Written evidence from Homeless Link (CFI
16)
Homeless Link, the national membership organisation
for agencies working with people who are homeless, is pleased
to contribute to the Health Committee's follow-up inquiry. Our
particular interest is the way that Commissioning of health services
impact on homeless people and the agencies which work with them.
We welcome the Committee's further review of what
we see as critical aspects of the proposals to reform commissioning
processes and structures. The health needs of homeless people
are known to be among the most severe and most costly in our communities.
Without action to ensure these needs are addressed in these new
commissioning processes, there is a significant risk that the
health reforms will overlook vulnerable groups and will fail in
its aim to improve "the health of the poorest fastest."
We have focussed our submission below on the points
raised in the Commissioning report of most concern and relevant
to the client group we support.
SUMMARY OF
KEY RECOMMENDATIONS
— If
homeless people are to have the services they need then they must
be more visible in the new commissioning system; this means a
standard flag in GP systems and a requirement for JSNAs to record
the needs of groups with significant levels of health inequalities
such as homeless people.
— Mechanisms
which will incentivise joint working need to include a fully integrated
outcomes framework to ensure that services join up to meet the
needs of homeless people. This should be underpinned by the recognition
of the wider services which contribute to health outcomes in addition
to those which are clinically driven.
— In
order that homeless people are not left behind there should be
a statutory duty for Health and Wellbeing Boards and GP consortia
to address the needs of homeless people within their commissioning
and planning structures.
— There
needs to be a clear point in the commissioning process where wider
agencies than those involved in Health and Wellbeing boards or
consortia can provide input into decisions or challenge those
which have not taken into account specific patient groups.
1. CONTEXT FOR
OUR SUBMISSION
1.1 The health of homeless people is significantly
worse than the general population. High levels of complex need
contribute to and are caused by a person's homelessness resulting
in high levels of working age mortality, a higher level of long
term conditions and greater likelihood that people will have more
than one health need.
— Eight
in 10 homeless people have one or more physical health need.
— Seven
in 10 of homeless people have one or more mental health need.
— Over
half use drugs, and one in five drink alcohol problematically.
— Nearly
half of those with a mental health problem self medicate with
drugs or alcohol.[49]
1.2 Not only is their poor health significant
but the cost to the NHS of homeless people is much higher. A report
by the Department of Health last year found that:
— The
total cost of hospital usage is conservatively estimated to be
£85 million, four times greater than an equivalent number
of non-homeless hospital users.
— Inpatient
costs are eight times higher than comparison population (aged
16-64).
— Homeless
people attend A&E five times as frequently as the non-homeless,
this would imply a total of around 53,000 attendances annually
by homeless people, costing around £5 million per annum.[50]
1.3 The reason for this enduring ill health is
the complexity of individuals and their circumstances. Homeless
people often have a range of conditions which services are not
equipped to respond to, for example mental health and substance
use problems combined with enduring physical health issues. Their
ill health is also often caused or made worse by factors outside
of health, for example poor housing, and, correspondingly, their
ill health often makes their other circumstances worse.
1.4 Homeless people have spent decades being
understood only in terms of their housing needs, while their significant
health problems are a key and often defining factor in the homelessness.
Over the past few years we have significant progress, with improved
access into mainstream provision and the development of specialist
services in some areas to meet the needs of the most disadvantaged.
However, we are concerned that amid the transition to new systems
in the NHS, rather than building on what we have learnt from these
services they will be lost. We are already seeing evidence of
this as spending decisions are being made. While the health reforms
do represent an opportunity to get it right, there is a significant
risk that these reforms will overlook vulnerable groups and fail
to address the health of homeless people.
We would like to make comments on three of the specific
points outlined in the Committee's inquiry:
2. The Committee's intention to review the
arrangements proposed for integrating the full range of clinical
expertise into the commissioning process [paragraph 91]
2.1 We are pleased that the Committee identifies
the need for GPs, in their new role as commissioners, should draw
on a wide pool of practitioners in order to make informed decisions
which bring the most benefit to patients. This is of heightened
concern for people who are homeless, who are often not visible
to mainstream services making it hard for some health professionals
to have an understanding of their health needs and how to adequately
meet them.
2.2 Rightly, organisations like the NHS Confederation
have raised concerns about the accountability for commissioning
services for people not registered with GPs. Although homeless
people who are engaged with homelessness services are often encouraged
to register with GPs by services, this does not mean that they
are a visible population within the GP population. For example,
while many care records systems may have the function to record
an individual's housing status there is not a consistent marker
in the system. There is little evidence that this information
is being audited or aggregated by services to give them a picture
of need. Among the GPs we have spoken to who are experts at working
with homeless people they believe that this activity is undertaken
variably and as such homeless people are unlikely to be flagged
in electronic systems.
2.3 They are also less likely to be visible in
the practice. Data gathered by St Mungo's and Homeless Link shows
that while homeless people are likely to be registered with a
GP they do not always maintain contact with their GP particularly
if they have more serious health needs. Instead Accident and Emergency
is often used to access secondary healthcare. This can mean that
they are not a visible presence in their GP practice and may mean
that healthcare needs are not always captured on their records:
In St Mungo's 2010 snapshot survey key workers were
asked to estimate where their clients most often access health
care from. A third stated that their clients most regularly access
health care through accident and emergency. This was despite 95%
being registered with a GP.
Homeless Link's national Health Audit data found
that:
— 85%
were registered with a GP and 82% had visited their GP in the
previous 6 month period
— However,
despite this, 41% had been to A&E and 31% had been admitted
to hospital at least once in the previous six months.
— There
was also evidence of attitudinal and access barriers at a GP level.
9% had been refused access, usually due to behaviour or having
no fixed abode status.[51]
2.4 It would seem from this evidence that even
where clients are registered, this still results in high access
of acute services. While this is due in some cases to the severity
of health need among this population, it also indicates that some
GP practices and other services are not managing homeless people's
health at a primary care level. Evidence that more complex and
serious conditions among homeless people are not being supported
through their GP also comes from soon to be published joint research
between Marie Curie and St Mungo's looking at homeless people
dying with advanced liver failure. One of the key findings of
the report was the limited involvement of GPs despite clients
requiring palliative support.
2.5 Homeless people, for a range of reasons may
lack visibility among GPs for the full range of health needs.
Similarly, due to the way information about individuals is recorded,
homeless people are often not seen as a group for which action
could be targeted.
2.6 This lack of visibility and the poor use
of primary care services despite high levels of ongoing health
needs indicates that existing commissioning processes do not take
account of homeless people's needs and that the services available
to them are not the right ones. If the visibility of vulnerable
groups was made a priority in the new commissioning system this
could play an important role in securing the right services for
homeless people.
2.7 We suggest to the Committee that if homeless
people are to have the services they need then they must be more
visible in the new commissioning system; this means a standard
flag in GP systems and a requirement for JSNAs to record the needs
of groups with significant levels of health inequalities such
as homeless people.
2.8 Commissioners must also draw on the expertise
of local providers and specialist health professionals who have
a more detailed understanding of the needs of complex groups.
In many areas, PCTs have developed specialist commissioning teams
for vulnerable groups such as homeless people, which has led to
the provision of more responsive and targeted services. This expertise
must be safeguarded in the new structures.
2.9 GP commissioners must also make clear channels
by which housing, social care and voluntary sector providers can
input into decisions and service design. Good health should not
be seen as an outcome which can be achieved solely through clinically
driven solutions: solutions which take into account and work holistically
around wider social care, housing and welfare needs are more likely
to be sustained and achieve better outcomes. Voluntary sector
providers which work with the groups GP commissioners often perceive
as "hard to reach" are well placed to provide this expertise.
We would urge the NHS commissioning board to place a greater requirement
on Consortia to systematically seek and incorporate this into
service design.
3. The Committee's intention to review the
effectiveness of the structures proposed in the Bill which are
designed to safeguard co-operative arrangements which already
exist and promote the development of new ones [paragraph 107]
3.1 The Committee has rightly attached significance
to services which work across health and social care boundaries
or are otherwise intimately linked. As above, we believe health
outcomes are rarely achieved solely through clinically driven
health services in isolation, particularly for more complex client
groups.
3.2 It is important that the mechanisms used
to ensure integration across services and sectors are judged in
terms of their ability to meet the needs of those with the most
complex conditions and multiple needs. One of the biggest failures
in the current system is the disjoint between services which result
in homeless people falling through the net and stuck in a cycle
of deteriorating health and worsening life circumstances.
3.3 There are many examples of where the failure
of services to collaborate currently contributes to the poor health
of homeless people, for example:
— Siloed
approaches to people with multiple needs, resulting in services
"passing the buck" and requiring individuals to follow,
for example, substance use pathways before they can access mental
health support regardless of whether this is the right approach
for individuals.
— Gaps
between Supporting People services and social care: there is limited
access to personal care and support through social services which
can undermine vulnerable people's ability to recover from health
conditions.
— Poor
and inappropriate housing is a cause of physical and mental health
problems; however there are limited health interventions in housing
environments or initiatives to tackle how housing contributes
to ill health beyond current environmental health measures.
3.4 To achieve better joined-up working in health
for the benefit of homeless people it is important that the accountability
and foundations of shared and integrated services are built on
an understanding of reducing inequalities and tackling multiple
conditions. This needs to be underpinned in the new outcomes framework.
Health outcomes must be recognised as a shared responsibility
across services to enable health and social care commissioners
to release resources to flexibly meet local needs in partnership.
3.5 The JSNA presents a key opportunity to identify
health inequalities and multiple conditions, and look at how local
services can best join up to meet them. However, this needs to
be articulated as a specific duty for local authorities as they
co-ordinate the JSNA. There needs to be a clear process for review
and redress for communities should they feel the JSNA fails in
achieving this aim. We ask the Committee to seek greater clarity
on how local authorities will facilitate this process.
3.6 In order that consortia and health and wellbeing
boards can drive forward more integrated working, there need to
be clearer mechanisms for involving the wide range of agencies
who meet health outcomes in shaping services in each locality.
Providing clear channels for local providers to access to Health
and Wellbeing Boards will help identify shared outcomes, and develop
opportunities for pooled budgets and joint commissioning.
3.7 Given the important of housing related support
to achieving health outcomes for each locality, we believe improved
integrated working would also be achieved by including a local
director of housing or other delegated authority from housing,
in membership of health and wellbeing boards as a minimum requirement.
4. The Committee's intention to review the
arrangements for local accountability proposed in the Bill [paragraph
118]
4.1 We strongly believe there needs to be clearer
mechanisms to hold all commissioning decisions to account, not
just those at a consortia level.
4.2 There has been great emphasis on decisions
been driven by the local partnerships between consortia and health
and wellbeing boards, which will be underpinned by the JSNA and
other evidence of local need. However, what the current proposals
lack, are clear channels for the public and local stakeholders
to challenge not only the decisions been taken in response to
this evidence, but the needs assessment process itself if they
feel some groups have been excluded from this.
4.3 This presents a real risk for "unpopular",
hard to work with and expensive groups such as homeless people.
If they are protected in the commissioning system by accurate
assessment and recording of their needs, it is to be hoped that
the services they need will follow. However, if this does not
take place there is a strong risk that homeless people will be
even further left out in the cold literally as well as metaphorically
in many cases. At present there is inadequate detail about how
both patients and groups which support them can challenge service
design if they feel this is the case, outside of the proposed
HealthWatch. As it stands, we do not feel HealthWatch has enough
authority within the commissioning process to provide a means
to challenge service design and delivery.
4.4 The services which homeless people need are
unlikely to be profitable and highly likely to be more expensive
than mainstream alternatives. Sophisticated commissioners will
need to understand the long term costs and benefits of interventions
but this focus may be lost if there is an over emphasis on shorter
terms gains on investment.
4.5 Where homeless people do access mainstream
support there is a danger that they will be excluded from service
provision or written off because of the high cost of working with
them. As we have seen in some parts of the last Government's back
to work programmes, those who are hardest and most expensive to
work with are "parked" by providers while those for
whom it is easier to achieve outcomes with are "creamed".
In a payments by results model there is a danger that this perverse
incentive will transfer to the NHS.
4.6 To an extent there is already anecdotal evidence
that this happens in the NHS. The specialist homeless GPs we work
with and service providers say that some GPs will not register
homeless people or people with no fixed abode (NFA). How the NHS,
GP Consortias and providers can be held to account to provide
an adequate service for all under the new system is an important
question.
4.7 We would like there to be clear opportunities
in the commissioning process where agencies not invited to participate
in Health and Wellbeing boards or consortia can provide input
into decisions or challenge those which have failed to take into
account specific patient groups.
4.8 We believe that homeless people and other
vulnerable groups need specific protection within the system to
ensure their needs are not missed, in particular those who have
been or are sleeping rough or at risk of sleeping rough. We would
like to see a statutory duty for Health and Wellbeing Boards and
GP Consortia to address the needs of homeless people within their
commissioning and planning structures.
Homeless Link is the national umbrella organisation
for frontline homelessness charities in England. Currently we
have more than 470 member organisations. Our members include hostels,
day centres, outreach and resettlement agencies, housing advice
centres, health projects, drug and alcohol services and faith
run voluntary services. As the collaborative hub for information
and debate on homelessness, we seek to improve services for homeless
people and to advocate for policy change.
Through this work, we aim to end homelessness in
England. www.homeless.org.uk
We would like to thank Hazel Cheeseman, Policy and
Public Affairs Manager at St Mungos, for her input to this submission.
February 2011
49 Homeless Link's Health Needs Audit, 2010. Data based
on over 700 homeless people www.homeless.org.uk Back
50
Healthcare for Single Homeless People, Office of Chief Analyst;
Department of Health, 2010 Back
51
Homeless Link's Health Needs Audit, 2010 Back
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