Equality and Inclusion
Guidance for considering the needs of people experiencing homelessness in commissioning health services
Produced by Equality and Inclusion Team – NHS Midlands and Lancashire Commissioning Support Unit May 2019 1
Equality and Inclusion
Acknowledgements Thank you for the contributions made by
• VOICES – Voices of Independence Change and Empowerment in Stoke-On-Trent • Healthwatch • Lancashire LGBT
Alternative formats This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact 0121 612 1500 or e-mail midlands.lancashire@nhs.net
Review date: May 2021
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Contents Introduction and aim of guidance
04
Definition of homelessness
05
Data regarding homelessness in England
06
Entitlements to healthcare
08
UK legislation protecting the rights of people experiencing homelessness
11
NHS England Long Term Plan
16
Healthwatch and common experiences in relation to healthcare
17
Health problems associated with people experiencing homelessness
19
Examples of good practice in healthcare
27
Considerations for Equality Impact Assessments
30
Recommendations
32
References
34
Further information and sources used in this guidance
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Introduction
Aim of guidance This guidance is for decision makers that commission health services in England. The aim of this guidance is to promote good practice for commissioning decisions and provide information to help assess potential impacts for this vulnerable group of people. This guidance aims to promote equality, address health inequalities and uphold human rights of people experiencing, or at risk of experiencing homelessness. This document is intended to supplement other guidance, and should be read in conjunction with relevant guidance published by NHS England and Public Health England. Midlands and Lancashire Commissioning Support Unit (MLCSU) Equality and Inclusion team has produced separate guidance that specifically considers the needs of asylum seekers and refugees, which supplements this document.
The guidance provides decisions makers with: •
General information about people experiencing homelessness
•
Statistics regarding homelessness in England
•
Legislative information relating to people experiencing homelessness
•
Common health problems and other determinants associated with people experiencing homelessness
•
Considerations for Equality Impact Assessments
•
Recommendations
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Equality and Inclusion
Definition Homelessness is defined as the state of not having an available and adequate home in the UK or abroad to live in; this can take a variety of circumstances: •
Rooflessness – a state of being without shelter of any kind (living and sleeping rough on the streets)
•
Staying in a hostel, night shelter, bed and breakfast
•
Staying with friends/family (sofa surfing)
•
Living in a split household – a family living in separate properties because they are unable to be housed together
•
Living in a property with no legal right to inhabit (squatting)
•
Living in a property that has risk of violence, abuse, or threat of eviction
•
Living in inadequate housing – e.g. a property that unsafe and/or unfit for habitation, living in a caravan on an illegal campsite, or a houseboat with no permitted mooring site
For this guidance, we will consider all of the related circumstances when referring to people or groups experiencing homelessness. Where information is specific to rough sleepers, we will highlight this.
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Data There is limited national data available regarding homelessness. From the available data, it is difficult to gain a clear picture of the number of people / groups experiencing homelessness in England, as there is no single agreed method of recording homelessness. There are different sets of data available regarding different types of homelessness. Crisis lists four types of homelessness (1), and we have used these types to look at available statistics for England.
Rough sleeping The Ministry of Housing, Communities and Local Government’s Rough Sleeping Statistics Autumn 2017, England report highlights that in 2017, approximately 4,751 people were counted as sleeping rough in England, which was 15% higher compared to the previous year (2). The highest numbers of rough sleepers were counted in London and the South East, however, the report highlighted a significant increase in the number of rough sleepers in North West England .
The report shows that since the current recording methodology was put in place in 2010, there has been a significant increase in the number of people sleeping rough in England. Homeless Link’s analysis of the Rough Sleeping Statistics (3) highlights that there are more male rough sleepers compared to women. In 2017, 3,965 men were recorded as sleeping rough compared to 653 women. 133 people did not state their gender.
83.4% rough sleepers are male, 13.7% female. 2.7% unknown (2017 data)
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Temporary accommodation
Statutory homelessness
The Ministry of Housing, Communities and Local Government reported that on 31 March 2018, 80,720 households were in temporary accommodation. This included night shelters, hostels, women’s refuges, social housing temporary accommodation.
Information from The Ministry of Housing, Communities and Local Government shows that between 1st January – 31st March 2018, local authorities in England accepted 13,320 households as being statutorily homeless (4).
Data shows a 5% increase on the figure in March 2017 (77,220), and was 68% higher than in 2010 (48,010) In 2018 there were estimated 80,720 households in temporary accommodation
Hidden homelessness Some people who are experiencing homeless do not show in homelessness statistics – such as people who stay with family/friends, sofa surfers, people squatting in properties, or people living in inadequate housing that has not been reported to an authority.
13,320 households were statutorily homeless
There is no accurate monitoring for rough sleepers
Charities are reporting an increase in the number of people at risk of experiencing homelessness
Many people experiencing homelessness do not appear in statistics
Why are there more homeless people? The reasons for the increase in the number of people experiencing homelessness may be due to a number of factors, however homeless charities note that changes to the welfare system in the UK have had a significant impact on people who are, or are at risk of, experiencing homelessness. Homelessness charities note that the national roll out of Universal Credit and how payments are assessed has led to increased rent arrears, arrears in payment of council tax leading to risk of eviction. 7
Equality and Inclusion
Entitlements The following information provides an overview of the entitlements to health services for people experiencing homelessness. For this vulnerable group, access into health services will help to reduce inequalities. The NHS Act 2006 provides the statutory requirements for provision of health services in England. The following information specifically relates to access to services for people that are experiencing homelessness who may not have a fixed address. Access to Primary Care Everyone has the right to choose a GP practice that best suits their needs; a GP practice must accept patients, unless there are reasonable grounds to refuse them, such as: •
•
•
The GP practice is at maximum capacity, and is unable to register new patients The practice may not be accepting patients that do not live within its boundary It may not be clinically appropriate to register with a GP practice – for example if the GP practice is far away from where the patient is based.
Overseas visitors A person who is an overseas visitor may not necessarily be entitled to NHS treatment, however a practice can still register them as an NHS patient (although this is not a statutory requirement). Asylum / Refugees People that are seeking asylum or have refugee status are entitled to register with a GP. People seeking asylum may become at risk of homelessness if their claim for asylum is refused by the Home Office, or the renewal of refugee status is not granted.
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People experiencing homelessness NHS England has produced the leaflet People who are homeless how to register with a doctor (GP), which advises patients and GP practices that people experiencing homelessness cannot be refused GP registration on the basis of where they reside, and there is no regulatory requirement to provide identity, address or immigration status in order to register as a patient (5). Endorsement of guidance NHS England’s guidance regarding residential status and GP registration is endorsed by: • The British Medical Association (6) • Care Quality Commission (7) Should a GP practice have any queries or concerns regarding the registration of a person experiencing homelessness, the practice should contact their lead commissioner.
GPs cannot refuse to register a patient due to being homeless … without good reason Access to Secondary Care In circumstances of serious illness, anyone can go to an accident and emergency department / urgent treatment centre, regardless of their housing status. People that are experiencing homelessness can access nonemergency and planned care in hospitals, usually via a referral from primary care. There is evidence that attendances to accident and emergency departments are higher in people that are experiencing homelessness compared to the general population. Help with paying for Prescriptions
Under the Homelessness Reduction Act 2017, hospitals and urgent treatments centres are required to refer people that are, or at risk of, experiencing homelessness to the Local Authority in order to ensure they have safe accommodation for their recovery.
People experiencing homelessness will not be charged for medicines received via prescription if they have a HC2 certificate. The NHS Business Services Authority advises that people experiencing homelessness can apply for Help with Health Costs if they provide a correspondence address in their application form, answer all questions and explain what income they are living on.
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Dental Care
Registering with health services when a person doesn’t have a fixed address
NHS England are responsible for commissioning of all dental services in England. This includes:
There may be circumstances when patients do not have a fixed address. This may include:
• • •
• •
Specialist dental services Community dental services Out of hours dental services.
There is limited published guidance regarding access to dental services for people experiencing homelessness. NHS England has advised that a person experiencing homelessness should be able to attend at any NHS dentist’s surgery that has an available appointment, although they may have to join a waiting list to join a practice accepting NHS patients. For people requiring an appointment for urgently needed dental treatment, anyone, regardless of their residential status, can contact the NHS helpline 111 to access an emergency dentist. In some cases, patients may be advised to attend accident and emergency / urgent care centres with severe dental infection, toothache, oral abscesses etc.
• • • • • •
The state of being homeless Seeking asylum / failed asylum claim Undocumented migrants Gypsy, Traveller, Romany groups Overseas visitors People fleeing domestic abuse Unstable accommodation (e.g. people living in tents, sheds) People trafficking
When registering patients in primary care, where possible avoid using ‘No Fixed Abode’ (NFA) in the registration process. Ask the patient if they have an alternative contact address that can be used for sending correspondence. There is a read code that can be assigned to a patient’s record if they are experiencing homeless: 13D2. homeless single person Section 4.9.9 of NHS England’s Primary Medical Care Policy and Guidance Manual (PGM) states: “Where necessary, (e.g. homeless patients), the practice may use the practice address to register them if they wish. If possible, practices should try to ensure they have a way of contacting the patient if they need to (for example with test results).” (8) Other alternative addresses could include a hostel, a temporary address, or a day centre / other service centre
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Legislation Legislation protecting the rights of people that experience homelessness in England There is a range of legislation that protects the rights of people that experience homelessness in England. A summary of key legislation is detailed in the table. Further detail is provided below however, this is not exhaustive, and other relevant legislation may apply dependent on the circumstances. Summary of legislation protecting the rights of people experiencing homelessness
Health
• •
National Health Service Act 2006 Health and Social Care Act 2012
General
• • • • • • •
Housing Act 1996 Homelessness Act 2002 Homelessness Reduction Act 2017 Equality Act 2010 Public Sector Equality Duty Human Rights Act 1998 Modern Slavery Act 2015
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National Health Service Act 2006 (as amended by the Health and Social Care Act 2012)
Under section 14 of the Health and Social Care Act 2012, CCGs have specific duties to: •
The National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) introduced legal duties to NHS and public health organisations to reduce health inequalities and to integrate health, social care, and other related services to reduce inequalities, both when accessing services, and in the outcomes from using services.
•
Have regard to the need to reduce inequalities between patients in access to health services and the outcomes Exercise their functions with a view to securing that health services are provided in an integrated way, with health-related and social care services, where they consider that this would improve quality, reduce inequalities in access to those services or reduce inequalities in the outcomes achieved Include in an annual commissioning plan an explanation of how the CCG proposes to discharge their duty to have regard to the need to reduce inequalities Include in an annual report an assessment of how effectively the CCG discharged the duty to have regard to the need to reduce inequalities
Housing Act 1996
•
The principal legislation that protects the rights of people experiencing homelessness is Part 7 of the Housing Act 1996, which details the duties that local authorities. Part 7 of the Housing Act 1996 has been amended and added to by subsequent legislation
•
The Homelessness Act 2002
Modern Slavery Act 2015
The Homelessness Act 2002 introduced a statutory requirement on local authorities to review the current and projected levels of homelessness, and to develop a strategy to reduce and prevent homelessness.
Emerging evidence from the homelessness sector suggests a link between people experiencing homelessness and modern slavery
“Homeless people are vulnerable to being trafficked or held as victims of modern slavery by virtue of being homeless and having associated support needs (such as alcohol or drug misuse and mental health issues), that can impair their judgement or ability to protect themselves. Alternatively, victims of modern slavery are vulnerable to becoming homeless since they do not have support networks and have nowhere to go after they leave safe-house support provision.” Source: Understanding and Responding to Modern Slavery within the Homelessness Sector, 2017 (9) 12
Equality and Inclusion
Homelessness Reduction Act 2017
Equality Act 2010
The Homelessness Reduction Act 2017 made significant changes to existing legislation.
People experiencing homelessness as a group do not constitute one of the protected characteristics under the Equality Act 2010. However, there is evidence that as a cohort, people experiencing homelessness often experience multiple ‘disadvantage’ due to intersectionality (disadvantage through having over lapping protected characteristics). This may be attributed to their race, religion, age, sex, sexual orientation, disability, gender reassignment, pregnancy and maternity, and marriage and civil partnership.
The Act strengthened the Housing Act 1996), and introduced legal duties to local authorities to reduce and prevent homelessness, including a new duty on public authorities to refer service users that may be, or are at risk of, experiencing homelessness to local authorities – the duty to refer. The duty to refer applies to services provided by NHS trusts and NHS foundation trusts, in connection with the provision of NHS health services in: i.
accident and emergency services provided in a hospital and urgent treatment centres ii. any other providers of community and primary urgent care services iii. in-patient treatment Once treatment has been received via an NHS health service, the Homelessness Reduction Act 2017 should ensure that a person has safe accommodation to go to following discharge. Commissioners should seek assurance from providers that there is a process in place for referrals to be made to the local authority (where there is consent from the patient).
Public Sector Equality Duty The Public Sector Equality Duty (PSED) was created under the Equality Act 2010, and places a legal obligation on public bodies to consider equality and inclusion as part of their day-to-day work. Public authorities, and organisations that exercise public functions, must have due regard to the need to: •
•
•
eliminate discrimination, harassment, victimisation, and any other conduct that is prohibited by the Equality Act 2010 advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it foster good relations between persons who share a relevant protected characteristic and persons who do not share it
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Human Rights Act 1998
Human Rights
Article 2: Right to life This is an absolute right. NHS organisations have a duty to not take away anyone’s life, and a positive duty to take reasonable steps to protect life.
This section summarises parts of the human rights legislation that relate to homelessness. Article 3: Right to freedom from torture and inhuman or degrading treatment This duty is an absolute right that protects people who have suffered treatment that is very severe. Public / state authorities have a positive duty to protect people from torture, inhuman treatment and degrading treatment. Article 14: Protection from discrimination The Human Rights Act 1998 does not protect people from discrimination in all areas of life – however other legislation is in place to support this, such as the Equality Act 2010. Article 14 is a duty to ensure that people are able to secure all the other rights of the Human Rights Act without discrimination.
Public organisations should consider the right to life when making decisions that may put people in danger, or decisions that affect life expectancy.
Article 8: Right to respect for private live, family life and the home The Human Rights Act 1998 does not automatically give anyone a right to a home, however it does contain a right to respect a home that a person already has, and a right for a person to access and live in a home without interference or intrusion. This right is not an absolute right – there are circumstances where a person’s home can be taken away if it is necessary, legitimate, and is proportionate. Article 8 also contains a right to respect for family life, including the right for a family to live together.
Definition An absolute right is a right that cannot be limited or interfered with by any organisation, e.g. NHS Clinical Commissioning groups, or the state.
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Severe Weather Emergency Protocol and extended weather provision Health organisations, Social Care providers, and Local Authorities are working closer together to improve health and social care for communities. During extreme weather, there is no legal protection for people sleeping rough in England, even if conditions are life threatening. The Severe Weather Emergency Protocol (SWEP) provides a humanitarian obligation on local authorities to provide shelter in order to prevent death due to severe weather. Other guidance available
The aim of SWEP is to: 1. Prevent death 2. Engage individuals with support services SWEP notes that rough sleepers are more likely to suffer from poor health and risk of harm, and therefore are at increased risk when there is severe weather. Detailed guidance regarding SWEP and extended weather provision is available at the following web link: https://www.homeless.org.uk/ourwork/resources/guidance-on-severeweather-emergency-protocol-swep-andextended-weather-provision
There is also a range of published guidance that specifically address homelessness for other vulnerable groups: Military Veterans https://www.ssafa.org.uk/helpyou/veterans/support-homelessveterans People leaving the justice system / ex-offenders https://www.gov.uk/leavingprison/support-when-someone-leavesprison Asylum seekers and refugees https://www.gov.uk/asylumsupport/what-youll-get https://www.midlandsandlancashirecsu. nhs.uk/download/publications/equality_ and_inclusion/Asylum-Guidance.pdf
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NHS England Long Term Plan
“The number of people sleeping rough has NHS England published the NHS Long Term Plan in January 2019. Within the plan, there is a commitment to •
reduce health inequalities
•
improve health outcomes for vulnerable groups
Section 2.32 of the plan summarises the health needs of people experiencing homelessness. It is expected that Commissioners, service providers, and local authorities will implement the NHS Long Term Plan through Integrated Care Systems.
been increasing in recent years. People affected by homelessness die, on average, around 30 years earlier than the general population. Outside London, where people are more likely to sleep rough for longer, support needs may be higher. 31% of people affected by homelessness have complex needs, and additional financial, interpersonal and emotional needs that make engagement with mainstream services difficult. 50% of people sleeping rough have mental health needs, but many parts of the country with large numbers of rough sleepers do not have specialist mental health support and access to mainstream services is challenging. We will invest up to £30 million extra on meeting the needs of rough sleepers, to ensure that the parts of England most affected by rough sleeping will have better access to specialist homelessness NHS mental health support, integrated with existing outreach services.” (10)
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Healthwatch
Healthwatch are an independent champion for people who use health and social care services in England. Each local authority has its own local Healthwatch organisation. The sole purpose of Healthwatch is to understand the needs, experiences and concerns of people who use health and social care services and represent their views within local decision making and planning. There have been a number of Healthwatch reports that provide insight and understanding of the issues for people experiencing homelessness. The following information provides a selection of reports and key outcomes. The key themes highlighted in these reports are poor patient experiences, GP registration issues and high A&E attendance. Healthwatch Stoke-on-Trent, July 2016 Healthwatch Lancashire – Listening to those who are homeless and living in deprivation in Lancashire, November 2016 Healthwatch spoke to 100 homeless people across Lancashire. The majority said they did not feel supported by NHS services and not listened to when they visited health services. Some responses reported problems getting registered with a GP as they did not have a fixed address and would attend A&E instead. (11)
Healthwatch surveyed 46 GP practices and found that nearly half were refusing to register people experiencing homelessness. Key findings: • • •
47.8% GP practices refused to register a homeless person 26.1% were unsure if they would 26.1% would register a person experiencing homelessness (12)
“Homelessness is rising throughout the UK. This research highlights just one of the barriers many homeless people face in seeking to recover. The issue of homelessness is complex. Where people take steps to recover, they may come across real barriers and feel genuinely stuck.” Andy Meakin, Director of VOICES project. 17
Equality and Inclusion
Healthwatch Waltham Forest ‘Talking with the homeless community in Waltham Forest’, June 2015 (13) Healthwatch spoke to 50 people at focus sessions held within support organisations. Key findings include: • •
Low registration rates with a GP Reported difficulties in getting registered Difficulties in contacting the GP and getting GP appointments Perception of a lack of dignity and respect from health staff Conflicting advice between hospital and GP Feeling rushed, and concerns dismissed at GP appointments High use of A&E services due to problems getting to see a GP Hospital services not joined up with other services such as alcohol and substance misuse teams Problems with dental health due to life style and difficulties in getting dental appointments
• • • • • •
•
The report also highlighted some positive experiences: • •
•
Positive experiences of Pharmacist services Positive experiences identified within specific GP practices. These offered flexible appointments, addressed mental health needs quickly (within 2 hours of contacting the practice) Monthly outreach ‘health service bus’ enabled a patient to see a doctor and get investigations sorted
Healthwatch Bristol – Homeless Services in Bristol July 2015 (14) Healthwatch Bristol worked with homeless groups and key findings include: • • • • • •
Difficulty in accessing services Difficulty in getting information about treatments Language needs – difficulty in getting translation services Mixed experiences for dual diagnosis (such as mental health and substance misuse) Mobility issues – difficulty in accessing services without transport or money for transport Difficulty in getting registered with a GP when people did not have a fixed abode address
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Further information: https://healthwatchbristol.co.uk/wp-content/uploads/2016/06/HomelessnessReport-KLGCL.pdf
Equality and Inclusion
Common health problems
Health Inequalities The Marmott review into health inequalities, Fair Society, Healthier Lives, was published in 2010. The report noted that health inequalities were closely related to deprivation. The review stated that good housing and employment is a protective factor of health.
Information on the health and wellbeing of people experiencing homelessness highlights that this vulnerable group face greater health inequalities compared to the general population, and their overall health is poorer compared to the general population. Homelessness can be a cause of ill health, and ill heath can contribute to homelessness
The following information provides a summary of common health problems faced by people experiencing homelessness.
Health inequalities closely related to deprivation
Good housing is a protective factor of health
Source: http://www.instituteofhealthequity. org/resources-reports/fair-societyhealthy-lives-the-marmotreview/fair-society-healthy-livesfull-report-pdf.pdf 19
Equality and Inclusion
Life expectancy
This compares to 76 years for men and 81 for women in the general population (15).
Data from the Office of National Statistics shows that the average age of death for homeless males is 44 and 42 for women.
In 2017, men made up 84% of deaths of people experiencing homelessness.
Deaths of people experiencing homelessness, by sex and age group, 2017 100 90 80 70 60 50 40 30 20 10 0 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74
Male
Female
Source: Office for National Statistics – Death registrations (England and Wales)
Mental health Poor mental health is a factor in the cause, and a consequence of, homelessness. There is increased prevalence of mental health conditions in people experiencing homelessness; people experiencing homelessness are twice as likely to have experienced a mental health issue compared to the general population. Pre-existing mental health conditions may be exacerbated by stress associated with homelessness.
Housing is a health issue. Research shows that housing problems, and worries regarding housing status have a detrimental impact on mental health, with anxiety and depression the most commonly discussed conditions (16). There is a link between serious mental health illness and alcohol / substance misuse. Around a fifth of adults experiencing homelessness have a dual diagnosis of a mental health condition(s) and alcohol/substance usage. People experiencing homelessness are nine times more likely to commit suicide compared to the general population (14). 20
Equality and Inclusion
Physical health
Chronic conditions
People experiencing homelessness are over twice as likely to report a physical health issue compared to the general public.
Chronic Obstructive Pulmonary Disease (COPD)
Conditions typically associated with older age are more commonly reported by people experiencing homelessness, for example joint pain or problems with bones/muscles, heart disease and eye conditions, showing the impact that the state of homelessness has on health. There is increased risk of physical injury or death from falls amongst this cohort compared to the general population. People experiencing homelessness are seven times more likely to die from a fall compared to the general population, with evidence indicating that falls are be more likely to related to drug / alcohol usage.
Higher risk of developing a health issue
Higher risk of falls, respiratory problems and coronary heart disease
There is limited information on the prevalence of chronic conditions amongst people that are experiencing homelessness. Groundswell carried out research on respiratory health (17), and the findings show that rates of diagnosed respiratory health conditions and lung disease are significantly higher compared to the general population. 4.9% of people experiencing homelessness have a diagnosis of COPD, compared to 1.9% of the general population (17) Linked to this, may be an increased risk of chronic conditions related to higher smoking rates, substance misuse and the physical environment in which they may be residing – Groundswell’s research found that rough sleepers slept in areas of mould and pigeon droppings.
Coronary Heart Disease There is increasing evidence that death due to coronary heart disease and heart attack may be higher in people that experience homelessness. Research from Crisis shows that men and women experiencing homelessness have a higher risk of death due to heart attack or coronary heart disease compared to men and women in the general population (18).
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Equality and Inclusion
Diabetes
Foot conditions
There is very limited information available, however, people experiencing homelessness with Type 1 / Type 2 diabetes may find it more difficult to manage their condition, and as a consequence experience poor glycaemic control.
International research highlights that foot conditions are prevalent amongst people experiencing homelessness. This vulnerable group, particularly rough sleepers, may experience trauma and wounds to their feet due to wearing inappropriate footwear, walking and/or standing for long periods of time, and exposure to weather extremes. Common foot problems that people experiencing homelessness may suffer include:
Substance misuse Substance misuse, which may include alcohol misuse and drug misuse, are common causes of death amongst people experiencing homelessness. Data from Crisis estimates that over a third of deaths in people experiencing homelessness are caused by substance misuse. In terms of alcohol misuse, people experiencing homelessness are seven to nine times more likely to die from alcohol-related disease, and are twenty times more likely to die from drug-related use. Further information suggests that in terms of death specifically due to drug misuse, men experiencing homelessness are more likely to die compared to women experiencing homelessness (18).
• • • • • • •
Blisters Calluses Long and onychomycotic nails Fungal skin infections Pitting keratolysis Frost bite Trench foot
People experiencing homelessness may also have foot conditions in relation to other chronic health problems such as Diabetes and Coronary Heart Disease.
Violence Research has indicated that people experiencing homelessness, particularly rough sleepers, are at increased risk of anti-social behaviour, and/or being a victim of physical violence and verbal abuse compared to the general population. Incidents of, and/or fear of, criminality impacts on this cohort’s physical and mental health and wellbeing. Research indicates that the constant risk and uncertainty of their safety affects this group’s physical and mental wellbeing.
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Communicable diseases
TB, HIV and Hepatitis C is higher compared to general population
The incidence of communicable diseases such as Tuberculosis (TB), HIV, and Hepatitis C is higher compared to the general population. Shared usage of drug paraphernalia in this cohort may be a factor in the higher prevalence of HIV and Hepatitis C.
Oral health
The incidence of active TB is high in people experiencing homelessness. There is also a risk that this cohort experiences delayed diagnosis and poor treatment outcomes – people experiencing homelessness may think that the symptoms of TB are merely an impact of their lifestyle, and so delay seeking treatment; or they may lack adequate access to primary healthcare.
Dental services are commissioned by NHS England.
There is an increased likelihood to exposure to TB bacteria for this cohort due to immune stresses associated with being homeless, for example rough sleeping, exposure to weather, poor nutrition, substance use, and gathering in accommodation settings where other people sleep and socialise.
Common dental problems that this vulnerable group experience include bleeding gums, cavities, dental abscesses, and gum / mouth pain.
58% are unclear what dentist services they are entitled to
Dental problems are common due to a variety of factors including: • • • • •
poor dental care poor diet drug and alcohol misuse acts of violence lack of clarity regarding entitlements to dental services
Groundswell conducted research into the oral health or people experiencing homelessness, and found that of those surveyed, 58% were unclear of what NHS dentist services they were entitled to, and 31% had unsuccessfully attempted to register with a dentist (19).
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Women’s health Women’s homelessness is underrepresented in official statistics. The methodology for collecting rough sleeping data requires that people are seen bedding down, or about to bed down (e.g. lying down, sitting on, or standing next to bedding/tents/doorways/bus shelters or encampments). Compared to men experiencing homelessness, many women rough sleep differently, avoiding sleeping in the street by taking public transport, walking through the night, or by blending into 24-hour service environments such as hospitals, stations and airports. As shown on page 20, life expectancy for women experiencing homelessness is poorer compared to men experiencing homelessness.
There is limited information available regarding access to routine screening for women experiencing homelessness, however, stakeholder groups, such as Groundswell, suggest that women in this vulnerable group are more likely to face barriers in accessing routine health screening such as cervical and breast screening, and other NHS health checks and contraception. There is growing research (from Crisis, St Mungo’s, Against Violence and Abuse (AVA), and Homeless Link) that some women may experience homelessness as a consequence of domestic abuse and other forms of violence. A project by Women’s Aid found, while 40% women experiencing homeless stayed with family and friends in order to escape domestic violence, while 11% of women had slept rough (20).
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Lesbian, Gay, Bisexual and Transgender (LGBT) health This section of guidance has been developed with support from Lancashire LGBT. There is a range of research based on health needs of LGBT community relating to homelessness.
Research highlights that LGBT people experiencing homelessness are often estranged from their family and have little or no support system. The needs of LGBT rough sleepers were similar to heterosexual people, but with regards to sexual orientation, the key themes relating to health include: •
Stonewall organisation reports that: 18% of LGBT people have experienced homelessness at some point in their lives 28% of LGBT people with disabilities have experienced homelessness at some point in their lives 25% of Trans have experienced homelessness at some point in their lives (21) 25% of trans people were discriminated against when looking for a house to buy or rent. This compares to 20% non-binary experienced discrimination (22) Research highlights that sexual orientation is linked to the risk of experiencing homelessness, with 8% of young LGBT people having to leave home for reasons relating to sexual orientation or gender identity (23) The risk of becoming homeless may be due to discrimination by landlords, rejection from family members, suffering from domestic violence / abuse
•
Services to have a knowledge of LGBT issues – including sexual orientation and gender identity Hostels to have awareness as often LGBT people go back into the closet / stealth rather than risk discrimination
Impacts of experiencing homelessness related to health are: • • • • • •
Poor mental health, including feeling suicidal Body image issues Eating disorders Risky sexual behaviour Drug and alcohol misuse Physical violence due to hate crime homo/bi/transphobia experiences
Research shows that the experience of accessing health services is often poor, and LGBT people may feel reluctant to access health services due to past poor experiences. People report going back on the streets after being discharged from hospital, with outreach services often providing a vital link to support patients with substance misuse, sexual health and mental health needs. (24)
LGBT people in lower income households are more likely than people in higher income households to have experienced homelessness (21) 25
Equality and Inclusion
Children and Young peoples’ health Children and young people living in families that are, or are at risk of, experiencing homelessness are likely to experience detrimental impacts on health and wellbeing. These may include: • . • • • • •
impact on access to health care / immunisations stress/anxiety and link to behavioural issues access to schools impact on educational attainment absenteeism from school bullying/isolation at school due to being singled out as homeless
Young people leaving the care system
A range of support, available through health services, local authority, and Public Health England should be able to identify and support families that are, or are at risk of, experiencing homelessness (for example children’s centres). Support may be multidisciplinary, involving the voluntary sector such as foodbanks.
Over 8,000 16-18-year olds leave the care system each year. Young people leaving care are at an increased risk of experiencing homelessness compared to the general population. This is due to a lack of support when transitioning from the care system to independent living, and limited availability of housing options when leaving care. The reason why care was accessed can also be a cause of homelessness; children often access the care system due to the breakdown of family relationships, and may have experienced neglect, physical, emotional or sexual abuse. On leaving the care system, young people do not always have familial links in place to support them.
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Examples of good practice in health care
Following a desktop search for examples of good practice, there was a limited number of examples specific to healthcare / commissioning. The following case studies have been collated to show where good examples of work is helping to improve health outcomes for people that are experiencing homelessness. Pathway Programme
Following its introduction:
The NHS Long Term Plan cites the University College London Hospitals’ (UCLH) Pathway Programme.
•
UCLH has developed the Pathway Programme for patients experiencing homelessness that are admitted to hospital. It involves a team consisting of: • • •
In-hospital GPs Dedicated Pathway nurses Workers to support and address the housing, financial and social issues of patients
• Outcomes
A&E attendances by supported individuals fell by 38% There was a 78% reduction in bed days.
Pathway, now a charity, helps the NHS to create hospital teams to support patients experiencing homelessness and ten hospitals in London, Leeds, Bradford, Manchester and Brighton have since adopted the model.
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13 people experiencing rough sleeping attended the initial clinic and 10 of these received the flu vaccine
Increasing flu vaccination in Leicester NHS Leicester CCG and Leicester City Council Public Health set up a nurse led outreach clinic to address variation of low uptake of the flu vaccine – for patients who were rough sleepers. Initial work evaluated take up of the vaccine. Wider understanding of the issues of this group indicated that they were not regularly accessing GP and nurse appointments, and were not offered the seasonal flu vaccination and therefore at greater risk of developing flu. The NHS, working in partnership with the Leicester City Council Outreach team, established the dedicated clinic within the Anchor Centre arranged for 6am to 7.30am. This early clinic enabled patients to have the vaccine whilst accessing a breakfast and hot drink. The Outreach and Street Drinkers Forum was pivotal in encouraging people to have the vaccine and access other health and social care advice. Further information on this intervention: https://www.england.nhs.uk/atlas _case_study/practice-nursespromoting-flu-vaccines-to-thehomeless-community
Outcomes
The clinic provided opportunity to provide general health advice to those that had not received any medical advice for some time. The work of the Anchor Centre was pivotal in helping vulnerable people access health assessments and treatment. People accessing the clinic have given positive feedback about the nursing team and support they receive from the outreach team. The clinic reflects a good use of resources, which maximised take up of the vaccine with this vulnerable group. There is also an added outcome of wider reduction of hospital admissions linked to higher rate of vaccination rates. This case study has been adapted from information on the NHS England Atlas of Shared Learning.
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Overcoming barriers to accessing healthcare In 2017, NHS Digital commissioned Seaview to carry out research on people experiencing homelessness and their use of technology relating to healthcare. 64 people experiencing rough sleeping were interviewed, and barriers to technology use were identified as: • •
Confidence in digital skills lack of access and affordability.
Other issues were also identified – such as concerns regarding confidentiality, physical health challenges and limited literacy. This group also reported feeling stigmatised when using IT facilities in library settings. Following this research, pathfinder projects were established to provide targeted support to digital health skills and access to health information and support for people experiencing homelessness (25).
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Equality Impact Assessments
This section summarises considerations for equality impact assessments. An Equality Impact Assessment (EIA) is a tool that examine the impact that new or existing policies, services and other work that public organisations may have on specific groups of people. An EIA identifies and addresses current and potential inequalities that may result from policy and service development. The EIA is a means of demonstrating how an organisation has considered legal duties under the Human Rights Act 1998, the Equality Act 2010 and the Public Sector Equality Duty 2011. The EIA process also demonstrates due regard responsibilities to vulnerable groups under the Health and Social Care Act 2012, and helps an organisation demonstrate how it meets the Brown, Bracking and Gunning principles. When policies and services are being designed or reviewed, an EIA should take a range of information into account – including local information on people experiencing homelessness, their health needs, and current or potential inequalities that may result from policy and service development. An EIA should be a standard part of policy and decision-making processes within public organisations.
An EIA is informed by engagement work, which highlights any impact from a decision. Engagement work with people that experience homelessness will help decision makers to understand their needs and how they will be impacted by decisions. Access to homeless groups can be gained through support organisations. Engagement work may also include the workforce where staff have in depth understanding of the issues and reality of working with this vulnerable group.
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Equality impact assessments help to identify potential equality risks
EIA – key considerations
EIAs are a good way to demonstrate how due regard has been taken
•
When considering the potential impacts on people experiencing homelessness, assessment information may take the following into account: •
•
Any local data on numbers of people experiencing homelessness Existing homelessness support groups and services that may be indirectly or directly impacted by the decision General level of knowledge of homelessness health needs that may be impacted by the decision (impact may be negative or positive)
What are Brown, Bracking and Gunning Principles? The Brown, Bracking and Gunning principles are detailed in case law and link to how public organisations can meet their duties under the Public Sector Equality Duty (section 149 of the Equality Act 2010).
Brown
Bracking
Gunning
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▪
▪
▪
▪
▪
▪
The organisation must be aware of their duty Due regard is fulfilled before and at the time any change is considered, as well as at the time a decision is taken. Due regard involves a conscious approach and state of mind The duty cannot be satisfied by justifying a decision after it has been taken The duty must be exercised in substance, with rigour and with an open mind in such a way that it influences the final decision The duty is a nondelegable one, and a continuing one
▪
▪
▪
The duty is upon the decision maker personally. What matters is what he or she took into account and what he or she knew A public body must assess the risk and extent of any adverse impact and the ways in which such risk may be eliminated before the adoption of a proposed policy. A public body must have available enough evidence to demonstrate that it has discharged the duty. Public bodies should place considerations of equality, where they arise, at the centre of formulation of policy, side by side with all other pressing circumstances of whatever magnitude.
▪ ▪
▪
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Based on Fairness and Proportionality Consult at formative stage of the proposal Sufficient reasons must be put forward for the proposal to allow for intelligent consideration and response Adequate time must be given for consideration and response The product of consultation must be conscientiously taken into account
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Recommendations
The following ten recommendations have carefully been developed with a view of improving the decision making that affects health outcomes and experiences for homeless groups. 1. Improve the general understanding of health needs Commissioners to have a general understanding of the issues related to people experiencing homelessness – to help identify potential areas of service design that can: • • • •
address health inequalities reduce risk of discrimination advance equality of opportunity foster good relations between different communities
2. Workforce Training to give staff skills and knowledge to work effectively with people experiencing homelessness and provide person centred care.
3. Involvement of support organisations in decision making As health commissioning evolves into integrated working processes across geographical areas, Integrated Care Systems (ICSs) should consider working in partnership with stakeholders and organisations supporting / advocating the needs of people experiencing homelessness. Homeless-Friendly works with NHS GP surgeries and other healthcare provider organisations to support people experiencing homelessness, encouraging organisations to make a pledge to examine processes and share good practice. Further information is available at the following link: http://www.homelessfriendly.co.uk/
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4. Look at good practice to reduce health inequalities Health services need to improve for this cohort and this may involve innovative practice in primary and secondary care, for example improve monitoring for these patients, providing extended appointments, outreach services, community nursing and care navigation.
5. Registering people with a G.P CCGs should seek ways to ensure that GP practices are aware of the patient registration process and implement it correctly, and work with GP practices to develop an appropriate, consistent methodology/coding that can be added to a record to clearly identify patients that are experiencing homelessness.
6. Identify variation of health interventions Audit variation in access to primary care interventions by people experiencing homelessness – for example, take up of vaccinations and health screening programmes.
7. Develop innovative working Tailor support for different groups, as different cohorts within this vulnerable group have different and complex needs, such as young people, men, women, LGBT, people with HIV. Share good practice across the health sector to promote better health outcomes for people experiencing homelessness.
8. Include people experiencing homelessness within equality impact assessments Include consideration for people experiencing homelessness in equality impact assessment documents to provide robust evidence toward compliance of the Public Sector Equality Duty.
9. Duty to refer Ensure that providers understand their duties under The Homelessness Reduction Act 2017, including their duty to refer (with consent). Ensure that processes are in place for referring patients to the Local Authority.
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References The following references were accessed February 2019 1. https://www.crisis.org.uk/ending-homelessness/homelessness-knowledgehub/types-of-homelessness/ 2. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/682001/Rough_Sleeping_Autumn_2017_Statistical_Release__revised.pdf 3. https://www.homeless.org.uk/sites/default/files/siteattachments/Homeless%20Link%20%20analysis%20of%20rough%20sleeping%20statistics%20for%20England%202 017.pdf 4. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/764168/Statutory_Homelessness_and_Prevention_and_Relief_ Statistical_Release_Jan_to_Mar_2018__REVISED_.pdf 5. https://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Documents/how-toregister-with-a-gp-homeless.pdf 6. https://www.bma.org.uk/advice/employment/gp-practices/serviceprovision/patient-registration-for-gp-practices 7. https://www.cqc.org.uk/guidance-providers/gps/nigels-surgery-29-looking-afterhomeless-patients-general-practice 8. https://www.england.nhs.uk/publication/primary-medical-care-policy-andguidance-manual-pgm/ 9. https://www.antislaverycommissioner.co.uk/media/1115/understanding-andresponding-to-modern-slavery-within-the-homelessness-sector.pdf 10. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-termplan.pdf 11. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriage s/deaths/bulletins/deathsofhomelesspeopleinenglandandwales/2013to2017 12. https://england.shelter.org.uk/__data/assets/pdf_file/0006/1362885/Findings-TheImpact-of-Housing-Problems-on-Mental-Health.pdf
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13. https://www.crisis.org.uk/media/236798/crisis_homelessness_kills2012.pdf 14. http://groundswell.org.uk/wp-content/uploads/2017/10/Room-to-Breathe-FullReport.pdf 15. http://groundswell.org.uk/wp-content/uploads/2017/10/Groundswell-HealthyMouths-Report-Final.pdf 16. https://www.womensaid.org.uk/research-and-publications/nowomanturnedaway/ 17. https://www.stonewall.org.uk/sites/default/files/lgbt_in_britain_home_and_commu nities.pdf 18. https://www.stonewall.org.uk/sites/default/files/lgbt-in-britain-trans.pdf 19. https://metrocentreonline.org/sites/default/files/201704/National%20Youth%20Chances%20Intergrated%20Report%202016.pdf 20. https://stonewallhousing.org/wpcontent/uploads/2018/09/FindingSafeSpaces_StonewallHousing_LaptopVersion. pdf 21. https://healthwatchlancashire.co.uk/wp-content/uploads/2014/06/Homeless-depv.1.3-3.pdf 22. https://www.healthwatchstokeontrent.co.uk/wpcontent/uploads/2016/07/Gatekeepers_VOICES-and-HW-Stoke-ReportFINAL.pdf 23. https://www.healthwatchwalthamforest.co.uk/sites/default/files/homeless_fg_repo rt.pdf 24. https://healthwatchbristol.co.uk/wp-content/uploads/2016/06/HomelessnessReport-KLGCL.pdf 25. https://www.kingsfund.org.uk/blog/2019/02/nhs-digitisation-reach-furthest-first
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Further information / Sources used in this guidance The following information was accessed in February 2019 http://england.shelter.org.uk/housing_advice/homelessness/rules/what_is_homeless ness https://www.gov.uk/government/publications/homelessness-applying-all-ourhealth/homelessness-applying-all-our-health https://www.gov.uk/universal-credit https://www.gov.uk/government/publications/universal-credit-and-homelesspeople/universal-credit-and-homeless-people-guide-for-supporting-organisations https://contactcentreservices.nhsbsa.nhs.uk/selfnhsukokb/AskUs_HWHC/engb/5804/am-i-entitled-to-apply/15739/can-i-apply-for-help-with-health-costs-if-i-amhomeless https://www.nhs.uk/using-the-nhs/nhs-services/dentists/dental-treatment-for-peoplewith-special-needs https://www.equalityhumanrights.com/en/human-rights/human-rights-act http://www.legislation.gov.uk/ukpga/2012/7/section/26/enacted https://www.england.nhs.uk/wp-content/uploads/2015/12/hlth-inqual-guid-commsdec15.pdf https://www.crisis.org.uk/ending-homelessness/homelessness-knowledgehub/health-and-wellbeing/ https://www.crisis.org.uk/media/236798/crisis_homelessness_kills2012.pdf https://www.homeless.org.uk/facts/homelessness-in-numbers/health-needs-auditexplore-data https://www.crisis.org.uk/ending-homelessness/homelessness-knowledgehub/health-and-wellbeing/mental-ill-health-in-the-adult-single-homeless-population2009/ https://www.crisis.org.uk/media/20611/crisis_mental_ill_health_2009.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5147925/ https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(01)00062-7/fulltext https://www.crisis.org.uk/ending-homelessness/homelessness-knowledge-hub/typesof-homelessness/its-no-life-at-all-2016/
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http://groundswell.org.uk/what-we-do/peer-research/healthy-mouths/ https://bda.org/news-centre/blog/homelessness-and-oral-health-a-neglected-issue https://www.tbalert.org/about-tb/global-tb-challenges/tb-and-homelessness/ https://www.nice.org.uk/guidance/qs141/chapter/Quality-statement-6Accommodation https://www.homeless.org.uk/sites/default/files/siteattachments/Article%20Womens%20Homelessness%20Nov%202017.pdf http://groundswell.org.uk/what-we-do/health/homeless-womens-health/ https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/homeless-womenstriving-survive.pdf https://www.mungos.org/wp-content/uploads/2017/07/Rebuilding-Shattered-LivesUpdate-Nov-2015-1.pdf https://avaproject.org.uk/wp-content/uploads/2016/03/Case-by-Case-London-refugeprovision-Full-Report.pdf https://www.local.gov.uk/sites/default/files/documents/22.7%20HEALTH%20AND%2 0HOMELESSNESS_v08_WEB_0.PDF https://www.homeless.org.uk/sites/default/files/siteattachments/Young%20and%20Homeless%202018.pdf https://www.theproudtrust.org/wp-content/uploads/download-managerfiles/AlbertKennedy_ResearchReport_Youth-Homelessness.pdf https://stonewallhousing.org/wpcontent/uploads/2018/09/BuildingSafeChoices_full.pdf https://stonewallhousing.org/project/beyond-abuse-project-report/ http://www.homelessfriendly.co.uk/
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