Returning home from a hospital stay should be a cause for celebration. Unless, that is, the person is homeless and the hospital would prefer to see them back on the streets prematurely than face bed-blocking charges. Anabel Unity Sale reports
Hospital discharge can be just as problematic as admission for homeless people. With the government pushing hospitals to tackle bed-blocking by introducing fines, it is claimed that wards are rushing discharge procedures and failing to involve agencies that have the expertise to help.
Yet homeless people are more likely to have poor emotional, physical and mental health than the rest of the population. Their needs are complex, and may include substance misuse. In any case, when a homeless person goes into hospital it is usually because of a health crisis rather than for planned treatment. If they are placed on an open ward their presence may stand out and other patients and visitors may react negatively.
Alice Evans, head of policy at homelessness agencies’ membership body Homeless Link, warns that experiences like these can result in homeless patients discharging themselves prematurely. She adds: “This can also happen if people have alcohol and drug dependency or if they are anxious about losing their accommodation. They just get up and leave.”
There is also the question of benefits. In an emergency the patient will have no chance to amend arrangements. And if they do have a hostel bed and the hospital fails to inform staff, the hostel might assume the individual has moved on and re-allocate their place.
The Broadway day centre in west London sees 120 homeless and vulnerably housed adults a day from the boroughs of Hammersmith & Fulham and Kensington & Chelsea. Some clients have experienced discharge problems from hospital (see Dumped on Broadway). Project manager Bev Johnson bemoans the lack of liaison between hospitals, social services, housing and homelessness agencies. “Not enough hospitals know what services are available and who to approach for help,” she says.
Alcohol and drug problems are a prime reason for hospital admission. Anecdotal evidence points to councils using this as evidence that a homeless person, by dint of being an addict, has made themself intentionally homeless. And, if someone making a claim for housing fails the intentionality test, the local authority doesn’t have to provide accommodation.
Homelessness charity Shelter is unhappy about the interpretation of intentionality and says the status should be defined more precisely. A spokesperson says: “It is one of the most subjective criteria used to assess homelessness, and it can differ greatly from authority to authority.”
In acknowledgement of the difficulties surrounding hospital admission and discharge of this client group, last December the Department of Communities and Local Government and the Department of Health issued guidelines to improve practice.(1)
Sue Reed is the DH official who helped produce the guidelines and has been homelessness adviser to the DH’s health and care partnerships division for 15 months. She says the guidelines were necessary because some professionals were ignoring procedures when dealing with a homeless person in hospital.
Ideally, Reed says, any homeless person should be eligible for housing. But, as local authorities have a limited supply of accommodation, they have to establish criteria and make decisions based on local needs.
So what can practitioners do to address hospital discharge more effectively? “It sounds simple, but ask about someone’s housing status, and whether their is housing adequate,” says Reed. “Then they should know to contact other departments and agencies.”
Evans and Johnson both call for practitioners to make greater links to ensure these clients do not slip through the gap once they are discharged from hospital. Evans recommends routine multi-disciplinary discharge meetings in hospitals.
Dealing with the discharge of homeless or vulnerably housed people relies on effective communication between health, social care and other agencies. There are examples of this approach working well with other groups, such as older people, so why shouldn’t homeless people be entitled to the same level of service?
Dumped on broadway (back)
The Broadway Centre is a drop-in centre providing basic medical services through a Healthy Living Centre to homeless or vulnerably housed people in London.
When Anton arrived at the centre one morning by ambulance he had the line from a drip still in his arm. He was disoriented and confused. English was not his first language. He had been in hospital for several weeks. Now, the hospital had declared him “fit for discharge”. Anton explained he was homeless and hospital staff took him to the Broadway Centre.
There was no warning from the hospital to centre staff, no conversation with the ward sister, just the delivery of a vulnerable man with nowhere to go. The ambulance crew had emergencies to attend and apologised to centre staff who were protesting about Anton’s situation.
Staff called the hospital and were told that, as Anton was deemed fit for discharge, there was no longer a bed for him. But the centre had no bed for him either. Anton carried only a small plastic bag of belongings he didn’t know the part of London he was in and had no support networks to tap into. He had no medication for his condition, just a letter for a GP.
The centre was due to close at 4.30pm so time was running out to find help. It looked like Anton would be spending the night on the streets. The centre called the hospital and threatened to send him back in a taxi if he was not collected. After much discussion, the hospital sent someone to collect him, thanks in part to the persistence of centre staff.
But for many others like Anton, there’s no option other than a return to life on the streets.
Steps to good practice
● Identify the organisations that should be involved in a person’s admission to and discharge from hospital, such as social services, voluntary organisations and housing departments.
● Set up a steering group with these parties to oversee development and implementation of a local agreement for hospital admission and discharge of homeless or vulnerably housed people.
● Review existing systems.
● Draw up a local agreement – building on existing procedures and covering information sharing – and ensure it is fit for purpose.
(1) Hospital Admission and Discharge: People who are Homeless or Living in Temporary or Insecure Accommodation, DCLG, 2006
Health Inclusion Advisory Project Group
London Network for Nurses and Midwives
The Risk Factor: Homelessness, hospitals and the law
Anabel Unity Sale
This weeks other feature articles from the adults sector
Involving service users in mental health services in Wales
This article appeared in the 8 March issue of the magazine under the headline “Dishonourable discharges”