The government says improving the health of homeless people is a priority. But health services for the client group are being cut just as need is going up, reports Helen Mooney.
Last autumn, health secretary Andrew Lansley vowed to make improving the health of homeless people and other marginalised groups a government priority by setting up a national health inclusion board to champion their needs.
Lansley said the government had a responsibility to look after the “most vulnerable” in society, while board chair Professor Steve Field said it was a “scandal” people in hostels or other homelessness services died, on average, in their early 40s. That was then, but so far the National Health Inclusion Board, which includes doctors, nurses, charities and specialists in reducing health inequalities, has not met.
Meanwhile, healthcare provision for homeless people is being cut despite increasing need, found Homeless Link’s annual survey of needs and provision (SNAP) among homelessness organisations.
Moreover, some fear that Lansley’s plan to devolve NHS commissioning responsibility to consortia of GPs, scrapping primary care trusts, could make matters worse.
Homeless people traditionally have far higher health needs than the general population, often because of a “tri-morbidity” of physical health problems, mental illness and substance misuse.
Not meeting that need means considerable cost to the NHS in the long term.
Homeless people use hospital services at a rate four times greater than the general population, rising to a rate eight times higher for inpatient services, according to Department of Health figures.
Their average length of stay is also well above average, 6.2 days compared to 2.1 days for the general population, due to the severity of their needs.
The 2011 SNAP survey found projects were seeing more people with physical, mental health and substance misuse problems than before, but their ability to meet these needs was moving in reverse.
The proportion of services whose clients could access drugs services fell from 95% to 89% from 2010-11, with falls for alcohol services (96% to 92%), physical health (97% to 93%) and mental health services (96% to 95%). All these measures had increased from 2008-10.
In physical health services, there was a particularly sharp fall in the availability of nursing care while, for substance misuse provision, the biggest decreases were found in structured treatments and day programmes.
Homelessness agencies have traditionally accessed health services from the NHS and other external providers but cuts in these had led many specialist services to develop in-house provision, the SNAP found.
Homeless Link chief executive Jenny Edwards says that she is disturbed by the findings: “So much progress has been made in the past five or six years and now it looks as if this has turned around and is dropping back very rapidly.”
She says that NHS and social care teams working with homeless people are often seen as the most expensive as well as the easiest to cut.
“Cutting back may save costs in someone’s budget but it will inevitably mean a bigger cost elsewhere in both the justice budget and in the emergency health budget,” she warns.
Peter Cockersell, director of health and recovery at homelessness charity St Mungo’s, agrees: “Health services for homeless people have always been inadequate; there is never quite enough and, even in specialist services, there are only just enough.
“What is worrying is that specialist services like substance misuse specialists are being cut and homeless people are being referred to social services, but they are then assessed as not meeting social service criteria so there is a double whammy,” he explains.
He warns of a spike in A&E admissions and increasing levels of untreated mental health issues in the homeless population.
Another area of concern is what impact the government’s NHS reforms will have on the ability of homeless people to access healthcare. With GPs due to take over responsibility for commissioning healthcare, the Local Government Association has voiced concerns that their commissioning decisions will focus on patients they are in contact with at the expense of marginalised groups.
Jonathan Phillips, co-chair of the Association of Directors of Adult Social Services’ mental health, drugs and alcohol policy network, warns that the need for commissioning consortia to make savings could lead to further health cuts for homeless people. He says consortia will have to be judged on how effective they are at commissioning for the “whole population. “At the moment there is a big if as to whether that will happen at the same time as making savings,” he says.
Charles Fraser, chief executive of St Mungo’s and a member of the national health inclusion board, says that in many areas of the country the health needs of homeless people have never been measured and therefore effectively do not exist.
“The one thing I want to say to Andrew Lansley is these reforms must ensure that the health of the most disadvantaged is the number one priority.”
Case study: Closure of Nottingham substance misuse centre means nowhere to go
After 20 years helping thousands of homeless people with alcohol and drug problems, offering access to both accommodation and specialist treatment services, Nottingham’s Handel Street day centre closed at the end of March when its funding was cut by Nottingham Council.
Jason Marriott says the closure of the day centre he ran has left homeless people without vital healthcare
Jason Marriott was the centre’s team leader and now heads the rough sleepers outreach team in Nottingham. He says that the closure of Handel Street has had a direct impact on the lives of those who used it.
“We offered a doctors’ surgery with specialist substance misuse GPs and a substance misuse health team. We got people onto a script, and offered access to the health services they needed – that has gone.”
“The closure of the centre also means increased A&E attendance at £3,000 a visit, or the cost of a police custody suite, or an ambulance being called out at £500 a time. The cost to the public purse is much greater in the long term,” he explains. Framework’s chief executive, Andrew Redfern, fears there will be further cuts to come. “We fear a large rise in homelessness with all its costs and associated social problems.”
A former homeless person, Andrew Withnall, used Handel Street centre to get his life back on track. Before coming to the centre, he was homeless and using alcohol as a way of blocking out his problems, drinking six to eight litres of strong cider every day. “Over the years I’ve slept in doorways, sheds and old mattresses. It was so cold on the streets I ended up having colds and flu most of the time.”
Withnall arrived at Handel Street at the end of 2010 and worked hard to conquer his addiction and his depression. He regularly had breakfast and lunch at the centre and is full of praise for its staff. “Handel Street was wonderful and the staff really cared. It hurts me so much to think that it has closed. I don’t know where people will go.” He fears that the closure of the centre means others like him may not be so lucky.