HC 1048-III Health CommitteeWritten evidence from Crisis (PH 127)


Crisis, the national charity for single homeless people, welcomes the Government’s commitment to tackling and reducing health inequalities through improved public health services.

The Government’s new public health strategy must take particular account of the needs of vulnerable or excluded people, including homeless people.

A greater emphasis on prevention of health conditions and wider availability of health advice and information could have real benefit for homeless people.

We welcome the role of local government in promoting integration between health services and other services, including housing and homelessness.

Health and Wellbeing Boards have a lot of potential, but it is important that their membership includes key stakeholders from the housing, homelessness and voluntary sectors.

Commissioning public health services at local authority level may hinder partnership working and collaboration across boundaries.

The Public Health Outcomes Framework is welcome, but could be amended to make the indicators more sensitive to the problems caused by homelessness.

We support the introduction of a health premium, but would like to see more information about how it will work in practice.

Payment by results poses real risks for more vulnerable groups, and should be properly evaluated before it is implemented across the health service.

Homelessness and Public Health

1. Homeless people experience serious health inequalities. Sleeping rough or staying in hostels, overcrowded, temporary or substandard accommodation can have a damaging effect on a person’s physical wellbeing. Mental health problems are very prevalent and can be both a cause and consequence of homelessness.

2. The average age of death for a rough sleeper is only 42, compared with the national average of 76 for men and 79 for women. Common health problems include respiratory conditions, with one in ten people diagnosed with TB having a history of homelessness, foot conditions and dental problems, many of which are preventable. 32% of clients of homelessness services in England have mental health needs. 35% of those sleeping rough in London have mental health needs and 18% have a mental health need combined with a substance misuse issue (dual diagnosis). Rough sleepers are 35 times more likely to commit suicide than the general population.

3. Homeless people often place a low priority on their own health, as more immediate concerns like food and shelter can take over. This means that health problems often go untreated and escalate into more serious conditions, requiring emergency or acute care.

4. Crisis has long campaigned for widened access and improved health services for homeless people. However, alongside this, a greater emphasis on health promotion and preventative care could be of real benefit to homeless people.

5. We recommend that public health promotion and information is accessible to all, and that public health professionals actively target vulnerable groups, such as homeless people. Health information sessions and leaflets should be made available within homelessness services, such as hostels and day-centres. Health information should also be tailored to meet the needs and priorities of vulnerable groups, ensuring it is relevant and useful to them.

6. Consideration must be given to there being a range of ways for public health professionals to engage and communicate with homeless people in order to provide public health information. There is certainly a place for accessible written information, such as leaflets and posters, and this should be made available in places frequented by homeless people such as existing homelessness services. However, written information will not always be effective in communicating health messages, not least because some homeless people and other vulnerable groups have problems with literacy or do not have English as a first language. Other ways to communicate could include, for example, “peer to peer” education, where homeless people help to educate others about issues such as preventing common health conditions, or drop-in information sessions.

The Future Role of Local Government in Public Health

7. We welcome the decision to require each local authority to have a Director for Public Health and the fact that their budget will be ringfenced.

8. We welcome the proposals to give these Directors responsibility for increasing integration and partnership between public health and other services, such as housing, transport and social care, in order to help prevent ill health and reduce health inequalities. It is important that knowledge and best practice on working with homeless people is shared between different agencies.

9. We are generally supportive of the introduction of Health and Wellbeing Boards, but it is important that they are easily accessible and representative. They should certainly be strongly encouraged to engage with the voluntary sector and make use of their expertise. We would ideally like to see membership being opened up to third sector partners so they can fully contribute. Frontline agencies working with homeless people, and homeless people themselves, are very well placed to offer advice on the need for public health initiatives in their local areas.

10. We would also recommend that those involved in housing and tackling homelessness are included in the Health and Wellbeing Boards, such as the strategic lead for housing within the local authority. This will help to enable a joined up and holistic approach to commissioning services.

Arrangements for Commissioning Public Health Services

11. Whilst we recognise there could be merit in the move to commission public health services at local authority level, we would advise some caution.

12. Although the current PCT structure is not perfect, many trusts have built up significant bodies of knowledge in commissioning health services, particularly in public health, for vulnerable people. It is vital that this expertise is not lost.

13. For some specialised public health initiatives, budgets could be pooled and services jointly commissioned on a regional or sub-regional basis. Some may not be required in every local authority area, but on a regional or sub-regional basis there is likely to be a need. This is particularly important in large cities such as London where people frequently move between boroughs and can find it hard to access continuing support. It also provides an efficient way for commissioners to invest in higher cost services for a relatively small number of patients without risking either duplication or gaps in provision.

Public Health Outcomes Framework

14. The Public Health Outcomes Framework includes a wide range of health determinants and indicators and covers many important areas. We would suggest that the following indicators are included to provide an even more comprehensive structure.

15. We strongly support the inclusion of indicators based on housing and poverty. Currently only statutory homelessness figures are included as an area for improvement. Whilst this is welcome, there are many vulnerable, homeless people who are not included in these figures. Many single homeless people sleep rough or live out of sight in hostels, bed and breakfasts, squats or on family and friends’ sofas and all of these vulnerable housing situations can impact on health.

16. Consideration needs to be given as to how to count people in these situations who are often not included in official statistics. This could include rough sleeper counts, statistics for people deemed homeless but not in priority need, hostel bed spaces, numbers of people in temporary accommodation, and consultation with local housing and homelessness service providers.

17. We believe it is important to build in some recognition that homeless people are particularly likely to live with preventable health conditions. In tackling many of the indicators, such as emergency readmissions, local authorities will need to specifically address ways in which they can support homeless people to access the treatment they need at the right time to prevent relatively minor health conditions snowballing.

18. We would suggest that an indicator on mortality rates among people with no fixed abode is included. Due to the extremely low life expectancy for rough sleepers, it is important that local authorities tackle mortality of homeless people as a priority.

Arrangements for Funding Public Health and the Health Premium

19. We are generally supportive of the move to tackle health inequalities using the health premium. However, further details will be needed on how the health premium is to be calculated before we are satisfied that it will really reward councils working with the most vulnerable people.

20. Decisions as to which areas will receive the highest funding levels must include an assessment of housing need and homelessness. Vulnerable housing and homelessness can be hard to measure, so wide indicators such as the demand for homelessness services and number of hostel bed spaces should be used.

21. We have some concerns about the use of payment by results, both for public health services and in the wider NHS.

22. It is often hard to measure outcomes when working with particularly vulnerable people. There must be a recognition that some people will have further to go to achieve good health, and that good health will mean different things to different people.

23. It is therefore particularly important that appropriate indicators are developed and worked into the outcomes framework to take these difficulties into account and ensure that health premium funding is truly based on the progress local authorities are making in working with more vulnerable patients.

24. Payment by results is to be introduced in a number of other areas, such as rehabilitation of offenders, but it has not yet been properly evaluated. It is important that further evaluation takes place in order to determine whether payment by results is effective in obtaining the desired outcomes in health.

June 2011

Prepared 28th November 2011