Integrated health and social care for people experiencing homelessness

Context

This guideline includes recommendations on ways to improve access to and engagement with health and social care services for people experiencing homelessness. It also gives advice on how commissioners, planners, providers and practitioners across disciplines and agencies can work together to support and improve outcomes for people experiencing homelessness.

In this guideline, 'people experiencing homelessness' means people aged 16 and over who:

Underlying causes of homelessness include structural, societal and economic factors, and inequalities, such as poverty and deprivation, unaffordable housing, unemployment, exclusion and discrimination. People experiencing homelessness often experience severe and multiple disadvantage and unmet health and social care needs that may be contributing factors for becoming homeless as well as consequences of homelessness. Experience of psychological trauma and adverse childhood events are common in people experiencing homelessness, and the prevalence of people who are neuroatypical or have a brain injury is higher than in the general population. Homelessness and access to appropriate housing is a public health issue.

People experiencing homelessness have far worse health and social care outcomes than the general population. The average age of death for the homeless population is around 30 years lower than for the general population according to the Office for National Statistics' Deaths of homeless people in England and Wales: 2019 registrations.

'Inclusion health' is a term developed to address the health and care needs of groups that are traditionally excluded, including people experiencing homelessness. The needs of the homeless population overlap considerably with other inclusion health groups. Internationally, these groups have mortality rates that are 8 times higher than the general population for men and 12 times higher for women (Aldridge et al. 2017). Many of these premature deaths are from preventable and treatable conditions according to a 2019 study by the same authors (Aldridge et al. 2019). The Office for National Statistics' 2019 report showed that the causes of most deaths of people experiencing homelessness in England and Wales were registered as drug-related poisonings, suicides and alcohol-specific deaths.

People experiencing homelessness use more acute hospital services and emergency care than the general population. When admitted to a hospital, the length of hospital stay is usually much longer because of multiple unmet needs. Barriers to access and engagement with preventive, primary care and social care services can mean that problems remain untreated until they become very severe and complex. These barriers include stigma and discrimination; lack of trusted contacts; fragmented, siloed and rigid services; strict eligibility criteria; and lack of information sharing and appropriate communication.

In addition to a moral responsibility, there is an economic imperative to tackle homelessness. The costs of homelessness to society are significant. The report by Pleace and Culhane (2016), published by Crisis, estimated the total public sector costs of a person experiencing homelessness to be as much as £38,736 per year in England (based on 2019/20 prices). This estimate included the NHS costs (£4,298), mental health services (£2,099), drug and alcohol services (£1,320), criminal justice sector costs (£11,991) and homelessness services (£14,808). On average, it was estimated that preventing homelessness for 1 year would reduce the public expenditure by approximately £10,000 per person. In 2020/21, 11,580 single households were assessed as rough sleeping in England (Ministry of Housing, Communities & Local Government, 2021), and if these people were prevented from experiencing 1 year of homelessness, annual public spending would fall by as much as £115.8 million. If other forms of homelessness were included, these cost savings would be substantially higher. Given the financial implications of homelessness to society and the far worse health and social care outcomes, most interventions that address homelessness are likely to be cost effective or even cost saving from the wider public sector perspective.

The Ministry of Housing, Communities & Local Government's rough sleeping strategy outlines its commitment to ending rough sleeping and preventing homelessness. The homelessness legislation includes duties for local authorities to assess, prevent and relieve homelessness. The NHS Long Term Plan includes a commitment to improve access to specialist homelessness mental health support for people sleeping rough in areas with the highest rates of rough sleeping. During the COVID‑19 pandemic, local authorities, health services, and the voluntary and charity sector have worked in partnership to respond to homelessness, including the 'Everyone In' initiative, recognising that rough sleeping and homelessness are public health issues. This has shown that with appropriate funding, integrated working and prioritisation of the most vulnerable in the society, there are opportunities for positive change.

This guideline provides guidance on models of service provision, for services that are specific to people experiencing homelessness, as well as improving access and engagement with mainstream services. It aims to integrate services as much as possible as a way to improve outcomes for people experiencing homelessness and contribute to ending homelessness.