The ‘duty to refer’: why the CQC should review their inspection regime

Sir Ian Kennedy calls upon the Care Quality Commission (CQC) to add compliance with statutory duties regarding homelessness to regimes for inspecting hospitals.

The introduction of the Homelessness Reduction Act 2017 (HRA) placed new legal duties on NHS trusts to refer patients who are homeless or at risk of homelessness to local authorities’ housing departments. 

The ‘duty to refer’ came into force in October 2018, but many physicians report that the change was not communicated to hospitals, many of which are believed to remain in breach of the Act. More importantly, failure to implement the Act is resulting in patients continuing to be discharged when it is not safe to do so. The CQC could act to help ensure that hospitals comply with the Act, preventing hundreds of patients being discharged to sleep on the streets again this winter. 

More importantly, failure to implement the [Homelessness Reduction] Act is resulting in patients continuing to be discharged when it is not safe to do so

Sir Ian Kennedy QC, emeritus professor of health law, ethics and policy at the School of Public Policy, University College of London

A moral imperative

Discharging homeless patients when they do not have access to food, water, and facilities for rest and rehabilitation should be unthinkable. Yet, in areas of the country without specialist ‘Pathway’ teams, it is still common practice to do so. Underlying the legal requirement and the compassionate arguments focused on helping these vulnerable people, there is solid clinical evidence. Integrated, clinically led, specialist homelessness teams in secondary care improve health outcomes. They can also reduce subsequent admissions.

When we challenge the inverse care law – that strange beast which ordains that those who need healthcare most have the greatest struggle in gaining access to it – the results can be astonishing.

Encouraging compliance with the Homelessness Reduction Act

Charities and government departments provide free introductory training for hospital trusts on the HRA. The Faculty for Homeless and Inclusion Health has published authoritative national standards for caring for excluded patients, endorsed by the RCP, the Royal College of Psychiatrists and the Royal College of General Practitioners, among others.

The Faculty’s annual conference offers a thorough grounding in ‘inclusion health’ and showcases cutting-edge approaches to patients with multiple complex needs. There are multiple, easily accessible opportunities to learn about this area, and yet we know that many have not.

The CQC and the ‘duty to refer’

If compliance is not yet universal (or even widespread), despite the resources made available, clearly further measures are needed. Inspection can promote raised standards, address problems and thereby lead to improved healthcare.

A number of us have written to the CQC asking them to include compliance with the HRA in current inspection regimes, to safeguard anyone at risk of homelessness. Until the CQC take this step the Faculty for Homeless and Inclusion Health has recommended that trusts carry out self-assessment, asking such questions as:

  1. What systems does the trust have in place to identify homeless patients?
  2. Does the hospital have an annual monitoring process for this population of patients?
  3. Has the trust designated someone to take responsibility for the ‘duty to refer’?
  4. Does the trust have an approved protocol for referring identified patients  to the local housing authority and other relevant services?

Responding to homelessness

Long-term rough sleeping is associated with a combination of physical and mental illnesses and addiction, all commonly rooted in childhood psychological trauma. The most effective interventions for such patients integrate physical, mental health and addictions services with support through advocacy and case management.

[Pathway teams] can provide advice on interactions between street drugs and prescription medicines, support ward staff in managing behaviour, and offer clean, dry clothing for homeless patients.

Sir Ian Kennedy QC, emeritus professor of health law, ethics and policy at the School of Public Policy, University College of London

The RCP recommends that all secondary care providers treating homeless patients should put a suitable support system in place: those with sufficient numbers of patients should host a clinically led Pathway homeless healthcare team.

Pathway teams are patient-centred. They have the time, skills and resources to build trust with patients. They can provide advice on interactions between street drugs and prescription medicines, support ward staff in managing behaviour, and offer clean, dry clothing for homeless patients.

The teams forge strong connections with social care and community services and some offer ‘respite’ or ‘sanctuary’ facilities that can reduce delays in discharge by providing nursing support in an environment such as a hostel.

While these teams offer the highest level of support, guidance on good practice is now available to all hospital physicians. The ‘duty to refer’ may seem complex, but it makes a single, simple request: refer patients facing homelessness to the advice and support they need. Doing so could change their lives forever.

Sir Ian Kennedy QC is a leading health ethics expert and trustee of the homeless healthcare charity Pathway. He is emeritus professor of health law, ethics and policy at the School of Public Policy, University College of London and visiting professor at the London School of Economics.

The full version of this article appears in February’s Commentary magazine.