Delivering Health Care to Homeless People: An Effectiveness Review

Executive Summary

This research was undertaken for NHS Health Scotland by Deborah Quilgars and Nicholas Pleace. The Executive Summary is presented below and the full report is now available on the NHS Health Scotland website. It can be downloaded in PDF format HERE.

• This report reviews evidence on the provision of effective health services for homeless people. It draws on a literature review encompassing Scottish, English and international research and on a small number of focus groups and interviews with health professionals, homelessness workers and other interested parties conducted in Edinburgh, Perth and Kinross and Argyll and Bute during the Spring of 2003. Local authorities, NHS Health Boards and 103 organisations involved in providing homelessness services in Scotland were also asked to submit relevant evidence and reports. A search of relevant websites was also conducted.



• Although levels of rough sleeping are falling, overall homelessness in Scotland is increasing. Two thirds of the people assisted under the previous homelessness legislation were lone adults, with the remaining third mainly being composed of homeless families with children. There has been a growth in the use of temporary accommodation for households awaiting permanent rehousing, including homeless families.



Access to healthcare for homeless people

• The evidence base is quite well developed on access to healthcare among people sleeping rough and lone homeless people living in emergency accommodation in Scotland (and in England). There is less information available on access to healthcare among other groups of homeless people, such as homeless young people, homeless families and homeless people with a Black or minority ethnic background.



• The main barriers to healthcare for homeless people include the administration of the NHS, which is in part dependent on patient"s having a permanent address. Homeless people can also encounter attitudinal barriers, including negative attitudes or refusal of service by some administrative staff or medical professionals. There is some evidence that homeless people may be reluctant to use health services because they anticipate a hostile reception and that low self-esteem can lead individuals to neglect their health. In some cases, mental health problems, drug or alcohol dependency, or a combination of the two, can make it difficult for some homeless people to effectively access healthcare or maintain contact to ensure continuity of care. Homeless people may also face more immediate "survival" needs, such as food and shelter, which can mean that all but the most pressing healthcare needs are ignored.



• Location can have a marked impact on the provision of health services for homeless people. It is logistically more difficult and more expensive to provide health services in rural areas of Scotland, where homelessness is relatively dispersed. In contrast, the comparatively high concentrations of homelessness in Scotland"s major cities makes the development of specialist services more practical.



• Homeless people can find it difficult to access mental health and Drug and Alcohol services in Scotland. There can be particular problems for homeless people with multiple needs (a drug/alcohol dependency and mental health problems).



Access to healthcare for different groups of homeless people

• Homeless women often experience sexual assault while homeless. Many women have become homeless following an experience of domestic violence. They may need services that ensure they feel secure and may be reluctant to engage with services that have a predominantly male patients.



• Homeless families may encounter difficulties in accessing healthcare if they are resident in temporary accommodation. Temporary accommodation may also undermine the health status of homeless families. Families may in some instances find it difficult to access healthcare because they face a range of more immediate needs or need some support in accessing health services.



• Homeless young people may not prioritise health needs unless they become debilitating. There is some research evidence that they may be reluctant to approach health services because they anticipate a hostile reception or because they have difficulty in tasks like completing forms. There is also research evidence that very low self-esteem among some young homeless people may contribute both to becoming involved in behaviour that places their health at risk and towards a tendency to neglect their health. There are particular concerns about the numbers of care leavers who become homeless and the rising levels of young people sleeping rough in Scotland. In addition, there is some research suggesting very high rates of heroin use among homeless young Scots.



• There is little research evidence on access to healthcare, or the health needs, of homeless people who are members of minority groups. This includes homeless people with a Black or minority ethnic background and homeless people who are lesbian, gay, bisexual or transgender.

Health services for homeless people

• The evidence base on specialist health services for homeless people in Scotland is not always very well developed. Existing studies tend to be descriptive, rather than evaluative, and some aspects of healthcare provision for homeless people have not been researched. English research is similarly descriptive and patchy. The most rigorous and systematic research in this field tends to be North American.



• Health services for homeless people in Scotland and in other countries in the UK range from small, informal alterations to mainstream NHS services through to the provision of specialist primary care services for homeless people offering GP and nursing services alongside complementary services such as drug and alcohol workers, dentistry, podiatry and opticians. As the detailed operation and range of services varies considerably, it is difficult to categorise these services, but it is possible to view them as being positioned along a continuum that ranges from "informal" responses to full specialist primary care services.



• The main urban areas of Scotland tend to have more comprehensive health services for homeless people. Edinburgh, for example, has The Access Point, a full primary care service offering nurse, GP, community mental health and substance misuse services. In some smaller towns and cities, such as Aberdeen, Perth and Dundee, there has been a tendency to offer smaller, mobile nurse-led teams for homeless people, although there is a tendency toward expanding these services. In rural areas of Scotland, there are sometimes specialised workers and health professionals who enable and support access to the mainstream NHS for homeless people. For example, a health visitor and Community Psychiatric nurse are employed by a homeless day centre in Inverness.



• Informal alterations to mainstream services are thought to be relatively commonplace, but this is not an area that has been researched in Scotland. They include GPs allowing homeless people to use the address of their practice for the purposes of permanent registration, or the decision by an individual doctor to provide treatment for homeless people living in a nearby hostel.



• Training can be provided to improve the response of mainstream services to homeless people. Some research in London has suggested that improvements in patient"s satisfaction and staff"s attitudes towards homeless people can result from training.



• In some instances, hospitals employ staff to improve discharge arrangements for homeless people, as unplanned discharges can lead to poor outcomes for homeless patients. A number of these services have been developed in Scotland. Research suggests the importance of having systems that record whether an inpatient is homeless, planning in advance for discharge and working cooperatively with housing and social care agencies.



• Comprehensive primary care services can operate from a fixed site and/or provide outreach services. Most of these services in Scotland are funded through Primary Medical Service (PMS) arrangements. Many primary care services are increasingly integrated with other services as part of multi-service responses aimed at preventing homelessness and effectively resettling homeless people.



• Research suggests that comprehensive primary care services that work flexibly have high levels of patient satisfaction. Services that are successful in providing access to healthcare for homeless people also tend to have a "paternalistic" contract between medical professionals and their patients, which contrasts with the "patient as consumer" contract between the general public and the mainstream NHS. Services also aim to provide non-threatening, non-judgemental and open environments. Research also indicates that health services should work jointly with social housing and social care services, as part of a holistic multi-service response to homelessness. There have been few studies that have examined the clinical effectiveness of these services.



• Facilitator services are mobile services that provide some direct healthcare to homeless people in the community. These services can be nurse-led or they may employ a specialist health visitor. Some research has suggested that these services can run into some operational difficulties when there are problems in referring homeless people on to the mainstream NHS or when the role of the service is restricted, for example because a nurse-led service cannot prescribe. However, these flexible services, which aim to work positively with homeless people, are often valued. Not many of these services have been evaluated, but the available research suggests that they have improved contact between homeless people and the NHS.



• Research suggests that outreach dentistry services can be effective in reaching homeless people and can also encourage homeless people to return for repeat treatments. Services did however need to be flexible, provide reassurance and, where possible, work in ways that allowed homeless people to access them quickly. There has been little research on physiotherapy services for homeless people, one study finding positive effects overall, but also reporting difficulties in providing continuity of care. Research has not been conducted on opticians services or podiatry for homeless people.



• Mental health services for homeless people have been increasingly developed as part of the strategic response to rough sleeping, both in Scotland and in England. Some of the first UK services encountered problems in successfully resettling rough sleepers with mental health problems after they had been contacted by outreach teams, as there was a lack of suitable services to which they could be referred. Again, flexibility, the ability of services to adapt to the changing needs of their patients and joint working with other services were reported as being important. Research from the United States suggests that services based around assertive outreach may be effective in meeting the needs of "hard to reach" homeless people, such as some people sleeping rough.



• There is some emerging evidence that services that involve homeless people, as mentors or through peer-support schemes, can be effective in counteracting drug use among groups like homeless young people. North American research suggests that drug and alcohol services that are prepared to be open, tolerant and flexible may be more effective than services that place many expectations and rules on homeless people. There is some evidence that services linked to permanent accommodation may be more effective than some community based services. An assertive outreach model, being used in Edinburgh, has also helped homeless people address drug and alcohol dependency. There is research evidence that multi-disciplinary specialist services offering targeted support can reduce levels of drug use among homeless people, but that in order to achieve this an integrated approach covering housing stability and other health problems, as well as offering a broad programme of treatment, is necessary.



• Research suggests that comprehensive, tolerant and flexible services, addressing a range of needs, are required to successfully meet the needs of homeless people with multiple needs (both a mental health problem and a drug or alcohol dependency).



• Evidence on health promotion among homeless people is mixed. There have been some attempts at disease control and monitoring, mainly focused on tuberculosis, which have met with varying success. Health education has been undertaken with some groups of homeless people and reported different degrees of effectiveness.



• Modifications to the NHS designed to increase accessibility for socially and economically marginalised Scots, such as some social rented tenants, refugees and travellers, may also benefit homeless people. However, the extent to which innovations like Healthy Living Centres may benefit homeless people is unclear at the moment.

The overall effectiveness and role of health services for homeless people

• As the evidence base on access to health and health needs among people like homeless families, homeless young people, homeless women and homeless people from an ethnic or sexual minority is underdeveloped, our understanding of the range of interventions that may be needed is not as full as it should be. In contrast, there is a danger that health status and access to healthcare among people sleeping rough and lone homeless people in emergency accommodation is becoming over researched.



• High quality evaluative research on specialist health services for homeless people and on the effectiveness of modifications to the mainstream NHS to make it more accessible for homeless people is rare. It is consequently difficult to develop health services using models that have demonstrable effectiveness based on a high quality evidence base.



• It can be argued that health services for homeless people have inherently limited effectiveness. Homelessness constitutes such an intensive set of compound risks to health that no homeless person or household can ever be "healthy" in the sense of enjoying physical, mental and social well-being, as well as an absence of disease. Some argue that promoting "health" among homeless people not only extends beyond meeting medical needs, but that some other basic needs have to be met before medical needs can properly be addressed.



• The development of multi-service or "more than a roof" responses to homelessness, involving joint working between health, housing and social care services lies at the heart of Scotland"s response to homelessness. This policy recognises the basic argument that the healthcare needs of the homeless population can ultimately only be addressed through preventing homelessness where practicable and in supporting the resettlement of homeless households and individuals with appropriate multi-service packages.



• Health services for homeless people need to balance their role carefully within multi-service responses to homelessness against their prime responsibility to meet the clinical needs of homeless people. Both mainstream and specialist health services may have a role within multi-service responses, but they should not be expected to function as "one-stop" solutions for homelessness. Equally, it needs to be clear that homeless people should be given the option to pursue routes out of homelessness, but not expected or required to enter resettlement as a condition of seeking healthcare, as this could act as a barrier to services.