Integrated health and social care for people experiencing homelessness

Why the committee made the recommendations

There was qualitative evidence that people experiencing homelessness feel that they are offered less or lower quality care than the general population. Although the committee agreed that there were some limitations to the evidence, their experience corresponded with this. The evidence also highlighted various barriers to accessing care. Considering the multiple disadvantages and disproportionately poor outcomes observed in this population, the committee agreed that more effort and targeted approaches are often needed to level up outcomes. This also aligns with the NHS Constitution's first key principle of providing comprehensive service available to all, and its 'wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population'.

How the recommendations might affect services

The recommendations outline principles of good practice that in the committee's view should be happening across all services for people experiencing homelessness. However, practice is variable, and this may represent a change in practice for some services. Most recommendations would not lead to a significant resource impact, but may involve staff training and longer contact times. Any additional costs are likely to be offset by the benefits of improved engagement with care, for example, by accessing care before a crisis and reducing the burden on emergency services.

Economic analysis also suggested that reducing caseloads (and thus increasing time spent with clients) for practitioners working with people experiencing homelessness could be cost effective.

Return to recommendations

Why the committee made the recommendations

There was good qualitative evidence that people experiencing homelessness often experience stigma and discrimination and feel oppressed and unwelcome. Good evidence also reported that insensitive communication and closed body language are common experiences for them. Service users reported preferring simple language and explanations, instead of jargon, because it gives a sense of comfort and is more accessible.

The committee agreed with the evidence and discussed the merits of non-judgemental, recovery-oriented language. They agreed that the way in which practitioners communicate can have an impact on people's recovery journey, their willingness to engage with services, their sense of hope and their potential for recovery. The committee discussed the importance of using sensitive language that does not lead to the person feeling blamed for their issues (for example, avoiding phrases like substance 'abuse' or 'failed' to attend).

There was limited qualitative evidence on people's preferred communication methods, which reported that receiving appointment information by letter was ineffective for people without a reliable address. The committee discussed that letters are still the main method of communication for many service providers. Good qualitative evidence also showed that people without access to the internet and those without a phone have difficulties accessing healthcare (digital exclusion). The evidence corresponded with the committee's experience, recognising that various methods based on the person's preferences and communication needs should be available to improve timely contact and access to services.

The committee discussed that resources and forms are often written in a complex way and mostly available only in English. They agreed that this is a further barrier for people whose first language is not English. Good qualitative evidence also suggested that low literacy levels among some people experiencing homelessness can add to difficulties in accessing care. The committee agreed that this could include some migrants and people with learning disabilities or acquired brain injury. They therefore emphasised the need to tailor communication and information provision to people's needs and preferences, taking into account a wide range of possible speech, language and communication difficulties.

Good qualitative evidence showed that the presence of an advocate (including a peer advocate) helps people experiencing homelessness to gain confidence and a sense of control over their health and care needs. The committee had confidence in the evidence and agreed, based on their experience, that advocates (including peer advocates) can play a significant role in supporting people with correspondence and attending appointments, and in bridging the gap between practitioners and people experiencing homelessness. The committee were also aware that NICE is developing a guideline on advocacy services for adults with health and social care needs (publication expected September 2022).

The committee noted that the advocate could be someone who the person is familiar with, such as a family member or a friend. But they also noted that some people may be entitled to an independent advocate under certain circumstances. For example, the Care Act 2014 mandates that local authorities must arrange an independent advocate to support and represent a person to assist in their involvement in specified social care processes if the person has substantial difficulty in being involved in the process, and if they do not have an appropriate person to support them.

Moderate-quality evidence from qualitative studies showed that people experiencing homelessness felt that there was a lack of help or information about services available to them (such as overall entitlement to care, oral health, maternity services, screening and infectious diseases). This corresponded with the committee's experience, and they agreed that to improve engagement with health and social care services, it is important to give people information, support access, and make sure that they know their rights to health and social care. They considered this particularly relevant for migrant populations who may not be familiar with the local health and social care system and their entitlements, or who may have limited or no recourse to public funds.

How the recommendations might affect services

These recommendations reinforce existing NICE guidelines on communication and information provision for the general population. However, there are some aspects that may need particular attention when working with people experiencing homelessness. There may be a need for some extra staff training on communication, and on the available health and social care services and support for people experiencing homelessness, including legal entitlements for care.

Giving everyone – including staff – the right information about what services are available will help relationship and trust building, and may lead to better access and engagement with services. For example, people may be more likely to access primary care services or specialist services directly instead of relying on emergency services. This can lead to problems being picked up and dealt with earlier, reducing morbidity and mortality, and associated costs such as for crisis care, and unplanned or emergency care.

Services already use various communication methods to support access to and engagement with services. But tailoring the method to each person's preferences and needs may need some reorganisation of current practice.

Advocate roles could be carried out by a professional or a peer supporter, or sometimes a family member or a friend. There are various advocacy models aimed at facilitating the relationship with service providers, and supporting people to access information and services or attend appointments. Any additional costs could be offset by the beneficial effect on the person's recovery including potential reductions in morbidity and mortality. For example, there is a link between non-attendance at appointments and increased morbidity and mortality in people experiencing homelessness.

Return to recommendations

Why the committee made the recommendations

How the recommendations might affect services

Although there are legal requirements to collaborate under the Care Act 2014 and the National Health Service Act 2006, health, social care and housing services have different legislative and commissioning frameworks and the committee discussed that collaboration is sometimes challenging and the level of integration varies.

Services working in silos can increase the risk of undiagnosed or misdiagnosed conditions across the mental, physical and disability spectrum, cause morbidity and mortality, and result in substantial costs to services. Commissioners and planners will need to ensure that frameworks are in place to support integrated multidisciplinary health and social care services where this is not already happening. For example, by facilitating coordinated multi-agency and multidisciplinary working, and strengthening information sharing and communication systems.

Improving integrated service provision should lead to improved outcomes, more appropriate use of services, and a lower need for emergency care and hospital admissions, reducing associated costs. Services will need targeted efforts to improve outcomes and to meet the needs of people experiencing homelessness, and commissioners will need to plan for more funding per person than in mainstream services. However, this should lead to savings later on.

Joint Strategic Needs Assessments are done by public health teams within local authorities, but there is some variation in the extent to which the health and social care needs of people experiencing homelessness are considered, and service users and experts by experience are involved. When done thoroughly and with all the relevant information, including relevant findings from Safeguarding Adults Reviews, it can inform targeted and efficient provision (for example, specialist service provision) and identify opportunities for more integrated services. This will also ensure that services meet local needs, and improve access and engagement. This will reduce morbidity and mortality, and reduce public sector costs associated with homelessness.

Most services have ways to record data on housing status for audit purposes. This would not be a new practice, although some services might not be doing it or do not have processes flexible enough to record it in a meaningful way. Services could improve this by adjusting existing data-recording methods.

Compared with current practice, commissioners may need to look across a larger footprint to develop services. This approach will also enable them to account for mobility and people experiencing homelessness not being tied to a specific place. This may mean commissioning groups coming together to form partnerships.

Involving peers in delivering care or support and co-designing services is already happening in some areas and organisations, particularly in the voluntary and charity sector. It will involve costs in terms of training and support for peers and potential incentives or remunerations; however, involving peers can reduce pressure on practitioners and therefore result in cost savings. There was evidence that it can be cost effective.

Access and engagement with services may not be straightforward in this population, so commissioners will need to ensure multiple ways of enhancing access to care. There are examples of good practice across the country, but practice is variable. Services will have to consider approaches that can be tailored to the specific needs of the person. Currently, because of the lack of flexible services, people often end up in crisis and use expensive emergency services, or do not access services, resulting in disproportionately complex morbidity and premature mortality.

GP registration refusals are relatively common in current practice and commissioners and planners will need to reinforce NHS guidance and support GP practices to ensure that people experiencing homelessness can access GP services.

Finally, economic analysis carried out for the guideline suggested that reducing caseloads for practitioners who work with people experiencing homelessness could be cost effective.

Lower caseloads will mean that services will have to recruit more staff, which might be challenging in some areas. However, availability of trained staff should not be a barrier; for example, services may find it easier to recruit staff to junior roles and provide on-the-job training.

Return to recommendations

Why the committee made the recommendations

How the recommendations might affect services

Models of service provision vary in current practice. In some areas with high rates of homelessness, there are no specialist homelessness multidisciplinary teams, or services are often focused on a single aspect of care or are mainly medically led; for example, mental health teams, drug and alcohol treatment services, community-based or hospital-based multidisciplinary teams, or housing-related multidisciplinary teams. Many multidisciplinary teams do not cover the wide range of support that is needed. Services will need to involve practitioners from across multiple agencies to make sure that the team has relevant expertise.

Recommendations on multidisciplinary teams may mean a change in service configuration. However, there may not be a need to employ new staff but to reorganise, collaborate with other agencies and form a team from existing professionals. Forming a multidisciplinary team may entail pulling together a team from different services working with a person experiencing homelessness. Alternatively, it may involve having a permanent integrated multidisciplinary team under single management within a service (that is, a coexisting co-located team), which would represent a more substantial change.

In areas with low rates of homelessness, having designated leads on homelessness may be a change in practice, but it is unlikely to have a significant resource impact because these are not expected to be entirely new job roles. These arrangements will be different across the country, and will depend on the demand and the level of need.

There is economic evidence that homelessness multidisciplinary teams represent value for money and are potentially cost saving. Having specialist multidisciplinary teams or designated leads should mean better integration and efficiency of services, more streamlined and personalised care and improved engagement with care and support, which in turn should lead to reduced morbidity, mortality and associated costs. There will likely be a reduction in wider public sector costs, including local authority homelessness services and the criminal justice system costs, because people will be more likely to progress in their recovery journey and maintain their accommodation. Such a service model can also mean better management of resources, for example, a reduction in inappropriate referrals, inappropriate use of hospital beds, and duplication of effort.

Return to recommendations

Why the committee made the recommendations

There was some effectiveness evidence that suggested that peer support to navigate hepatitis C screening and services might help people to engage with services, and this was found to be cost effective. Other effectiveness studies also suggested that peers could increase uptake of tuberculosis screening and hepatitis vaccination to the same degree as professional staff. Although there were some concerns about the quality of the evidence on peer approaches, the committee were confident, based on their experience, that involving peers in delivering care or support and co‑designing services is efficient and beneficial, not only for the services and the people experiencing homelessness but also for the peers themselves. They also heard from expert witnesses who highlighted the value of involving people with lived experience in the development of policies, procedures and protocols.

The qualitative evidence also highlighted that people experiencing homelessness value support from peers who have similar experiences and have recovered and grown from that experience. The committee highlighted their experience and knowledge of the beneficial impact of being a peer, describing how peers can progress to become professionals if supported.

Based on the evidence and their expertise, the committee agreed to list ways in which peers may be able to support people experiencing homelessness and how peers can improve services. Peers can take up different roles in terms of intensity, responsibility and tasks, and may gradually progress in these roles. The committee emphasised that it is important to support peers with adequate supervision and governance structures, including confidentiality and data protection. Training needs of peers might include, for example, first aid and mental health first aid, safeguarding, trauma-informed care, advocacy and risk management.

Qualitative evidence highlighted the obstacles and challenges that peers might encounter, including supporting someone with similar issues to their own while trying to maintain their own recovery. The committee agreed that peers should be supported to continue their own recovery journey and development by encouraging them to progress to become professionally employed, which is beneficial in many ways for the person acting as peer support, the people they are supporting, and services.

The committee also discussed that it is important to consider how to match the peers with people they support. For example, some people may prefer or request peer support from someone with the same cultural or language background, but sometimes this may be a reason for a person to refuse peer support because of the risk of stigma or confidentiality breech.

How the recommendations might affect services

There are existing peer networks, for example, for people recovering from drug or alcohol dependency issues. There are also peers working with people experiencing homelessness in some areas and in some organisations, in the voluntary and charity sector in particular. But the committee agreed that there is the potential to involve more experts by experience in service design and delivery. Peer support has the potential to improve access to and engagement with services, and reduce morbidity and mortality, and associated public sector homelessness costs. There may also be important benefits to peers themselves, leading to better long-term outcomes.

Peers could be recruited through homelessness services or in collaboration with voluntary and charity sector organisations and housing associations. Services will also need to provide support and training for peers as well as incentives or remuneration. Involving peers can reduce pressure on practitioners and can result in cost savings. Organisations may need to adjust their recruitment practices and policies to lower barriers to the employment of peers.

Return to recommendations

Why the committee made the recommendations

People experiencing homelessness are often unable to access health and social care because of barriers at systemic, local and individual levels. Various themes from mixed qualitative evidence highlighted examples, such as strict eligibility criteria, rigidity of appointment systems, limited opening times, short appointments, long waiting lists, siloed services in multiple locations, cost of transport and experiences of stigma and discrimination. The committee also drew on their own knowledge and experience of these barriers to access.

The committee agreed that an outreach model, in which the services go to the people instead of expecting people to come to them, is a helpful established approach to reaching people who do not access services. There is limited effectiveness evidence on outreach models, although evidence on a London-based outreach service to screen vulnerable people for hepatitis C and offer peer support for getting treatment in secondary care was shown to be cost effective. Moderate-quality evidence from qualitative studies suggested various benefits of outreach services, including increased access to immediate care and increased knowledge of health issues, available services, and healthcare entitlements. The evidence also highlighted that outreach services can be more flexible than traditional healthcare services and that bringing services to people builds a feeling of trust and connection with service providers while reducing the sense of isolation. The committee considered outreach services important to identify people who might otherwise be missed. They had confidence in the evidence and agreed that it corresponded with their experience.

There was good but limited effectiveness evidence that community drop-in services are helpful in reaching people and are preferred by service users. There was also good qualitative evidence that services are often complex, fragmented and difficult to navigate. The committee agreed that providing information and support to navigate care and services can improve people's access to and engagement with health and social care. Based on their knowledge and experience, the committee suggested approaches that could improve access and engagement. For example, low-threshold services that avoid restrictive eligibility criteria and make minimal demands on the client by offering support and care without trying to influence their habits; providing food, vouchers, transport support, internet access or other practical help can incentivise and enable people to engage with care; and providing psychologically informed environments and trauma-informed care can improve engagement with people who often have underlying negative and traumatic experiences.

The rigidity of appointment systems can lead to people being dropped from services if they miss appointments. There was some limited qualitative evidence illustrating the difficulties people experiencing homelessness face when they miss appointments. Some services have policies that prevent people accessing care at that service again or financial penalties for missing appointments. Based on the committee's experience, this is a major problem for many people experiencing homelessness and they agreed that services should show flexibility and understanding to facilitate engagement. The committee discussed the clear association between missed appointments and premature death and agreed that providing more flexible appointment systems and alternative ways of accessing care is therefore essential in improving outcomes.

High-quality evidence from qualitative studies highlighted that strict eligibility criteria to access healthcare services sometimes forced people into crisis situations before help could be provided, or excluded them from accessing services altogether. Based on the committee's expertise, this is particularly prevalent among people with coexisting mental health problems and drug or alcohol treatment needs, which are common among people experiencing homelessness. Sometimes, people with coexisting mental health problems and learning disability can be excluded from accessing the respective services.

Some services, particularly in social care, may have minimum age criteria that can stop people getting the support they need. Premature aging and frailty, defined by the British Geriatrics Society, the Royal College of General Practitioner, and Age UK as 'a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves', are common among people experiencing homelessness with severe and multiple disadvantage, so care and support should be based on assessed need, not biological age. Flexibility in the eligibility criteria could prevent the situation from escalating and help people to receive support earlier, leading to better outcomes.

Good qualitative evidence highlighted that some people are unaware of the free or low-cost services available to them, particularly dental care, if relevant paperwork has been processed. The committee discussed their experience that often these forms that enable free access to essential services such as eye care, prescription costs and dental care (such as HC1 and HC2) are not readily available, or are only available electronically. The forms can be challenging to fill in and only available in English.

The committee considered digital exclusion to be a major barrier to accessing health and social care. Qualitative evidence showed that people without access to the internet and those without a phone experienced difficulties in accessing healthcare.

The NHS Primary medical care policy and guidance manual states that everyone in England can register with a primary care provider free of charge. This includes people experiencing homelessness, people without a stable address, asylum seekers and refugees. However, according to good qualitative evidence and the committee's experience, many people experiencing homelessness are still refused registration with a GP. Resources are available from the NHS on improving access for all: reducing inequalities in access to general practice services.

The committee were keen to highlight the legal duties of public sector workers as mandated by the Homelessness Reduction Act 2017. In particular, the duty to refer anyone who is identified as being homeless or at risk of homelessness to the local authority. They discussed that despite the legal requirement, this does not always happen in current practice because processes are not in place to do this, and frontline staff lack time and knowledge. An expert also highlighted the need for health and social services to improve legal knowledge among their staff. Guidance on duty to refer from the Department for Levelling Up, Housing & Communities and Ministry of Housing, Communities & Local Government gives an overview of the legal duty. The Department for Levelling Up, Housing and Communities' code of guidance advises local authorities on how they should exercise their homelessness functions in accordance with the Homelessness Reduction Act 2017. The committee discussed that every encounter with a person experiencing homelessness could be an opportunity for engagement with care and support. Approaches such as Making Every Contact Count and Making Every Adult Matter could be used to facilitate this and help frontline staff better understand the services available for onward referral.

The qualitative evidence highlighted that long waiting times are a barrier to accessing and engaging with health and social care, affecting people experiencing homelessness in particular. The committee agreed that people experiencing homelessness are a priority because their multiple disadvantages put them at an increased risk of deterioration and premature mortality and morbidity. They discussed that long waiting times can be particularly challenging for people experiencing homelessness and can mean that the opportunity to engage with them is missed altogether, for example, if the person moves to another area or forgets about the appointment. They also discussed that people experiencing homelessness may have particular difficulty coping psychologically with long waiting times because of the fundamental feeling of unsafety and exclusion that homelessness causes. Long waiting times could lead to further deterioration of physical and mental health, and could compound feelings of disengagement and exclusion.

How the recommendations might affect services

Current practice is variable. For services that do not have multiple points of access to care or flexible services, these recommendations will represent a change in practice. Services will need a variety of approaches that can be tailored to specific needs. Currently, because of the lack of flexible services, people are using expensive emergency services or are not accessing services at all, resulting in excess morbidity and mortality, and associated high public sector homelessness costs. For example, inflexible appointment systems increase the risk of missing appointments, and there is a link between missed appointments and premature mortality. Missed appointments also cost the NHS millions of pounds a year; for example, missed GP appointments in the general population cost NHS England around £216 million a year in addition to the disruption for staff and other patients (Missed GP appointments costing NHS millions, NHS England 2019).

Transport costs are a considerable barrier to access to and engagement with services, and continuity of care. Practice is variable between different areas. People experiencing homelessness often have multiple morbidities, which could make them eligible for a free travel pass, but often do not have one because of bureaucratic challenges. Currently, a clinician (usually a doctor) needs to sign the paperwork for a free travel pass. Services could broaden the list of professionals able to approve applications, which could make free travel easier to access. The cost of providing free travel will be relatively low compared with the cost of missed appointments and the costs relating to unaddressed needs. For example, an annual bus pass in London costs approximately £900 (Transport for London bus and tram fares), but if a person with a leg ulcer misses multiple appointments, then this may lead to an infection and in some cases amputation, costing the NHS at least £8,000 (NHS England National cost collection for the NHS), in addition to the impact on the person. Services will need to work collaboratively to agree who will cover travel costs within their local system.

Some mental health or drug and alcohol recovery services will need to modify their eligibility criteria. This may lead to more people accessing services. But there may also be savings from avoiding crisis situations and unplanned care and providing more efficient support, leading to better long-term outcomes.

More practitioner time may be needed to help people with forms and other paperwork. But this can help prevent deterioration and the need for more expensive care, for example, emergency care, in the future.

In recent years, there has been an increase in the use of digital approaches to providing support within the homelessness sector. To avoid this leading to digital exclusion, some services may need to improve access to online health and social care information and support. There may be some costs associated with this, but providing access to digital services and information can improve engagement with services and avoid the need for costly emergency care.

A significant barrier to accessing health and care services for people experiencing homelessness is that GP practices ask for an address when registering. Recommendations on this reinforce NHS guidance and should result in more people registering with a GP and accessing services that they are eligible for and entitled to. This has the potential for substantial reductions in morbidity and mortality, and public sector costs associated with homelessness.

There is variation in the extent to which frontline staff are aware of their legal duties under the Homelessness Reduction Act 2017, including the duty to refer. Services may need to support their staff in legal literacy and to have the skills and knowledge to identify and support people experiencing homelessness. Training could be delivered in low-cost ways, such as remotely, using pre-recorded sessions, and could coincide with existing training. Both governmental and voluntary organisations have produced materials that are readily available online. The cost for this is therefore not expected to be significant and it could lead to better and more efficient care. Timely and appropriate care can avert the need for expensive crisis care and A&E visits, and reduce other public sector costs associated with homelessness.

Long waiting times for appointments in current practice are a significant barrier for engagement and timely care. Situations can quickly deteriorate, or the person might disengage because their needs are not being met. Shorter waiting times for people experiencing homelessness may avoid a crisis, lower the chances of needing expensive emergency services, and prevent complex morbidity and premature death.

Return to recommendations

Why the committee made the recommendations

Qualitative evidence highlighted that people experiencing homelessness often face barriers to accessing services through standard routes, and are often disengaged with health and social care. Outreach is an established way to bring services to people who may otherwise find it hard to reach them. There is limited effectiveness evidence on outreach models, although evidence on a London-based outreach service to screen vulnerable people for hepatitis C and offer peer support for getting treatment in secondary care was shown to be cost effective.

Moderate-quality evidence from qualitative studies suggested various benefits of outreach services, including increased access to immediate care and increased knowledge of health issues, available services, and healthcare entitlements. The evidence also highlighted that outreach services can be more flexible than traditional healthcare services and that bringing services to people builds a feeling of trust and connection with service providers while reducing the sense of isolation. The committee considered outreach services important to identify people who might otherwise be missed.

Because people experiencing homelessness have a wide range of health and social care needs, the committee agreed that outreach teams should be multidisciplinary and also equipped to respond to needs of people with different, intersecting experiences relating to, for example, gender, ethnicity and being part of the LGBT+ community. Evidence from several economic studies showed that a multidisciplinary approach in general provided value for money in relation to the homeless population. While this was not specific to outreach teams, the committee agreed that given the severe and multiple disadvantage people experiencing homelessness often face, multidisciplinary outreach teams are justified and essential for meaningful response to people's needs.

Good qualitative evidence showed that some people who are resistant to support or who feel overwhelmed by it might feel more motivated if ongoing support is available, including repeated attempts to engage with the person without placing pressure on them. The committee agreed, based on their knowledge and experience, that an 'assertive outreach' approach is useful in improving engagement for those who may be reluctant to engage with services and who would benefit from a high level of support. 'Assertive outreach' is most often used for people with complex mental health needs and drug or alcohol treatment needs. This is in line with the recommendations about maintaining contact with services in the NICE guideline on coexisting severe mental illness and substance misuse. The committee agreed that this approach could also be considered for other people experiencing homelessness who are likely to benefit from health and social care but who are disengaged, for example, because of lack of trust or previous negative experiences.

How the recommendations might affect services

Outreach is used in current practice in many areas to deliver a range of services, including primary care, mental health, opiate prescribing, and testing for chronic or infectious diseases such as hepatitis and tuberculosis, although the services provided through outreach vary depending on location. Outreach can happen in multiple settings, such as streets, parks, hostels, day centres or soup kitchens. Services generally understand its value in enabling access and engagement with health and social care, but commissioning of outreach services for people experiencing homelessness varies.

Additional resources may be needed to set up outreach in areas where it is not happening already. However, it has great potential to support this population, and improve engagement with services and long-term outcomes. It can also bring savings, for example, by avoiding missed appointments and visits to the A&E department.

Assertive outreach is used in some areas in current practice, particularly when engaging with people with complex mental health needs. It takes more practitioner time and may be more expensive, but persevering with people and improving engagement among people who would benefit from support is likely to substantially improve the health and wellbeing of people who have been marginalised, and reduce morbidity and mortality, and associated public sector homelessness costs.

Return to recommendations

Why the committee made the recommendations

There was no evidence on the effectiveness of different approaches to improving access to services through needs assessments, so the committee used their knowledge and experience to make the recommendations.

The committee were keen to emphasise the statutory and professional duty that health and social care professionals have to identify immediate risk of harm to self or others, in line with the Care Act 2014 and the Mental Health Act 1983, and professional codes such as the Nursing and Midwifery Council Code, General Medical Council's Good medical practice and Social Work England's Professional standards. The committee were aware of case reviews and Safeguarding Adults Reviews on people experiencing homelessness showing that this risk had been missed, leading to death. This is particularly relevant in the context of homelessness because there is a significant link between homelessness and risk of abuse, neglect and violence, serious mental health problems, self-harm and self-neglect, underpinning the disproportionate rate of premature mortality in this population.

The committee agreed that a comprehensive, holistic health and social care needs assessment within the context of the individual's wider circumstances improves access to health and social care and support that matches the person's needs. They agreed that a multidisciplinary approach is needed to ensure that the full range of health and social care needs are identified, including considering risk and safeguarding issues. Collaborative working also reduces unnecessary duplication and improves communication between professionals working in different services.

The committee were concerned that assessment is commonly perceived by people experiencing homelessness as a process of exclusion. People often have to keep repeating their stories and the assessments can turn into an assessment of eligibility for support rather than a person-centred attempt to understand a person's needs and circumstances. The committee agreed that involving the person in their own assessment process and involving a peer or an advocate could help improve the assessment process. Peers and advocates (who may be peer advocates) can play an important role in bridging the gap between the person experiencing homelessness and professionals. They can make the assessment process feel less formal and therefore more acceptable or accessible to people experiencing homelessness.

The committee were aware that hospital admissions related to homelessness have been increasing. They agreed, based on their knowledge and experience, that hospital admissions are an opportunity for a comprehensive and holistic assessment of a person's needs to enable appropriate personalised care planning that integrates health, social care and housing needs. A hospital stay can be an opportunity to start addressing the often complex and underlying issues that have led people to their situation.

The committee agreed that a comprehensive understanding of the person's physical, mental and social care needs as well as the underlying circumstances of their situation will help when conducting the statutory care and support needs assessment under the Care Act 2014, which sets out local authorities' duties to assess people's needs and their eligibility for publicly funded care and support. The committee noted that the recommendations on care and support needs assessment and care planning in NICE's guideline on people's experience in adult social care services provides advice on conducting the care and support needs assessment under the Care Act.

The committee were also aware that some people may be entitled to an independent advocate under certain circumstances. For example, the Care Act 2014 mandates that local authorities must appoint an independent advocate to support and represent a person in the local authority-led care, and support needs assessment or safeguarding enquiry if the person has substantial difficulty in being involved in the process, and if they do not have an appropriate person to support them.

The committee pointed out that after the person's needs are established and support planned to meet these needs, many people experience difficulties with ongoing support. Because the needs assessment process can be challenging, the committee agreed that the person's support needs should be reviewed as needed, when their situation changes or if they request it, but not based on standard review periods.

How the recommendations might affect services

Identifying immediate risk of harm to self or others reinforces a statutory and professional duty, and does not represent a change in practice.

A comprehensive assessment of health and social care and support needs involves a multidisciplinary approach, can be time-consuming and needs collaboration between professionals from different agencies. This should be happening across all services. However, practice is variable and these recommendations may represent a change in practice and result in a resource impact for some services.

Hospital admissions are good opportunities to provide a comprehensive and holistic assessment of safeguarding, physical and mental health, drug and alcohol treatment needs, and social care needs for people experiencing homelessness. This does not often happen in current practice and the committee thought that this was a missed opportunity to assess the person's comprehensive needs and start integrated care. The recommendations in this area may mean that services will need to plan for more tests, procedures and practitioner time. This could prolong a hospital stay, although discharge to the community would likely be safer and future admissions could be avoided. Such a proactive approach could have benefits in the long term, such as preventing people from getting into crisis because of unidentified needs, and reducing morbidity and mortality, and associated homelessness costs.

As a result of the recommendations, more people experiencing homelessness who may benefit from high levels of support may have an assessment of social care needs and go on to engage with services. But an appropriate assessment of the health and social care needs of some of the most marginalised people in society will ensure timely and appropriate care and support for them, with a potential for reduced morbidity, mortality and associated public sector costs.

Return to recommendations

Why the committee made the recommendation

Intermediate care is a multidisciplinary service that helps people to be as independent as possible and provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. Evidence from several economic studies suggested that it is cost effective and potentially cost saving. The committee agreed that providing such services would help avoid hospital admissions and ensure safe and timely discharge from hospital and transition to the community. Intermediate care can also prevent or shorten expensive inpatient care and provide appropriate care and support to people in need of more intense support than otherwise provided in the community.

How the recommendation might affect services

Intermediate care, including step-down and step-up care, would represent a change in practice because this service is currently rare for people experiencing homelessness. This would need some funding but there is evidence that intermediate care represents value for money. Furthermore, considering the immense human and societal costs of homelessness, providing care that can support recovery and prevent repeat homelessness is likely to be beneficial to society overall. Intermediate care can be delivered in the community, such as in suitable hostels, or in designated facilities.

Return to recommendation

Why the committee made the recommendations

The committee discussed that people experiencing homelessness can be vulnerable during transition periods. However, testimony by expert witnesses also highlighted that these can also be opportunities for engagement and intervention. The committee agreed that transition periods can be a chance to build foundations for lasting support in the community.

The committee noted that a phased, focused and person-centred approach to transitions is currently unusual. Often the person is discharged or moves between services, settings or areas without thorough planning, follow up or coordination. For example, sometimes the person's homeless status and related needs are identified only at the point of discharge from hospital into the community. Identifying needs and collaboration between professionals and agencies is therefore essential.

Effectiveness evidence comparing 'critical time intervention' (time-limited intensive support during a transition period) with usual care among people experiencing homelessness, including discharge from psychiatric inpatient care and moving from a homeless shelter to the community, showed benefits in terms of mental health service use, housing status and reduced psychiatric re-hospitalisation, although no difference in quality of life was reported. Despite some methodological limitations and mixed results in the evidence, the committee agreed that the general approach and key principles of critical time intervention should form the basis of recommendations on support for key transitions. This is because any transition between settings can be challenging, with a risk of people falling through the gaps, but with appropriate support, it can also be an opportunity for improved engagement and recovery.

The 'critical time intervention' model includes establishing a trusting and enduring relationship, and a gradual decrease in the intensity of support over a fixed period of time. The time period in the studies was 9 months, but the committee agreed that the length of time needed for intense support during transition would depend on the circumstances and needs of the person. The committee agreed that, to make successful transitions, it is fundamental to start support before the move and continue it during and after transition. This needs an effective and coordinated handover across teams and practitioners. Good qualitative evidence highlighted that staff from all types of services recognised that most care is provided in silos with minimal coordination between agencies and providers. The findings emphasised the need for a more coordinated approach with appropriate information sharing. Good-quality evidence from qualitative studies also emphasised the importance of information sharing between practitioners so that people do not have to repeatedly give the same information. A trusting relationship is also more likely when support is from a single person throughout, or a coordinated team, reducing the need to repeat life stories and any associated trauma. Critical time interventions are seen as a holistic approach to support. The committee wished to reflect this, emphasising the need to link people with other services and the wider community, according to their needs and preferences.

Irregular discharge (self-discharge against medical advice) represents a missed opportunity for services to engage with a person experiencing homelessness and to start integrated care. A common cause of self-discharge is when people experiencing homelessness have a history of problem opioid use and do not have access to the right dose of methadone according to their treatment plan in the community, so they self-discharge to address their withdrawal symptoms.

For some people with drug and alcohol treatment needs, a hospital admission is an opportunity to detox. If people experiencing homelessness return to the streets without appropriate support after detox, they have an increased risk of overdose and a risk that any care plans will fail. It is important that there are procedures to minimise self-discharges and prevent discharges to the street so that risks can be reduced, and discharges are as safe as possible. Reviewing incidents of self-discharge or discharge to the street can improve procedures and care in the future. The Department of Health and Social Care's Hospital discharge and community support: policy and operating model refers to the King's College London's support tool and briefing notes on transforming out-of-hospital care for people who are homeless, which outlines how safe and timely transfers of care can be delivered.

The committee also highlighted other NICE guidelines that cover important transition periods that may be applicable to people experiencing homelessness.

How the recommendations might affect services

There is wide variation in the support provided during transitions between settings. The recommendations should increase sustained support and lead to a more coordinated response to needs. This in turn could lead to reduced re-attendance after leaving hospital or breakdown of tenancy, and reduced morbidity and mortality.

Procedures to review cases when a person experiencing homelessness has self-discharged or has been discharged to the street may be a change in practice for some hospitals. But, by learning from these situations and improving practice, there would be an opportunity to prevent irregular discharge in the future and improve outcomes for patients. Having a dedicated homelessness multidisciplinary team or designated homelessness lead working with the discharge team can help strengthen links to community services where people get methadone to ensure they continue to receive the right dose in hospitals. Enhanced connections with social services and local authorities will help link people experiencing homelessness to the right support. This may need additional resources, but reductions in morbidity, mortality and associated costs should offset additional costs in the long run. There was evidence that effective hospital discharge represents value for money.

Return to recommendations

Why the committee made the recommendations

Access to suitable accommodation is a key determinant of health and social care outcomes. The committee discussed, based on their knowledge and experience, that there are various aspects of accommodation that can either hinder or help a person's recovery process and their engagement with health and social care. These might include practical and logistical considerations, such as the distance to health or social care services, accessibility, aids, and appropriate storage for medication.

There was good effectiveness evidence from the Housing First trials that people are more likely to stay housed if their accommodation has wraparound health and social care support. There was also evidence that this approach could be cost effective. The committee's experience of health and social care services designed to support housing was positive, and tenancy sustainment was commonly achieved through this wraparound approach. The committee agreed, based on their knowledge and experience, that the level of support depends on the person's needs, with some people needing specialist onsite support. These could be people with high levels of need or severe and multiple disadvantage who are vulnerable to abuse and exploitation, young people who have no experience of independent living, people who have experienced domestic abuse, or people with particular care needs who need support in everyday life because of premature aging, acquired brain injury or disability.

The committee discussed the lack of evidence on how to improve needs-based wraparound support for people with severe and multiple disadvantage and premature frailty, particularly those who have experience of rough sleeping. The committee made a research recommendation on the structural and systems factors in health and social care that could help or hinder commissioning and delivery of wraparound support integrated with housing and they agreed that research in this area should consider inequalities and collect data that enable the impact on different groups to be studied. The equality impact assessment provides further information on equalities considerations for this guideline.

Moving into independent accommodation may seem like a positive transition, but based on the committee's experience, this can be one of the most difficult times for people who may have a history of traumatic experiences, have severe and multiple disadvantage, feel profoundly unsafe or have low self-confidence. Such a transition often causes the person to reflect on what has happened to them, which can be triggering and cause re-experiencing of trauma. It can lead to relapses in recovery, including problems with drug or alcohol use. Furthermore, people living in temporary accommodation or on the streets can form bonds with their peers that provide mutual support and a sense of belonging. This may be replaced by a feeling of isolation and loneliness when moving into independent accommodation. Effectiveness evidence on 'critical time interventions' showed that time-limited intense support, gradually lowered over time during transition periods, did not sustain all benefits over time, so the committee agreed that emotional and practical support should be provided for as long as is needed in this situation.

The committee also agreed that an assessment of the risks that could jeopardise the person's recovery, alongside recognition of their strengths, can help recovery, inform appropriate support needs and help people to stay in housing.

How the recommendations might affect services

There is variation in current availability and provision of health and social care support associated with housing. The recommendations aim to reduce variation in practice.

The Housing First model has been used in England to some extent and there is evidence that it represents value for money, but the associated wraparound support is variable and sometimes lacking. To provide wraparound care and support, better collaboration is needed between housing, health and social care services. Services may need to reorganise existing resources, including improving communication between agencies and services and allowing more practitioner time.

Local authorities should already have a range of housing options for differing support needs, although in some areas, accommodation with onsite support might be limited.

Additional costs of providing wraparound support with accommodation, according to needs, are likely to be offset by improved health and social care engagement and outcomes, sustained tenancy, reduced use of expensive emergency services and a reduced return to homelessness and associated costs.

Risk assessment at the start of residency is a low-cost intervention that can potentially mitigate significant harmful outcomes.

Return to recommendations

Why the committee made the recommendations

No effectiveness evidence was identified on the role of adult social work, and safeguarding in particular, in an integrated response to the needs of people experiencing homelessness. The recommendations on safeguarding are based on testimony by experts who were invited by the committee to speak about the role of social work and adult safeguarding.

The experts highlighted the importance of understanding the person's backstory and historical context that led to the current situation, recognising the link between homelessness and self-neglect, the impact of trauma and how risk-taking can be a coping strategy. Because of the value of having a trusting relationship with the person experiencing homelessness, the experts emphasised the importance of having a single key person as a safeguarding lead in an integrated service model.

Section 42 of the Care Act 2014 requires local authorities to make a safeguarding enquiry if an adult with care and support needs is experiencing or at risk of abuse or neglect. The committee agreed that a social worker within a homelessness multidisciplinary team would often be best placed to lead on these enquiries for people experiencing homelessness because of their professional expertise on the assessment and related legal duties and powers.

The experts suggested that safeguarding issues related to homeless populations have historically not been widely considered by Safeguarding Adults Boards. The committee agreed that having a homelessness lead in the Safeguarding Adults Boards could enhance learning and improve practice. The committee also agreed that Safeguarding Adults Boards have an important role in promoting understanding and best practice within local agencies related to safeguarding people experiencing homelessness, including through their statutory strategic plan and annual report and learning from Safeguarding Adults Reviews. By analysing and interrogating safeguarding notifications related to homelessness, the Safeguarding Adults Boards can also enhance their understanding of the appropriateness of local safeguarding arrangements.

Finally, the experts highlighted the need for health and social care staff to understand the legal duties and powers related to safeguarding people experiencing homelessness, so that their welfare could be protected, concerns could be identified and addressed early, and harm mitigated.

How the recommendations might affect services

There are legal duties for safeguarding under the Care Act 2014 and the recommendations in this area only highlight the existing safeguarding responsibilities of service managers and local authorities. Teams involved in active safeguarding cases should already have legal literacy around safeguarding relevant legislation and the intersection of homelessness and multiple disadvantages, but may need more training.

Currently, based on the committee's experience, people experiencing homelessness often fall through the gaps, and safeguarding concerns are not identified and safeguarding notifications are not made. There may be a resource impact for services with practices that are sub-optimal and not aligned with legislation. Safeguarding will ensure that appropriate support plans are in place to manage the risks identified. For example, a person might be supported to move to more suitable accommodation.

Return to recommendations

Why the committee made the recommendations

People experiencing homelessness often need support due to severe and multiple disadvantage, including intersecting physical and mental health needs, psychological trauma, drug and alcohol treatment needs, and social care needs. The committee agreed that sustained effort and commitment from services is needed to support their recovery journey, which may often be non-linear.

Good-quality evidence from qualitative studies showed that people experiencing homelessness often experience a lack of consistency and continuity from health and social care services. There was also good qualitative evidence that ongoing, sustained support, and a service provider's patience and continued attempts to offer support, can improve the person's engagement when they might otherwise be resistant to support. Conversely, discontinuity or interruption of care could lead to disengagement with services.

There was plenty of good-quality evidence from qualitative studies emphasising the importance of a trusting and respectful relationship between the person experiencing homelessness and the person supporting them. The evidence showed that continuity of care enabled people to form a relationship with their care provider. The committee agreed, based on their experience, that a trusting relationship is rarely built through a short-term contact but usually needs consistent and sustained contact from 1 main lead or a small team of people who are part of integrated services across agencies.

Good qualitative evidence suggested that people experiencing homelessness often prioritise their immediate needs over receiving care. The committee discussed that addressing immediate needs can be an opportunity to build long-term engagement with services.

From their knowledge and experience, the committee were aware that people experiencing homelessness did not always follow a linear recovery journey and can encounter a relapse or crisis. Therefore, the committee thought it was important that services were flexible in allowing people to easily re-engage with services so that their situation would not escalate or deteriorate further.

Premature ageing and frailty is common in people experiencing severe and multiple disadvantage and homelessness, and the committee discussed that improvements in their wellbeing can be made if long-term care and support plans take this into account.

The committee also recognised that not all people will recover and risk of premature death is higher in people experiencing homelessness compared with the general population. Palliative care has often not been available for people experiencing homelessness and those who are approaching the end of their lives may remain in for example hostel accommodation without provision of appropriate end of life care that supports the person's preferences.

How the recommendations might affect services

The recovery journey for some people can take a long time, and services need to be persistent, invest in building trust, and recognise that the process will often not be linear. Currently, long-term continued support is quite rare, and funding of services is often not aligned with such an approach. For example, tenancy sustainment teams are often underfunded and only offer time-limited support of varying quality. Offering long-term support could cost more because it may, for example, need lower caseloads, although for many people, the intensity and frequency of support will likely lessen over time. But the value of investing in systems that facilitate longer-term support and sustained care and engagement is likely to outweigh additional costs through, for example, reduced homelessness and morbidity and mortality, and associated public sector costs. Investing in longer-term support will likely help prevent people from returning to homelessness and needing more acute support. Services may need more capacity initially, but longer-term provision of timely help can stabilise people and prevent a crisis, which will be more detrimental for the person and more costly to services.

Currently, people experiencing homelessness have limited access to palliative care services. This should be improved with the introduction of homelessness multidisciplinary teams, coordinated care and improved access to specialist services, including palliative care. Palliative care services already exist, and should become more accessible to people experiencing homelessness.

Return to recommendations

Why the committee made the recommendations

Good qualitative evidence showed that healthcare professionals felt ill-equipped and had insufficient knowledge of social determinants of health and homelessness, and the associated health needs for complicated health problems such as addiction and mental health problems. The evidence also showed that people experiencing homelessness felt that service providers did not understand the practicalities of being homeless and their specific needs. The committee discussed that further training and support was needed to strengthen the capacity of health and social care providers to address people's severe and multiple disadvantage and diverse needs.

The qualitative evidence also showed that training would raise awareness and improve provider knowledge in this area, and improve sensitivity and understanding for this population, so that care providers overcome preconceived ideas and judgemental behaviour. Good qualitative evidence showed that most people experiencing homelessness reported experience of discrimination on some level, with many recounting some form of prejudiced behaviour from service providers. The committee discussed that health and care providers should be trained to consider people's preferences rather than making assumptions about their needs and care solely based on their behaviour or appearance, for example. Furthermore, the committee discussed the importance of practitioners understanding and responding to the intersectionality of multiple disadvantages that people experiencing homelessness may face because of their characteristics.

Limited evidence from qualitative studies among service providers also showed that some lack awareness of the impact that trauma has on a young person's life and how it may manifest in their behaviour. The evidence suggested that providers who do not operate from a trauma-informed care approach may inadvertently serve as a barrier.

Experts also highlighted the importance of health and social care professionals' legal literacy and understanding of their duties and powers in relation to homelessness, mental capacity and safeguarding.

The committee were aware that there are various existing training and materials that organisations could use, such as e-learning for healthcare resources on tackling homelessness, free online training modules by the Faculty for Homeless and Inclusion Health and Public Health England's guidance on homelessness: applying 'All Our Health' and further resources in Health Education England's inclusion health education mapping and review.

Experts highlighted the importance of staff support and supervision, which enables reflection on experiences and practices to enable continuous learning for staff and development of both the staff and practices. The committee agreed that reflective practice and supervision can increase staff motivation and wellbeing, quality of care and services.

How the recommendations might affect services

Currently, there is variation in training opportunities for health and social care staff who encounter people experiencing homelessness. Most statutory agencies regularly train their staff, but training on some issues relevant to homelessness, such as legal duties and powers, is not common practice for all services. This extra training could be delivered alongside existing staff training programmes in a variety of low-cost ways, for example, by remotely using pre-recorded sessions, and could coincide within existing training. Because of existing training and materials, there is no expected significant resource impact.

Training to understand the needs of people experiencing homelessness may mean that more people access specialist homelessness services. Training and ongoing support will facilitate joined-up and more connected services, for example, between specialist services and mainstream services, and ensure a holistic approach and a framework of support. Improved knowledge and understanding will improve access and care for people experiencing homelessness. Practitioners will be better placed to give information about available health and social care services, and enable services to meet people's needs before their problems escalate. For example, most people could be legally housed by local authorities and councils if more professionals had a better understanding of homelessness law and guidance.

The recommendations encourage services to include these elements in their training more consistently. They can also influence the development of professional competencies for trainees and future practitioners.

Return to recommendations