Coming in From the Cold
3 December 2019 | Alison Phillis, Queen’s Nurse
People who become homeless have some of the highest and costliest health needs in the local community, but those needs are often overlooked when health and social care services are planned.
The reality of poor housing
‘Homelessness kills’ is the title of Bethan Thomas’ research which provides sobering reading: homeless men are more likely to die young, with an average age of death of 47 years old, compared to 77 years old for the general population.
The experience for women is even more terrifying. Homeless women die at a younger age than men: the average age of women dying in homeless accommodation or on the streets is 43 years old. The factors resulting in them becoming homeless are also known to keep them in insecure, violent or financially abusive domestic situations. 60% of women who had experienced homelessness report rough sleeping without reference to any agency for assistance in the early stages of being without a safe home: this reflects not only a lack of options but also limited knowledge about how to access the assistance available.
Home insecurity can occur as a result of social, economic or health factors. Home violence, abuse, mental ill health, moving out of care or prison, leaving the armed forces or hospital discharge, disability, bereavement or drug and alcohol addiction are all negative indicators for risk of homelessness. Increasing costs of living, changes to welfare and benefit provision, lack of affordable private rental housing, workplace instability, rising poverty experienced by people in work, increasing stress associated with the workplace are real life challenges. This is a critical public health message: homelessness can and does affect anyone.
The number of people living without a secure home doubled last year: the official estimated rough sleeper number was 169% higher in 2018 than in 2010, with London homelessness figures having doubled.
In addition to the 320,000 people living in temporary accommodation and those known to be rough sleeping, there is a hidden number of people who no longer have a place to call home but who do not actually meet the official duty to house criteria. These people may be sleeping on friends’ sofas, living in cars or sheds and moving from one place to another as they adjust to changes in circumstances. Further, there is a huge number of people who live in insecure homes, concealed and overcrowded.
Contact with health services
It is perhaps this hidden population that healthcare workers based in schools, out-of-hours and emergency services, GP practices, district nurses and health visitors will come into contact with.
Targeted services do exist: alcohol and drug misuse services, mental health services, dental public health services, immunisation and screening programmes, sexual health services, smoking cessation services. Local campaigns to reduce social exclusion are there, yet their success may be limited as they operate as part of the primary care delivery stream.
For many people living rough their priority needs are so basic – home safety, food, sanitary provision and clothing with dignity – that until these pre-primary care needs can be met, motivation to address the health influences are absent.
April 2018 saw a major shift in policy in the UK as the government recognised that without home security, people simply cannot engage with services to reduce re-offending, attend appointments and be supported to make better lifestyle choices.
In addition to making £50 million available to provide housing for those identified as at risk of home insecurity, the government has now made a commitment to end homelessness by 2027 with a plan to halve it by 2022.
The need for new approaches
At population level, this cohort poses a significant organisational and cost burden to planned and emergency health services. Future interventions must be designed with input from service users and placed appropriately to enable access. Measurement of success should focus on the enablement of sustainable lifestyle changes in an effort to reduce the health and social inequalities experienced by homeless people. This may include financially viable employment, safe and long-term housing, engagement with training and reduction in offending.
Successful voluntary programmes have been characterised by taking the lead from the user. By self-assessing their immediate needs, people experiencing homelessness have their physiological needs met first. In time, they are listened to and their views become intrinsic to the individual programme of engagement and recovery. Longer term change strategies such as alcohol and drug reduction programmes are introduced once relationships and trust have been established.
The factors responsible for creating health inequalities due to homelessness are complicated and interdependent. People without a home can enter into a deteriorating algorithm of a seemingly intractable descent into poorer health. However, the new legislation has energised agencies to work collaboratively to tackle the factors predisposing to homelessness at an earlier stage of the process. There is hope and the future does look different.
Alison Phillis, Queen’s Nurse