HC 1048-III Health CommitteeWritten evidence from St Mungo’s (PH 150)

1. Who We Are

1.1 St Mungo’s has been in operation for over 40 years. Based mainly in London and the South, we provide over 100 accommodation and support projects to homeless men and women, providing over 1,500 beds every night. Our service is divided into prevention of homelessness, emergency response, and recovery.

1.2 In our rough-sleeper focused hostels we are working with a population characterised by tri-morbidity (34% of our clients have physical health problems, mental health problems, and substance dependencies) and institutional neglect—they ignore services, and services ignore them. Our clients have vulnerable backgrounds:

11% of our clients were in care as children.

43% have been in prison.

51% do not have the literacy skills of 11-year-olds.

96% are unemployed.

2. Our Clients’ Health Outcomes

2.1 Our clients have high levels of need. In a 2010 snapshot survey of our clients we found that:

43% had a significant medical condition.

55% required regular medication.

25% had a disability.

70% had a mental health issue (diagnosed and suspected).

64% had a substance use problem.

2.2 This high level of need corresponds to high levels of mortality. To illustrate this we have looked at ONS mortality data for the male population in England and Wales aged between 25 and 65 as our clients are predominantly male and aged between 25 and 65. This is not a perfect comparison but gives an indication of the differing rates of death between homeless people and other groups in the population.

2.3 Among male routine and manual workers, generally considered to be a group with high levels of mortality, 0.5% of this population died between 2001 and 2003 (the most recent time period for which we could find data). Male managers have a lower level of mortality in this period; 0.2%. However, among our homeless clients the rate of deaths is much higher; nearly five times that of routine and manual workers and 12 times that of managers. Between 2001 and 2003 90 men died while resident of St Mungo’s this corresponds to 2.4% of all male St Mungo’s clients over this period.

2.4 We have implemented a number of successful interventions in recent years and we have also seen the rate of death among St Mungo’s clients go down. Between 2007 and 2009 63 men died, a rate of 1.8%. However, this is still unacceptably high and is an indicator of the very high levels of ill health in this population.

2.5 Despite these very high levels of multiple disadvantage, and the often critical nature of our clients’ health conditions, the great majority are not deemed needy to meet social services assessment criteria. The great majority of these people are therefore supported through Supporting People funded services, which are currently under great threat (the budget cuts imposed on us by local authorities this year alone range from 15–40%).

3. Barriers to Better Health and Wellbeing

3.1 Homeless people have this high level of need for a number of reasons. For some their health conditions will have caused or be linked to their homelessness, for example those with mental health problems or substance use problems often cite these as causal factors in them becoming homeless.

3.2 It is clear also that homelessness and poor housing exacerbate and cause health problems which are then poorly managed as a result of a person’s homelessness. Untangling the cause and effect of health problems for some people is difficult, however, providing an effective safety net of health support to ensure they are able to break that cycle can be more straightforward.

3.3 Homeless people have high levels of need. If they are not supported by charitable organisations or the Government those needs will go unmet as homeless people rarely have the social networks or family to provide support. As a result we see individuals trapped in a cycle of poor health and homelessness, using substances as a means of coping with their needs.

4. Our Overall View of the Public Health Reforms

4.1 We welcome the creation of Public Health England and a ring-fenced grant for public health. We also applaud the focus on tackling health inequalities and the wider determinants of health and the inclusion of public health in Health and Wellbeing Boards.

4.2 We are however concerned that the proposed commissioning systems risks the further fragmentation of commissioning leading to the withdrawal of services that our clients need such as, the mobile TB Bus which goes travels around London homeless projects offering on site screening or access to timely and appropriate substance use support. Homeless people form a relatively small group with high levels of need and poor health outcomes. These factors combine to make it vital that services our clients rely on are protected.

4.3 The changes to Supporting People funding suggest that local authorities will not prioritise homeless people automatically: although SP funding was not cut by the Treasury significantly at a local level, now it is no longer ring fenced, much more significant cuts have been made ranging from 13% to 60%. This is likely to trigger even worse health outcomes for homeless people, and increase the use of A&E etc. It is illustrative that homeless people are not a priority for local authorities and that they are not currently taking a system wide approach.

4.4 The mechanism through which a Director of Public Health will be responsible for improving the health outcomes of our clients is unclear. Our concern is that the Outcomes Framework will drive local assessment of need, constraining the JSNA so that if homeless people do not feature within an indicator on the Framework it will be less likely that their needs will be separately included in the JSNA. In the current Framework our clients are not included as a group despite extremely high levels of need.

4.5 The Health Premium which, if well designed, has the potential to drive resources towards the most disadvantaged is in danger of incentivising commissioners to direct services away from our clients as they are harder to deliver improved outcomes for.

4.6 We feel strongly that local responsibilities should be clarified through local authorities being mandated to provide certain services to adequate levels. For example, all Directors of Public Health should be mandated to commission drug and alcohol misuse services that are available to all who require them.

4.7 Our clients’ experience across the health and social care system suggests that those who are hardest to help are often at the back of the queue. They therefore need a targeted approach.

5. Emphasis on the Poorest

5.1 St Mungo’s welcome’s the principles behind the renewed emphasis on public health and the creation of Public Health England as the means of improving the health of “the poorest, the fastest”. Homeless people are more likely to die younger, have a long term illness and multiple conditions. The NHS, and in particular public health initiatives must focus on helping the poorest and must see homeless people as a priority group. We believe success should be judged on whether those in the worst circumstances benefit from the strategy and reforms.

5.2 We are pleased to see that many of the reforms to public health are underpinned by Prof Marmot’s review of health inequalities and that his approach of “proportionate universalism” has been embodied in the notion of improving the health of the poorest the fastest. We believe the Government needs to give additional consideration to Prof Marmot’s review and to focus on his recommendations as a means of reducing health inequalities. Only specific and targeted efforts will ensure that the strategy is a success in improving the health of the most disadvantaged, and for this to happen in a period of deep and widespread financial cuts, there has to be someone senior with direct accountability.

5.3 We believe that there is a need for a stated local mechanism to address the needs of those with the worse health outcomes. Such a mechanism could be, for example, a sub group of the Health and Wellbeing Boards with a remit to tackle multiple disadvantage. We would, therefore, welcome a requirement on local authorities as part of the reforms to public health to establish an inclusive mechanism to address entrenched health inequalities in specific communities in their area.

5.4 We believe the public health reforms would benefit if the principles of Inclusion Health were incorporated as a statutory requirement across Public Health England, the individual Health and Wellbeing Boards, as well as the GP Consortia and NHS Commissioning Board.

6. Wider Determinants of Health

6.1 As mentioned above, we are also pleased to see that the Government have adopted Professor Marmot’s life course approach and will look at the “wider determinants of health” alongside other Government departments. The health of homeless people is determined by a range of factors. Poor health is linked to housing status and rough sleeping contributes to a range of physical and mental health problems while in turn, for many, poor mental health leads to rough sleeping and chronic homelessness. Chronic homelessness could be defined as a public mental health issue. We also know that support through education and training can be a way out of substance dependence and can support people’s mental health.

6.2 We would like to see the minimum membership requirement for Health and Wellbeing Boards widened to include the strategic lead for housing. In addition there is a need for co-ordination from the top with high level joint action from DH and CLG on the health of homeless people.

7. Health Premiums

7.1 We are pleased that there will be a ringfenced public health budget and health premiums for “progress made against elements of the proposed public health outcomes framework, taking into account health inequalities.” We believe that dedicated resources for those experiencing the most profound health inequalities will be the key to addressing the health problems of homeless people and sustainably supporting them out of ill health and homelessness.

7.2 However, we have concerns that the Health Premiums will not reward areas who target their resources at improving the health of those at the very bottom of the pile. Those experiencing the most disadvantage are a small group of the population and as such sensitive measures are needed to capture improved outcomes for them. These may not be achieved through larger, population level, measures. The most disadvantaged groups, such as homeless people, require additional resources to be spent on them in order to achieve improved health outcomes.

8. JSNAs

8.1 We are pleased to see a renewed emphasis on the JSNA and that all parties will have a duty to contribute. Currently data on homelessness is rarely included as a dedicated part of JSNAs. It is essential that this is improved under new JSNAs if help for the poorest fastest is to be achieved.

8.2 We are aware that little central direction will be given to local areas on how to conduct the JSNAs and we are working with Homeless Link to put together guidance for local areas on how this could be achieved in areas where this would be appropriate.

8.3 We acknowledge the need for local variation and discretion and believe that this could help to ensure more locally sensitive documents. However, we do think the JSNA would benefit from some common standards in particular relating to vulnerable groups. For example:

The inclusion of wider sources of information beyond that collected by the state and including the wealth of information held by voluntary sector providers.

The principles used to define whether an area should be a priority or be included in the JSNA (for example if there is a demonstrable level of need in a locality).

The requirements to include users and providers locally in the development of the JSNA and ensuring that there are appropriate opportunities for challenging the domains included if organisations or individuals believe things have been missed out.

Clearer direction on how the JSNA should be used to inform commissioning priorities.

8.4 For JSNAs to identify the needs of homeless people, we need them to focus on “communities of need” not just categories of need. Populations with high intensity of need but small numbers are not well-documented by the approach which measures eg cardio-vascular disease across a borough.

9. Health and Wellbeing Strategies

9.1 We are pleased that all areas will be required to translate their JSNA into a Health and Wellbeing Strategy. We hope this will be a prominent document which is used to strategically inform the local authorities’ decisions across a range of areas. However, if this is to be the case then it is vital that housing’s contribution to health is clearly acknowledged in the process.

9.2 For any Health and Wellbeing Strategy to be locally owned, and part of “Big Society” rather than town hall officialdom, requires a participative process. We believe that key points in this process would be:

The integration of the principles of Inclusion Health—there is no point in doing work again that was well done in the first place.

Clear public accountability, which also entails clear and published targets.

A mechanism for participation by lay groups: for example, the Board should have sub-committees focusing on locally relevant issues, for example homelessness, which locally significant participants could attend.

Communities should be involved in devising their own solutions, in partnership with local public health and other agencies.

10. Data, Outcomes and Accountability

10.1 Existing data

10.1.1 We have some strong concerns about the feasibility of capturing useful and consistent data at the same time as getting rid of many requirements for local authorities to capture standard sets of information. If a key criteria in determining whether something should be an indicator is whether data is already captured about it the number of options available to choose from will shortly be significantly reduced.

10.1.2 We urge the Government to be joined up in its approach to data—in particular between Department of Health and Department of Communities and Local Government. We, along with other agencies, strongly believe that there is a lot of valuable information being gathered by local authorities which can and should be used for public health. No doubt there are some current data collections which society does not significantly benefit from being captured; however, we also believe that there is much to be said for using what we do gather in a smarter way.

10.1.3 Clear accountability for services needs to be determined at both national and local level. The clear collation of data relating to the delivery of the public health strategy will be crucial to measuring its value. As mentioned above, we feel strongly that local responsibilities should be clarified through local authorities being mandated to achieve certain outcomes to adequate levels.

10.2 Missing criteria

10.2.1 We are surprised, given the overarching vision of the public health strategy, that one of the criteria is not “By improving this indicator will the health of the poorest improve the fastest”. Given the stated intention of the public health reforms and he importance for society of narrowing health inequalities we believe this criteria would enhance the quality of indicators and ensure they are focused on the most challenging aspects of improving the nation’s health.

10.3 Outcomes

10.3.1 As we have said elsewhere, we believe a crucial driving principle of the reforms to public health has to be “improving the health of the poorest the fastest”, or “proportionate universalism” as Professor Marmot describes it. This approach should ensure that resources are targeted, proportionately, towards those in most need in order to reduce the widening inequalities between rich and poor in our society. We believe there are a number of ways in which this can be enhanced:

Target resources to groups with high levels of health inequalities linked to shared characteristics, for example homeless people.

Address the wider determinants of health.

Housing is a crucial factor alongside education, employment and mental wellbeing which must be included in the Government’s approach.

Address multiple disadvantage.

The groups of people with the worst health are those who have more than one support need. We believe that people often become homeless because the system is so poor at addressing the needs of people who have more than one condition. This is illustrated by the needs of our client group many of whom have tri-morbidity of substance use, mental health and physical health problems (with some individuals having multiple mental health, poly-substance use and a range of physical health conditions) which mainstream healthcare is currently ill-designed to treat together. It is estimated, conservatively, by the DH that homeless people directly cost the NHS £85 million per annum: much of this cost is as a result of multiple unmanaged conditions. In addition their are indirect costs to criminal justice, social housing and in lost tax and benefits payments etc. The public health reforms are a real opportunity to improve this situation, improve healthcare for homeless people, and reduce these costs.

June 2011

Prepared 28th November 2011