As we approach the end of a year which has seen the number of homeless people soaring, Dr Nigel Hewett, medical director of health charity Pathway, writes for the RCP on a new duty of care that is a step in the right direction towards making a difference for this vulnerable group.
Homelessness is rising. It is visible in any city centre, confirmed by national statistics and clear to many hospital consultants. A decade of austerity has driven growing numbers of vulnerable people onto the streets.
Once on the street, vicious combinations of physical and mental illness, often complicated by addictions, result in a downwards spiral towards (ironically) the most expensive elements of state provision: hospitals and prisons. But the main costs of homelessness are borne by the victims. The latest international research shows standardised mortality ratios of 8 for socially excluded men and 12 for excluded women . In lay person’s terms, the stark reality is that socially excluded people are ten times more likely to die than the rest of us.
Homelessness and health
Homelessness is a useful marker for people at high risk and barely surviving on the margins of society, but it has always been hard to tackle in the context of a walk-in centre, A&E, or an acute admission.
Without significant care needs it can be difficult to get a social worker involved, and until recently housing departments seemed set up to turn people away.[2[ Beyond the stereotypical homeless person, there are many more hidden homeless people, “sofa-surfers” staying with friends until they wear out their welcome, families in overcrowded temporary accommodation and others with no secure roof over their heads.
The main message for the medical profession is that for the first time, the Act places a new statutory duty on clinicians to refer homeless patients for assessment
The social dimension to homelessness presentation is often hidden through embarrassment and shame. But behind the self-harm, alcohol binge or unexplained assault might be a simple problem – nowhere safe to stay.
Recognising this, 11 inner-city hospitals across England and Wales facing significant numbers of homeless patients have adopted the evidence-based Pathway model of care coordination, helping homeless people access accommodation upon discharge from hospital, rather than returning to the streets. In areas with lower levels of need, pioneers like Dr Pippa Medcalf, the RCP inclusion health champion and a consultant in acute medicine have ploughed a lonely furrow, working to show that a dedicated housing worker in the hospital can really make a difference.
Thanks to her work and the hard work of health and housing charities, addressing homelessness is now within the reach of any clinician.
The Homelessness Reduction Act
The Homelessness Reduction Act 2017 is new legislation offering a new opportunity. It provides for prompt assessments for anyone who is homeless, or at risk of homelessness in the next 56 days. The main message for the medical profession is that for the first time, the Act places a new statutory duty on clinicians to refer homeless patients for assessment.
Many hospitals remain in breach of this duty and working with the Faculty for Homeless and Inclusion Health and Pathway, the RCP is promoting simple guidance for clinicians on how to meet the new duty to refer. A straight-forward referral process to a local email address informs the local authority and should trigger a full assessment and a personalised plan.
With there now being a statutory duty for services take action, hospital professionals now have good reason to ask a question that we might previously have avoided – “do you have somewhere safe to stay when you leave here?”
Dr Nigel Hewett OBE is the medical director of homeless health charity Pathway and secretary to the Faculty for Homeless and Inclusion Health.
You can follow Pathway's work on Twitter at @PathwayUK
- Aldridge RW et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet 2018;391(10117):241-50. http://bit.ly/2Dfc61q
- Dobie, S., Sanders, B. & Teixeira, L. (2014) Turned Away: The treatment of single homeless people by local authority homelessness services in England. London: Crisis.