HC 1048-III Health CommitteeWritten evidence from Homeless Link (PH 88)


This submission comes from Homeless Link, the national membership organisation for agencies working with people who are homeless. Our particular interest is the way that proposed arrangements for public health will impact on homeless people and the agencies which work with them.

The health of homeless people is significantly worse than the general population. High levels poor physical and mental ill health 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 increased rates of multiple needs.

We believe more needs to be done to ensure the proposals for Public Health will improve the health of the most vulnerable:

Closer integration with the wider NHS outcomes framework.

Greater accountability at a national and local level for reducing health inequalities, both for public health directors but also for Consortia and local government through health and wellbeing boards.

Closer integration and joint working arrangements at a local level between Directors of Public Health (DoPH), housing and other related services provided by, upon which achieving public health outcomes are dependent.

Context for our Submission

1.1 Homeless people experience many of the health and wellbeing needs covered by the new Public Health framework at a rate far higher than the general population. Because of their higher levels of need, homeless people use acute health services disproportionately to the general population, at 4 times the amount for hospital services, rising to 8 times as much for inpatient care. We believe improving preventative and public health services can go a long way to reducing both the ill health of homeless people and the wider costs on the NHS and wider community.

% who smoke

% who eat 5 or more fruit a day

% with mental health need

% use drugs

General population



30 %

10% (one or more illicit drug in last year)

Homeless population





1.2 The new Public Health strategy for England rightly states that good public health is strongly linked to appropriate housing and other wider determinants of health. We agree that only by integrating health with housing and social care can better health outcomes be achieved. However, despite some progress in recent years on tackling the root causes of ill health, homeless people still experience some of the most persistent health inequalities in our communities. The new role for public health provides an opportunity to change this.

Key Messages for the Committee

We have outlined our key points for the Committee to consider under the issues they will be reviewing for this inquiry. With the outcomes of the Listening Exercise expected shortly, we hope the opportunity will be taken to strengthen the current proposals for Public Health.

2. The creation of Public Health England within the Department of Health

2.1 Health policy has persistently failed to make real inroads in reducing health inequalities among homeless people and other disadvantaged groups. The creation of Public Health England offers the opportunity to step up efforts to tackle health inequalities and put preventative health services at the heart of local provision.

2.2 However the creation of a separate stream for public health must not relegate preventative and holistic models of health to the sole domain of Public Health. An approach which values earlier intervention, and takes into account the wider determinants of health, must also drive the wider NHS. Public Health England must therefore be closely aligned to the wider NHS framework and the lines of accountability between these bodies needs to be more clearly articulated. We would welcome clarity on this during the Committee’s inquiry.

3. The abolition of the Health Protection Agency (HPA) and the National Treatment Agency (NTA) for Substance Misuse

3.1 The health needs which fall within the remit of the HPA and NTA are some of those most prevalent among the homeless population. For example rough sleepers experience TB at 200 times that of the known rate among the general population. Research shows that nearly half of homeless day centre users (47%) have drug problems, and 52% alcohol problems.

3.2 We are concerned that the abolition of the HPA will see key areas of their remit unaccounted for. While this is proposed to fall within Public Health England and their Health Protection Units we recommend the Committee seeks further clarity about how this duty will be discharged. This should include clear indicators for vaccination, screening and treatment completion rates for infectious diseases in the outcomes framework for at-risk populations. Without this we face not only increased need among individuals but wider public health risks.

3.3 Bringing the NTA under Public Health may present opportunities for locally developed preventative and early intervention work around drug and alcohol treatment. However these services will need to be integrated into those commissioned by Consortia in the new NHS arrangements (for example acute services, dual diagnosis services). Public Health England will need to engage closely with the Department of Health to ensure the integration of outcomes framework and clinical standards; and local DoPH will need to have a clear remit to work with Consortia and other local services, such as housing, and employment via the health and wellbeing board, which are needed to sustain drug related outcomes.

4. The public health role of the Secretary of State

4.1 We note that the Health Bill [as amended in Public Bill committee] has made provision for the Secretary of State’s duty as to reduce inequalities “to have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service.” [section 3, 1B]

4.2 We call on the Committee to seek further clarity during their inquiry as to how the Secretary of State will discharge this duty, particularly with regard to how they will hold the NHS Commissioning board to account for reducing inequalities alongside Public Health England. The relationship between these bodies is at best vague in the current proposals yet it is within the prescribed remit of both to reduce inequalities.

4.3 The Secretary of State should consider appointing an Inclusion Board to guide the discharge of the public health role. They must ensure the outcomes framework incentivises targeted action to improve the health of the most vulnerable, and report annually on progress made by local public health directors and Consortia to improve services for those with the poorest health.

5. The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

5.1 Local government are well placed to co-ordinate much of their proposed work for public health, however we have some concerns for the Committee to consider about how they will discharge their duties.

5.2 There need to be stronger mechanisms for the involvement of key stakeholders—not just local government—in the arrangements for Health and wellbeing boards and the JSNA. For example housing is an important determinant of health, yet its role is underplayed in the current proposals. Health and Wellbeing Boards would be strengthened if their membership included more routine involvement from housing and voluntary sector providers. We hope the guidance for the early implementer programme of Health and Wellbeing boards will encourage this approach.

5.3 The current expertise held by public health teams needs to be protected amidst the transfer of responsibility to Local Government. We are concerned that the pace of change risks losing some of this.

5.4 We think the accountability arrangements for local government need to be strengthened. Currently there is little means for wider stakeholders to hold local government, or DoPH, to account if they feel the JSNA or Joint health and Wellbeing strategies fail to identify and respond to health needs within the community. We would like to see an expectation for more transparent reporting on how commissioning has acted on the priorities identified in the JSNA, and for HealthWatch to have a far greater authority to hold local government to account for improving the public’s health (eg to scrutinise health improvement plans).

6. Arrangements for public health involvement in the commissioning of NHS services

6.1 We think these arrangements need to be strengthened. It is vital Public Health Directors are involved in commissioning processes for wider NHS services so that these are fully integrated.

6.2 Public Health services are not prioritised in many mainstream services, despite evidence that they are the most effective in preventing more acute health conditions. We would like to see a strong duty for Consortia to engage with Directors of Public Health when drawing up commissioning plans. There should also be a clearer link for how the NHS Commissioning Board will work with Public Health England in the fulfilment of its responsibilities.

7. Arrangements for commissioning public health services

7.1 As we understand the primary commissioning arrangements will be from priorities identified in the JNSA and Joint Health and wellbeing strategies. We believe current arrangements could do more to draw on the expertise of voluntary sector partners who often play a key role in both delivering public health services, and engaging those with the most acute inequalities. There are no clear mechanisms for how agencies not formally part of this structure can both help determine commissioning priorities and in the delivery of services.

7.2 We suggest there is a clearer process for stakeholders to feed into health improvement plans, including a mechanism for routinely inviting voluntary and community sector (VCS) agencies to participate on areas relevant to their areas of expertise.

7.3 The new commissioning arrangements may open up opportunities for a wider range of providers to deliver health and wellbeing services. Many small, local agencies currently provide very effective and targeted services which fall into the remit of Public Health. However, they often deliver low volume services to very complex client groups where outcomes can be harder to achieve, and require a “spend to save” investment which commissioners can be unwilling to take.

7.4 This means that commissioning may favour larger providers who can carry this risk. Their capture of the market could stifle innovation and prevent the necessary transfer of resources into primary and community care. To mitigate against this the re-design of tariffs should reflect the complexity—and length of time—of treatment for some patient groups, and ensure that all providers are paid fair prices for their services. Alternative providers must demonstrate and be assessed on how they collaborate with other services as part of meeting their quality standard.

8. The structure and purpose of the Public Health Outcomes Framework

8.1 We welcome the focus the new Public Health Framework will place on preventative services and shared responsibility with other services for reducing health inequalities. Many of the complex health needs experienced by homeless people can be improved through more targeted and earlier interventions which the new public health framework could drive forward.

8.2 It is essential, however, that the existence of a separate framework for public health does not prevent other key players in the health system for taking responsibility for preventative approaches to health. The proposed framework for the NHS is a far more clinically driven framework. However we know that a holistic approach more often championed in public health is often most effective to improve people’s health.

8.3 To be a success therefore, we think greater steps are needed to align the Public Health Outcomes Framework with the NHS Outcomes Framework and the proposed social care outcomes measures. They must be understood and shared across each function. Each must take responsibility for preventative services and have an appreciation of the wilder determinants of health, rather than this be the sole domain of Public Health.

8.4 We welcome much of the proposed domains and indicators. However, to capture reduction in inequalities the framework must measure outcomes of more vulnerable and ‘hard to reach’ population groups. There must be provision to disaggregate this information by at-risk groups who are known to experience poorer health. A flag in the data systems to record homelessness would help provide this analysis.

9. Arrangements for funding public health services (including the Health Premium)

9.1 The health premium should not be viewed as the sole incentive for reducing inequalities which is a fundamental aim of public health. As such, the health premium should be designed to encourage local authorities and their partners to address areas of more acute inequality which may require additional resources or more targeted interventions. It should not be designed as a proxy for reducing inequalities across all areas of health improvement.

9.2 The formula should consider the variation in the “baseline” of need in an area: levels of need vary and change depending on the wider determinants (levels of unemployment, levels of affordable accommodation, etc) and these changes must be considered and reconsidered when measuring progress over time; and the longer term nature of progress for some public health improvement areas. Areas should not be punished or dis-incentivised for offering services which do not offer a quick fix but instead achieve outcomes over a longer period of time.

June 2011

Prepared 28th November 2011