-patient treatment services
Other public authorities to whom the duty to refer applies includes prisons, probation and Jobcentre Plus. The aim of the new duty is to help people who come into contact with a range of public services get access to homelessness services as soon as possible so their homelessness can be prevented from reaching crisis.
Although other health professionals, such as those based in local authority commissioned public health services (such as drug and alcohol treatment services) are out of scope of the duty, it is expected that referral pathways to LHAs should already be in place from these services.
Alongside the Homelessness Reduction Act, there has been an overhaul of the official homelessness statistics. Because the 2017 Act has introduced new statutory duties for local authorities, the previous P1E collection is no longer be fit for purpose and has been replaced by Homelessness Case Level Information Classification (H-CLIC).
H-CLIC collects case-level data, which provides more detailed information on the causes and effects of homelessness, long-term outcomes and what works to prevent it. It is hoped that this new data will provide a better picture of how local authorities are responding to single homelessness in England.
The government has also published a new Rough Sleeping Strategy, which is underpinned by the targets of halving rough sleeping by 2022 and ending it altogether by 2027.
A new rough sleeping team and Rough Sleeping Initiative (RSI) has been established at the Ministry of Housing, Communities and Local Government to drive this work forward, in partnership with other government departments, PHE and NHS England. The work is overseen by a ministerial taskforce and steered by an expert advisory group.
Core principles for healthcare professionals
Healthcare professionals should:
- be aware that homelessness is a consequence of a complex interplay between a person’s individual circumstances and vulnerabilities and adverse structural factors, that requires different levels of intervention
- know and understand the needs of individuals, communities and populations and know who else in the local ‘system’ has a responsibility for or an interest in meeting these needs
- understand the signs that someone is homeless, at risk of homelessness or otherwise vulnerably housed and adhere to the duty to refer to the local housing authority if working in the relevant health settings covered by the Homelessness Reduction Act
- consider how they may be able to support individual’s personalised housing plans
- think about the resources available in health and wellbeing, social care, housing, criminal justice ‘systems’, including the strengths and assets individuals and communities bring
- understand the range of interventions which can prevent, protect, and promote health for people at risk of becoming homeless, and what is in place locally
Healthcare professionals should be aware of the interventions at the population level, and the population context of homelessness. These include:
- people with lived experience of homelessness being heard in the design, commissioning and improvement of local services
- healthcare organisations recognising homelessness as evidence of health (and wider) inequalities in their policies, and taking appropriate action to contribute to homeless prevention and reduction
- Health and Wellbeing Boards recognising homelessness in their Joint Strategic Needs Assessment, and if appropriate, in their Health and Wellbeing Strategies
- Police and Crime Commissioner Police and Crime Plans and Community Safety Partnership plans that recognise the relationship between homelessness, health and offending, with this understanding informing local commissioning
- recognising the relationship between health and homelessness in the local housing authority’s homelessness review and making sure appropriate action is taken through the homelessness strategy and associated partnership group (if in place)
- local housing strategies and associated plans such as the Local Plan, recognise and respond to the demand for housing from people who are at risk of or actually homelessness
- local health needs audits of the homelessness population inform commissioning and services
- adhering to commissioning standards available for the prevention of homelessness, homelessness response and health of homeless people (see examples of good practice and NICE guidance)
- local data systems recording information about patients and service users housing circumstances, including homelessness, and this is used to inform integrated, person-centred, commissioning and delivery across sectors and services
- the local workforce (across housing, homelessness, health care and social care, and criminal justice systems) recognising the risk of, or actual homelessness, and taking appropriate action in response, for example, through the Making Every Contact Count initiative (if in place locally)
- feeding back on access to services and outcomes to local commissioners, as experienced by homeless patients or other homeless service users
Community health professionals and providers of specialist services can have an impact by:
- working with local authority housing options and homelessness services to identify and target populations at particular risk of homelessness, and/or households who are homeless such as families living in temporary accommodation, people living in hostel accommodation
- working with these organisations to develop pathways out of homelessness and to improved health, wellbeing and wealth outcomes
- getting to know information, advice, prevention and support services available in your area through the local authority and/or homelessness partnership, and using Homeless UK and specialist health care services through the Care Quality Commission
- auditing access to primary care by people experiencing homelessness, in partnership with people with lived experience and the local Healthwatch
- commissioning healthcare provision, including mental health care, that engages people who are experiencing homelessness, whether this is rough sleeping, insecure housing in the private sector and, if appropriate, through outreach to hostels
- commissioning integrated provision for people leaving hospital and other health institutions, and developing links with local offender management services including probation and, where relevant, local prisons. Putting in place protocols for timely referrals to services, to enable smooth transitions from institutions to safe and suitable housing in the community
- ensuring that there is integrated health service provision in place for homeless people across mental health, substance misuse and primary care, with joint commissioning arrangements in place between the local authority and clinical commissioning groups
- supporting people into accommodation appropriate for their needs, for example ensuring appropriate housing is available for those recovering from drug and alcohol dependence
- providing volunteer opportunities and/or employing people with lived experience of homelessness in designing, commissioning and delivering services
Family and individual level
Healthcare professionals can have an impact on an individual level by:
- enquiring about the household’s housing circumstances as a matter of course, and ensuring this is recorded
- fulfilling the requirements of the new public sector duty to refer where a person or household is homeless, or threatened with homelessness
- supporting and contributing to personalised housing plans as per the Homelessness Reduction Act
- providing holistic screening and health assessment (using tools such as the QNI health assessment guidance)
- providing person-centred interventions for an extended period of time for those who do not respond to brief interventions
- supporting individuals to attend appointments and engage in treatment (this may benefit from the involvement of peers)
- ensuring that individuals with deteriorating health and increasing needs are identified and receive adequate support including, where appropriate, social care
- checking homeless patients are registered with a GP and receive primary health care, vaccinations and screening programmes, and helping them to register when they are not
- contributing to and providing holistic health assessments for people at high risk of, or experiencing homelessness
- promoting access to community family programmes and activities that support healthy family relationships including those run by local voluntary and community groups
- providing healthcare support at the point families visit local authority housing services to seek assistance to prevent or respond to homelessness
- contributing to the assessment of children in need and their families
- ensuring attendance for child development checks and immunisation appointments amongst families living in temporary accommodation
- supporting access to domestic and sexual violence and abuse services, harm reduction and exiting services for women involved in prostitution
- building trust with patients
There are 2 specific indicators in the Public Health Outcomes Framework (PHOF) which relate to statutory homelessness:
- eligible homeless people not in priority need (1.15i)
- households in temporary accommodation (1.15ii)
Evidence suggests there is also a relationship between homelessness and following PHOF indicators.
Wider determinants of health include:
- school readiness (1.02)
- pupil absence (1.03)
- adults in contact with secondary mental health services who live in stable and appropriate accommodation (1.06)
- domestic abuse (1.11)
- first-time offenders and re-offending levels (1.13)
Health improvements include:
- smoking prevalence in adults (2.14)
- successful treatment of drug treatment – opiate users (2.15i)
- successful treatment of drug treatment – non-opiate users (2.15ii)
- successful treatment of alcohol treatment (2.15iii)
- cancer screening coverage – breast cancer (2.20i)
- cancer screening coverage – cervical cancer (2.20ii)
- cumulative % of the eligible population aged 40 to 74 offered an NHS health check (2.22iii)
- cumulative % of the eligible population aged 40 to 74 offered an NHS health check who received an HNS health check (2.22iv)
- cumulative % of the eligible population aged 40 to 74 who received an NHS health check (2.22v)
- average Warwick-Edinburgh Mental Well-being Scale score (2.23v)
Health protection includes:
- population vaccination coverage – Flu (at risk individuals) (3.03xv)
- people presenting with HIV at late stage of infection (3.04)
- treatment completion for TB (3.05i)
- incidence of TB (3.05ii)
Healthcare and premature mortality include:
- mortality rate from causes considered preventable (persons) (4.03)
- mortality from communicable diseases (4.08)
- emergency readmissions within 30 days discharge from hospital (4.11)
- excess winter deaths (4.15)
The NHS Outcomes Framework includes:
- domain two: enhancing quality of life for people with long-term conditions
- domain three: helping people to recover from episodes of ill health or following injury
- domain four: Ensuring that people have a positive experience of care Improving people’s experience of outpatient care
The Public Health England (PHE) collection Improving health through the home provides a single point of access to wide-ranging authoritative information on data, evaluation, evidence and research related to homelessness. PHE also produces annual support packs for commissioners of drug and alcohol services.
Further guidance on commissioning
Improving access to healthcare for Gypsies and Travellers, homeless people and sex workers is an evidence-based commissioning guide for clinical commissioning groups and health and wellbeing boards.
St Mungo’s briefing ‘Improving the health of the poorest, fastest’: including single homeless people in your JSNA sets out why the health needs of single homeless people should be identified in Joint Strategic Needs Assessments (JSNAs), and provides guidance on how to collect this information.
The Faculty for Homeless and Inclusion Health Homeless and Inclusion Health Standards for Commissioners and Service Providers sets out clear minimum standards for planning, commissioning and providing health care for homeless people and other multiply excluded groups.
Homeless Link’s Evaluation of the Homeless Hospital Discharge Fund.
King’s College London Mapping of specialist primary health care services for homeless people in England.
While there are no specific guidelines on homelessness, other guidelines do recognise that there is a relationship between homelessness and specific health conditions including:
- borderline personality disorder: treatment and management (CG78)
- antisocial behaviour and conduct disorders in children and young people: recognition, intervention and management (CG158)
- alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications (CG100)
- alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115)
- drug misuse – psychosocial interventions (CG51)
- quality standard for drug use disorders (QS23)
- tuberculosis (NG33)
- advice on HIV Testing (LGB21)
- severe mental illness and substance misuse (dual diagnosis) (in development, expected November 2016)
- NICE Clinical Pathway for Hepatitis B and C testing
- NICE Clinical Pathway for Oral Health Needs Assessment
- quality standard for transition between inpatient hospital settings and community or care home settings for adults with social care needs (QS141)
Resources are available to help healthcare professionals stay up to date on the latest evidence base and practice developments.
The Queen’s Nursing Institute manages a homeless health network and publishes Homeless Health News every 2 months, and offers other guidance, reports and free learning events and e-learning open to all health professionals working with homeless people.
Homeless Link provides a source of homeless health resources for practitioners working in all sectors, including health, and enables access to data from local audits of health needs and surveys of local provision.
The Care Quality Commission provides examples of good practice and inspection reports from specialist homeless health GP practices (all ‘outstanding’) are also a good source of information.
The Faculty for Homeless and Inclusion Health provides online resources and standards for commissioners and providers as well as opportunities to learn and network for health care professionals, and others working in this and related fields including vulnerable migrants, Gypsies and Travellers, sex workers.
Crisis is a source of research and guidance primarily in relation to homelessness as experienced by single people, including people who are sleeping rough.
Revolving Doors and Making Every Adult Matter are sources of research, guidance and examples of positive practice in relation to people experiencing homelessness, who have other needs relating to mental health problems and/or substance misuse, and have often had experience of the criminal justice system.
A number of academic institutions are particularly interested in homelessness and health and generate useful research including:
- King’s College London runs a homelessness research programme
- Heriot Watt’s work on homelessness, severe and multiple disadvantage and social exclusion
- The Centre for Housing Policy at the University of York