Art & science community nursing

Improving access to health care for homeless people Lamb V, Joels C (2014) Improving access to health care for homeless people. Nursing Standard. 29, 6, 45-51. Date of submission: May 20 2014; date of acceptance: July 15 2014.

Abstract Homeless people have the poorest health outcomes in our society and the number of people who are homeless is increasing. This article explores the effect that homelessness has on health, provides details of organisations that offer services to the homeless population of London, and highlights the role of nurses in advocating for improved services for homeless patients. The need to understand and address inequalities in access to health care is also discussed. An example of the authors’ practice is provided in the form of a case study.

Authors Venetia Lamb and Claire Joels At the time of writing were StreetMed outreach nurses, Homeless Healthcare, London. Correspondence to: [email protected]; [email protected]

Keywords Access, advocacy, case management, health education, health inequality, homelessness, homeless people, nursing care, social inequality

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ECONOMIC INEQUALITY IS rising in the UK (High Pay Commission 2012). This has major repercussions, including that the poorest people in society have the worst health and social outcomes (University College London (UCL) Institute of Health Equity 2010, Wilkinson and Pickett 2010). The number of people who are homeless is increasing (Crisis 2011). Average life expectancy for homeless people is 47 years for men and 43 years for women (Crisis 2011), in stark comparison to the average life expectancy in the UK of 85 years for

men and 89 years for women (Office for National Statistics 2012). Premature deaths among homeless people are often attributable to poorly managed physical and mental health problems, and long-term substance misuse (Thomas 2012). This article explores the effect of social and health inequality in relation to homelessness and discusses the effect of homelessness on health. It also discusses London-based organisations that provide services for the homeless population; it is beyond the scope of the article to discuss national health initiatives for homeless people. At the time of writing, the authors of the article were outreach nurses working for StreetMed, an organisation that provides care for the homeless population in London, and as such the article focuses specifically on the London area. An example of the authors’ practice is provided in the form of a case study. The broader role of nurses advocating for improved services for homeless patients is emphasised.

Scale of the problem In London during 2012/13, 6,437 people slept rough. This represents a 62% increase over two years (Broadway 2012, 2013). Outreach team members gathered these data by searching the streets for people sleeping rough. The numbers were subsequently recorded onto the Combined Homelessness and Information Network (CHAIN) database. The only national count of homeless people available is an annual snapshot gathered on one night of the year across the country, where the number of people sleeping rough is counted for the purpose of comparison year on year. The autumn 2013 count was 2,414 people across England, which is up 5% from 2012 and up 37% from 2010 (Department for Communities and Local Government 2014). As a result of the transient nature of the homeless population, this method of data collection is flawed and does not represent the true size of the population. However, it is the best method currently available and allows for comparison with previous years. Rough sleeping

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Art & science community nursing estimates do not reflect the far greater number of homeless people categorised in various ways (Box 1). There is no accepted calculation to show the overall number of of homeless people across all categories.

BOX 1 Categories of homelessness Types of homelessness:  Rough sleepers.  Hostel or supported accommodation.  Squatters.  Hidden homeless (sofa surfers and/or those unable to gain or maintain tenancy). Statutory homelessness: Local authorities have a duty to house people who satisfy the following criteria based on the five questions below (Housing Act 1996, Homelessness Act 2002): 1. Is the applicant eligible for assistance (based on immigration status)? 2. Is the applicant homeless or threatened with homelessness within 28 days? 3. Is the applicant in priority need? 4. Did the applicant become homeless intentionally? 5. Does the applicant have a local connection to the area? Applicants can be placed in bed and breakfast or other temporary accommodation while their claim is processed. Non-statutory homelessness: Where households or individuals are found not to be eligible, do not fall within the definition of priority need, are deemed to be intentionally homeless or have not gone through legal application for housing. Individuals and families who fall outside the definition of statutory homelessness include:  Single people or couples who have no dependent children and do not fall into the statutory definition of vulnerable.  Families with older children who are no longer dependent.

BOX 2 Common causes of homelessness  Relationship breakdown.  Leaving an institution such as prison, foster care or hospital.  Substance misuse.  Mental health problems.  Redundancy/unemployment.  Unaffordable housing.  Structure and administration of housing benefit. (Shelter 2014)

BOX 3 Commonly used addictive substances  Tobacco.  Depressants, for example alcohol, gamma hydroxybutyrate (GHB), cannabis, benzodiazepines, inhalants such as glues, aerosols and vapours, heroin, methadone, morphine and codeine.  Stimulants, for example amphetamines, cocaine and crack cocaine.  Hallucinogens, for example ketamine, lysergic acid diethylamide (LSD) and magic mushrooms. (Centre for Education and Information on Drugs and Alcohol 2013).

Health needs and homelessness There are various causes of homelessness (Box 2). Whatever the cause, the effect of homelessness on physical and mental health is negative. A recent audit by Homeless Link (2014a) found that, of the more than 2,500 homeless people who took part in the audit, 73% had a physical health need and of these, 41% reported the need was long term. Some form of mental health problem was reported by 80% of those audited. Addiction is a problem in the homeless population, with high levels of alcohol misuse. More than one third of homeless people use one or more addictive substances (Box 3) (Homeless Link 2014a). The physical and mental health needs of the homeless population are often managed inadequately in primary care. As a result, the health of homeless people often deteriorates, requiring more expensive secondary care intervention (Melvin 2012, Homeless Link 2014a). Homeless people attend emergency department services five times as often as the housed population (Aspinall 2014), are admitted to hospital four times as often and stay three times as long (Department of Health (DH) 2010a). This equates to an estimated £85 million spent on health care for homeless people annually, equivalent to £2,100 per homeless person compared with £525 per person from the general population (Taylor et al 2012). In addition to the cost benefit of more effective primary care provision for this population, a huge difference could be made to the lives of homeless individuals struggling with complex health and social difficulties. Many homeless people not only have chronic diseases, but also have medical problems associated with high-risk behaviour, for example, sexually transmitted infections and bloodborne viruses such as hepatitis B and C or human immunodeficiency virus (HIV) (Beijer et al 2012). A leading cause of death in the homeless population is overdose, often associated with poly-substance misuse (NHS National Treatment Agency for Substance Misuse 2004). Long-term intravenous drug use causes damage to veins. This, coupled with poor hygiene, poor injection technique and re-use of drug-related equipment, can lead to skin infections, deep vein thromboses, skin ulcers and abscesses (Giudice 2004). Liver cirrhosis and renal damage are seen in people with alcohol and drug addictions and are also leading causes of death in the homeless population (St Mungo’s and Marie Curie Cancer Care 2011). Homeless people are at much higher risk of developing pulmonary tuberculosis (TB) than the general population (Health Protection Agency (HPA) and Homeless Link 2013).

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Poor adherence to TB treatment within the homeless population increases the risk of multi-drug-resistant TB developing (HPA and Homeless Link 2013). Poor nutrition and tooth decay are also prevalent (Dental Health Services Research Unit 2011).

Difficulties accessing health care Homeless people may experience difficulty accessing primary and secondary health services. Common barriers to healthcare access are (NHS North West London 2013):  Inability to register with a GP due to lack of proof of identity or inability to prove residence in the catchment area.  Fear and denial of ill health.  Difficulty communicating health needs.  Stigma, low self-esteem and discrimination.  Lack of understanding of the system. In addition, there have been consultations carried out by the DH (2010b, 2013a) about whether to restrict entitlement to primary and secondary care for various groups of people who are not ordinarily resident in the UK. Following these consultations, restrictions have been placed on entitlement to secondary care, meaning that anyone not deemed to be ordinarily resident in the UK is liable to be charged for secondary care treatment (UK Parliament 2011). There is currently no restriction in accessing primary care, although homeless people can find it difficult to access primary care because of the barriers mentioned above (NHS North West London 2013), which has implications for public health (Migrants’ Rights Network 2013). Homeless Link (2014a) recommends the statutory duty of each clinical commissioning group (CCG) is to assess and address the health needs of the whole population, including vulnerable groups such as homeless people and to reduce health inequalities. This is best achieved through maintaining access to primary care for all, free at the point of use (Health and Social Care Act 2012). CCG assessment of health needs is carried out through annual joint strategic needs’ assessments of each CCG area across England, to which bodies such as the Faculty for Homeless Healthcare and the London Network for Nurses and Midwives have contributed to raise awareness about the health needs of homeless populations.

Homeless health services in London The provision of primary health care for homeless people within the 32 London boroughs

is variable. Only seven have designated GP surgeries specifically for homeless people and these are mainly in the inner boroughs, for example Hackney, Westminster, Camden and Tower Hamlets. A few London boroughs have specialist community mental health teams, which also conduct street outreach programmes, for example, Camden, Westminster, Brent, Harrow, Hackney and Redbridge. Some boroughs that do not have specialist provision have nurse-led drop-in clinics held in day centres and homeless hostels, for example Camden, Hammersmith, Acton, Southwark, Lambeth and Lewisham. However, many London boroughs have no dedicated services. The London Network of Nurses and Midwives (2014a) recently launched an interactive directory of existing services. Within hospitals in London the provision for homeless people is again inconsistent. Some hospitals have gold standard homeless pathway teams, for example University College Hospital, Royal London Hospital, Guy’s and St Thomas’ Hospitals and King’s College Hospital. However, many London hospitals have no provision at all. The aim of homeless pathway teams is to increase the quality of care for homeless people and co-ordinate hospital discharges. The Faculty for Homeless and Inclusion Health (2013) has devised standards for any service or healthcare professional who comes into contact with homeless people.

Hospital discharge Unsafe hospital discharge of homeless people is a regular occurrence. A report on hospital discharge practices across the country found that more than 70% of homeless people are discharged from hospital back to the streets (Homeless Link and St Mungo’s 2012). Inevitably, a proportion of those individuals are re-admitted shortly after discharge because some health needs that could be managed at home are not manageable on the streets (Homeless Link and St Mungo’s 2012). Issues around unsafe discharge of homeless people from hospital include (NHS North West London 2013):  Early discharge before patients’ needs are met.  Discharge without addressing housing needs.  Failure to communicate effectively with relevant agencies around discharge.  Discharge without clothing or transport. Healthwatch England is conducting a review investigating the experiences of homeless people when they leave hospital (Macdonald 2014). In an attempt to improve hospital discharges and reduce hospital stays and re-admissions among the homeless

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Art & science community nursing population, the DH set up a hospital discharge fund to provide one-off grants for new initiatives (DH 2013b). Some of the funds have been used to develop short-term supported housing to assist timely discharge from hospital, allowing longer-term housing options to be investigated while the homeless person remains in the dedicated, short-term accommodation. One such project is Homeless Healthcare’s Hospital Discharge Network. This project provides 38 beds across four boroughs (Hackney, Camden, Westminster and Lewisham) in existing hostels where extra support and nursing staff now provide intensive case management in an intermediate care environment, supporting timely discharge and preventing unnecessary re-admission (St Mungo’s Broadway 2014).

The transient nature of homeless people means that they often do not stay within one borough. Consequently, complexities may arise when establishing an individual’s connection to, and funding from, any given borough. Many services for homeless people in London are funded at borough level and are, therefore, restricted by borough boundaries. Certain services, for example, the Find and Treat Specialist Outreach Team, are funded across borough boundaries. Commissioning of homeless services at a London-wide level would result in more patient-centred, co-ordinated service provision, which would better meet the needs of the transient homeless population. Such an approach was advocated at the London Network of Nurses and Midwives Homeless Conference (2014b).

BOX 4 Case study This case study highlights the issues facing homeless people that arise because of a lack of multidisciplinary working between existing statutory services. It illustrates the case management and advocacy role of StreetMed. StreetMed received a referral from a street outreach team for a 54-year-old man who had become a rough sleeper after drug dealers took over his council flat. For the purposes of confidentiality, the pseudonym Joe will be used. The outreach team found Joe sleeping rough on a park bench. He had a wound on his head and showed clear signs of cognitive impairment. He had inappropriate bedding for the cold weather, was unkempt, smelt strongly of urine and was alcohol dependent. Joe had been seen in the emergency department following a fall in which he sustained a minor head injury, but had been discharged back onto the streets. The outreach team assisted Joe into emergency temporary accommodation provided by the council. StreetMed accompanied Joe to a community alcohol detoxification group and helped him to re-engage with the GP who prescribed vitamins to protect him from further cognitive damage. Soon after StreetMed met Joe, he experienced another fall and was taken to the emergency department. He was admitted to hospital with multiple rib fractures. However, the plan was to discharge him the following day, despite his high levels of pain, symptomatic alcohol withdrawal and the unsafe nature of his temporary accommodation. StreetMed and the hospital’s pathway team, which supports discharge of homeless patients, advised that Joe should not be discharged and he was moved to another ward in the hospital. There, he received inpatient care for nearly two months. Joe’s health improved with dedicated ward staff and good multidisciplinary care. He underwent alcohol detoxification and he was diagnosed with liver cirrhosis and old fractures. StreetMed successfully advocated for Joe to be referred to the physiotherapy team and social services. StreetMed also advocated for an assessment of his mental capacity and cognitive functioning, including a computed tomography (CT) scan. The CT scan showed atrophy of the brain, premature for his age but consistent with long-term alcohol use. Joe was diagnosed with ataxia and being at high risk of falls by the physiotherapist. The capacity assessment in relation to his housing and self-care showed he did not have capacity to make decisions because of his inability to retain information. An Independent Mental Capacity Advocate was arranged to advocate for decisions to be made in keeping with Joe’s wishes. Through abstinence from alcohol while on the ward, Joe’s mobility improved. He became safe to walk short distances and formed good relations with staff on the ward. However, he attempted to abscond a number of times and was given one-to-one nursing care. In collaboration with StreetMed, the social worker involved in his case found a housing project that offered 24-hour care and helped Joe to take control of his money. Joe agreed to limit his alcohol intake to two cans of lager per day and started eating well. He was not allowed to leave the property without a care worker but was encouraged to have independence within the home. Although Joe found the restrictions difficult, he agreed that he was better off in this environment where he was supported, received regular meals and felt safe. Important points illustrated in this case study for healthcare professionals to consider include (Nursing and Midwifery Council 2008):  Referrals by nurses to other agencies, for example social services, should be prompt.  Capacity assessments should be carried out on all patients showing signs of cognitive impairment.  Healthcare professionals coming into contact with homeless people should identify them as vulnerable individuals and take steps to safeguard them.

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StreetMed StreetMed is an innovative project comprising a nurse-led team that combines the skills of nursing and homeless outreach to bridge the gap in healthcare provision. The overall aim is to improve homeless people’s access to care, resulting in better health outcomes and reduced inequality. StreetMed reaches out to patients who are not accessing primary health services. It receives referrals of such patients from agencies, including outreach teams and staff within hospital. StreetMed meets patients in hospital, on the street, in hostels or in temporary accommodation, and carries out holistic assessments. It then takes steps to address the identified physical, mental and psychosocial health needs, taking into account the housing environment (Box 4). During 2013/14, StreetMed worked with 86 patients across 15 boroughs. Successes included increasing the number of patients registered with a GP from 17 to 48, and reducing the percentage of rough sleepers or those without secure accommodation from 68% to 37% of the caseload. An important component of the success of StreetMed has been the ability to follow patients across borough boundaries, providing integrated case management by advocating across housing and health services. StreetMed nurses have a sound knowledge of housing entitlement, enabling them to advocate effectively for housing, without which good health is impossible to achieve. The DH (2004, 2014) advocates the use of case management for high-risk people with complex needs, including people who are older and other complex groups with multiple needs. A case management model is an appropriate and efficient approach with which to address the diverse and multi-faceted needs of the homeless population (Dorney-Smith 2007). Early identification of palliative care needs and improving homeless patients’ access to palliative care services has been part of StreetMed’s case management role. Many of the patients referred to StreetMed have very poor health with multiple morbidities – 10% of the caseload died between 2012 and 2013. Those who died were aged between 39 and 45 years. StreetMed works closely with Peter Kennedy, the palliative care co-ordinator from St Mungo’s Broadway, who has developed a toolkit for assisting early identification of patients approaching the end of life. This is particularly useful in identifying end-stage organ failure, which can often be difficult to recognise and can result in sudden unplanned death (Kennedy et al 2013). Reducing emergency department attendance is an additional outcome of StreetMed’s work. Supporting access to primary health care has

been integral to achieving this goal. StreetMed accompanies patients to register with GP surgeries and attends health appointments with patients, assisting with transport costs when needed, and reducing non-attendance rates. StreetMed also works with a homelessness peer-support service called Groundswell, run by St Mungo’s Broadway. This service provides financial assistance and accompaniment to appointments for patients who are motivated to attend but need support to do so. StreetMed has helped patients to access a range of services, including prescribed methadone; a planned detoxification service; and social and mental health services. All of these primary care services have enabled various StreetMed clients to be treated more effectively and holistically in the community, reducing reliance on expensive secondary care.

Relevance to other nurses Healthcare professionals should prioritise homeless people when they access health services and take the opportunity to conduct a thorough assessment. The Queen’s Nursing Institute (QNI) has a Homeless Health Network across the UK and provides free online training on homelessness and health (QNI 2014).

BOX 5 Steps towards achieving safe discharge for homeless people  On admission, identify homeless patients and those living in homelessness services: – Ask if people have accommodation, whether they can return and if they risk losing it. – Contact the patient’s support services – this can prevent them losing their accommodation.  If a housing need is identified, know how to respond and who to refer them to: – Find out who to notify within the hospital and externally – is there a named contact? – Know how to make a referral to the local Housing Options team. – Ask local councils for training on the assessment and referral of homeless people. – Keep an up-to-date contact list of local agencies such as hostels, outreach teams and drug and alcohol services on each ward.  If homeless people discharge themselves: – Alert local services. – Record the self-discharge and the reason.  Ensure patients can access ongoing care: – Complete a social needs assessment. – Notify the GP and relevant agencies about follow-up treatment. – Provide a copy of the discharge plan and medication.  Help people return to their accommodation: – Let the housing agency know when patients are returning to ensure they can get in. – Avoid out of hours discharge. – Help patients to get home – they may need travel expenses.

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Art & science community nursing Healthcare professionals within hospital environments have a responsibility to ensure the safe discharge of patients back into the community. Box 5 summarises the steps towards achieving safe discharge for homeless people. Identification of homeless patients is crucial. This is easily achieved by asking patients if the address they have provided is their own address. Often homeless people supply a ‘care of’ address and are not identified as homeless. If the accommodation in which a patient is staying is temporary, such as a hostel or bed and breakfast establishment, the provider should be contacted to ensure the patient does not lose the accommodation during their hospital admission. A thorough assessment of the homeless patient should include assessment of substance use, physical health, psychological state, end of life care needs, access to benefits, housing status, ability to maintain independence, and GP registration. It is important to find out what local services exist within primary or secondary care. Information about specialist homeless services, such as day centres, can be found on The Pavement (2014) website, which catalogues homeless services across the UK. Homeless patients should also be referred

to mainstream services, in the same way as any other patient would be, such as mental health and physiotherapy. Primary and secondary care nurses can carry out referrals to agencies in the community. As demonstrated in the case study, such referrals have the potential to change patients’ lives, taking them out of the cycle of homelessness. Multi-agency care planning meetings should be conducted, assisting cohesive working between agencies, including housing providers where possible. A letter from any healthcare professional involved in the care of a homeless person, which the patient can take with them when they attend the housing department, has an effect on the success of an individual’s application for housing. Letters should address the five points detailed in Box 1 regarding statutory homeless status, particularly the health concerns indicating why the individual is in priority need of housing. In addition, anyone can refer a rough sleeper to StreetLink, and homeless people can also self-refer. StreetLink has a telephone line and website available across England, which enables the public to alert local authorities about rough sleepers in

References Aspinall PJ (2014) Hidden Needs: Identifying Key Vulnerable Groups in Data Collections: Vulnerable Migrants, Gypsies and Travellers, Homeless People, and Sex Workers. Inclusion Health Board, London. Beijer U, Wolf A, Fazel S (2012) Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis. The Lancet Infectious Diseases. 12, 11, 859–870. Broadway (2012) Street to Home Annual Report: 1st April 2011 to 31st March 2012. Broadway, London. Broadway (2013) Street to Home Annual Report: 1st April 2012–31st March 2013. Broadway, London. Centre for Education and Information on Drugs and Alcohol (2013) The Three Main Categories of Drugs. www.ceida. (Last accessed: September 4 2014.) Crisis (2011) Homelessness: a Silent Killer. A Research Briefing

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their area. This service offers the public a means by which to act when they see someone sleeping rough and is the first step to ensure rough sleepers are connected to the local services and support available to them. Emergency department reception areas are now considered to be a rough sleeping location. If a patient is using an emergency department as a sleep area, a referral to StreetLink should be made. Healthcare professionals should call 0300 500 0914 or log on to StreetLink relays the information it receives to outreach teams in the area of the homeless person, who then approach the person. The outreach team will usually take the homeless person to a short-stay hostel, subject to capacity, to enable an assessment of their housing options and support them to move on from the hostel.


Conclusion Homeless people have the poorest health outcomes in society. Premature deaths among homeless populations are often attributable to poorly managed medical and mental health problems, as well as long-term substance misuse. This article

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has explored the effect of social and health inequality in relation to homelessness and discussed the effect of homelessness on health. It has also detailed some London-based organisations that provide services for the homeless population. A case study is used to highlight the complications that often arise when discharging homeless people from hospital, and the role of nurses in advocating on behalf of homeless people when being discharged. The means by which nurses may instigate the involvement of organisations that can assist to prevent unsafe discharge of homeless patients, is also discussed. The involvement of such specialist organisations is shown to promote safe discharge and prevent costly and avoidable re-admissions to hospital that can occur following unsafe discharge NS

  facebook:  twitter: @HomelessLink  (Adapted from Homeless Link 2014b)

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Aftercare for Homeless People. press_office/1849_minister-w elcomes-new-hospital-afterc are-for-homeless-people (Last accessed: September 4 2014.) St Mungo’s, Marie Curie Cancer Care (2011) Supporting Homeless People with Advanced Liver Disease Approaching the End of Life. Marie Curie Palliative Care Research Unit, University College, London. Taylor K, Naylor H, George R, Hammet S (2012) Healthcare for the Homeless: Homelessness is Bad for Your Health. Deloitte Centre for Health Solutions, London. Thomas B (2012) Homelessness Kills: An Analysis of the Mortality of Homeless People in Early Twenty-First Century England. Crisis, London. The Faculty for Homeless and Inclusion Health (2013) Standards for Commissioners and Service Providers. Version 2.0. College of Medicine, Pathway, London.

The Pavement (2014) Services. services.php (Last accessed September 8 2014.) The Queen’s Nursing Institute (2014) Homeless Health Network. homeless_health (Last accessed: September 4 2014.) UCL Institute of Health Equity (2010) Fair Society Healthy Lives. The Marmot Review. Marmot Review Secretariat, Department for Epidemiology & Public Health, University College London, London. UK Parliament (2011) The National Health Service (Charges to Overseas Visitors) Regulations 2011. Statutory Instrument No. 1556. www. pdfs/uksi_20111556_en.pdf (Last accessed: September 4 2014.) Wilkinson R, Pickett K (2010) The Spirit Level: Why Equality is Better for Everyone. Penguin, London.

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Improving access to health care for homeless people.

Homeless people have the poorest health outcomes in our society and the number of people who are homeless is increasing. This article explores the eff...
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