Written evidence submitted by Pathway (TH0023)

 

Who we are and why we are submitting evidence

Pathway is the UK’s leading homeless and inclusion health[1] charity. Our mission is to improve the health of people experiencing homelessness and other socially excluded groups. We do this in a number of ways; supporting the NHS and ICSs to improve service provision and commissioning, research, policy and campaigning, improving healthcare education and awareness raising. We also host the Faculty for Homeless and Inclusion Health, an international membership body of over 2500 members.

As well as this written submission, Pathway is very willing to provide further evidence to the committee. For further information, please contact;

Pathway can also facilitate the Committee receiving evidence from frontline healthcare professionals who work in specialist homeless/inclusion health services, as well as from people with lived experience of homelessness.

Summary

As laid out in the NICE Guidelines NG214[2], there is a significant body of evidence demonstrating how the health and social care system can respond in an effective and cost-effective way to the needs of people experiencing homelessness and other socially excluded groups. However, these guidelines are rarely followed, and the system’s responses are too often characterized by inefficient and wasteful short-term approaches, which do not address systemic or structural factors and incur avoidable costs across the public sector. Missed opportunities to provide effective and joined up care for people experiencing homelessness result in avoidable pressures on both health and other public services and prevent people from ending their homelessness.

There is also a lack of system leadership at national level, to effectively coordinate the responses of health, housing, social care and other key statutory services. Collaborative and integrated responses are key to ending people’s homelessness, but the structures to push this forward do not exist.

Some key areas exist where resources are used in a particularly short-sighted and inefficient ways;

 

The following sections provide further detail to the points above;

 

Over-reliance on urgent and emergency care delivered in hospitals

People experiencing homelessness attend A&E 6 times more often than the general population and are 4 times more likely to be admitted as an inpatient[3]. Following hospital admissions, people experiencing homelessness are 2.5 times more likely to have an emergency readmission and 2.6 times more likely to have a subsequent A&E attendance[4]. The costs of providing care via A&E and emergency admissions are much higher than non-emergency and planned care which is delivered through primary/community services, outpatient services and planned, elective hospital admissions.

There are several important reasons why people experiencing homelessness are over-reliant on emergency care

When people experiencing homelessness do access services, there are missed opportunities to effectively identify their needs, provide holistic support and resolve their housing instability.[8] The result is extremely expensive to the system, as these patients do not get better, and are forced to rely on expensive emergency services, particularly A&E. Improving access to primary and community healthcare services for these patients would result in more efficient use of healthcare funding.

 

Hospital Discharges and the ‘revolving door’

A hospital attendance or admission is an opportunity to provide support for people facing homelessness, that can help to end their homelessness. However, following hospital visits, such patients are very frequently discharged to locations (street discharge, poor quality temporary accommodation) which do not allow them to recover, and/or discharged without the appropriate level of support from health and social care services[9]. A Freedom of Information request found that over 4200 people were discharged to the street in 2022/23, with only half of NHS Trusts responding.[10] The result is a ‘revolving door’ where people cycle in and out of hospital without getting better. This is extremely costly and inefficient, especially in the context of the extreme capacity pressures that hospitals are under.

The lack of appropriate discharge options for people experiencing homelessness also contributes to delayed discharges, as people stay in hospital longer than they need to. Delayed discharges are very expensive and reduce hospital capacity, incurring further costs across the healthcare system.[11]

Street discharges and other inadequate discharges represent missed opportunities to help people recover, deliver preventative care that can limit the need for future hospital admissions and provide effective support that can help to end peoples’ homelessness.

There is a strong evidence base demonstrating that a range of services (specialist intermediate care facilities, specialist hospital-based teams, specialist community healthcare services) improve hospital discharge outcomes, are cost-effective and result in improved health and social outcomes for people experiencing homelessness.[12] In particular, the Out of Hospital Care Model evaluation found that improving hospital discharge through specialist intermediate care provision generated significant savings across the public sector, including healthcare, housing, social care and criminal justice services.[13]

Pathway will shortly be able to share with the Committee a cost-benefit analysis of a prospective national specialist intermediate care programme, conducted by Alma Economics.

 

 

 

Information Sharing

Communication and information sharing between different NHS services can be challenging, largely driven by a lack of interoperability between the numerous different clinical systems used in the NHS. Services often cannot easily access and share patient information between them.

The result is that a large amount of time is wasted by healthcare professionals in collecting and recording information that has already been collected by another part of the healthcare system.[14] This is not only inefficient in terms of time and money but can cause lower quality of care and missed opportunities for preventative healthcare. It can be especially problematic when people are moving between different parts of the care system, for example from an acute hospital into the community, or between different geographical areas.

This is especially relevant for people experiencing homelessness, as they often live transient lives, which results in moving between different services and areas. These patients also often have multiple and complex health needs, which necessitates engaging with lots of different healthcare services. Constantly re-telling circumstances and life stories is potentially re-traumatising for people and can result in frustration and disengagement with healthcare services.

Improving information sharing between different healthcare services would improve the efficiency and effectiveness of healthcare delivery for people experiencing homelessness.

 

 

 

Data

Identifying people experiencing homelessness (and other excluded groups such as migrants) within healthcare data can be extremely challenging, which poses problems for ICS service design and commissioning, population/outcome monitoring and policy development. Improving the availability of healthcare data from people experiencing homelessness would improve our ability to effectively design services and policies to meet the needs of this patient group. Better data on and understanding of this patient group would allow resources to be used in a more efficient way.

Pathway, along with other organizations, has argued that improving the recording of housing status in healthcare settings would improve the availability of this important data, and has worked with both the Emergency Care Dataset[15] and the Mental Health Services Dataset[16] to improve their housing status recording. For more detail about Pathway’s work in this space, see reference.[17]

Short-term, unstable and non-recurrent funding for specialist services

Evaluations consistently show that specialist homeless/inclusion health services, such as specialist hospital teams, generate positive outcomes for patients, improve collaborative working within local systems, and are cost-effective.[18] However, these services are routinely commissioned with short-term funding (e.g. one year funding) and must constantly ‘prove’ their value, despite the strong evidence base. Often, these services are only recommissioned at very short notice.

Short-term funding makes staff retention extremely challenging, as a lack of job security causes staff to look for other, more stable employment opportunities. Resources are then wasted in re-recruitment processes, and all of the expert knowledge and relationships that have been built up are lost. Ensuring that specialist services have stable, long-term funding would represent a much more efficient use of resources.

Recent reporting has shown that many ICSs are using deficits.[19] This results in less funding availability and stability for specialist services.

Temporary Accommodation

It is well detailed that the current provision of temporary accommodation places extreme financial burdens on Local Authorities. The current temporary accommodation system also places avoidable financial burdens on the healthcare system for several reasons. First, research has shown that living in poor quality temporary accommodation is actively detrimental for both physical and mental health, in addition to preventing people from recovering from existing conditions[20]. The poor quality of available temporary accommodation is therefore driving avoidable financial burdens on the healthcare system.

Second, people who are placed in temporary accommodation can struggle to access essential healthcare services such as GPs, primary care and mental health services. People may be placed far away from services where they were previously registered, and being moved between different locations means people have to register with new services, which can be challenging. Being unable to access community healthcare services causes worse health outcomes and contributes to over-reliance on urgent and emergency care services, which are significantly more expensive to deliver[21].

 

Health services and preventing homelessness

Homelessness is extremely expensive across the public sector, including healthcare, housing, social care, the criminal justice system and so on. There is therefore a strong financial case that we should put more resources into preventing people from becoming homeless in the first place.

Health services have an important role to play in preventing homelessness. Firstly, research has highlighted that poor mental health, substance misuse issues, disabilities and neurodiversity (such as autism spectrum disorder) can be causal factors that contribute to people becoming homeless[22]. Improving the provision of services which identify and address these issues as early on as possible is an important part of preventing homelessness from occurring. For example, improving the provision of mental health services for children and young adults, early intervention for people with substance misuse issues.

Secondly, as services that interact with large numbers of the public, healthcare services should play a bigger role in identifying people who may be at risk of homelessness and taking appropriate action. This can include ensuring that the appropriate healthcare is given but also ensuring that people are referred to and can access support from housing and other social services.

 

Pilot programmes and generating evidence

As outlined in the NICE Guidelines NG214, there is significant and robust evidence about how the health and social care system can respond in an effective and cost-effective way to the needs of people experiencing homelessness and other socially excluded groups. However, rather than resources being put into setting up the services and systems that we know work, homeless health services must endlessly prove their value through inefficient pilot programmes. Rather than generating more unnecessary evidence, we should prioritize delivering the services that we already know to be effective.

An example of this is the recent Out of Hospital Care Model evaluation. The programme was allocated £16 million to establish and evaluate specialist hospital discharge and intermediate care services for people experiencing homelessness. However, following the pilot period, the majority of the services that were set up during the pilot were discontinued due to a lack of funding, despite extremely positive results and outcomes.[23]

The lack of secure funding continuation following pilots is also very challenging for staff retention, due to job insecurity. Not only does this mean that resources are wasted in re-recruiting staff, but a significant amount of knowledge and effective working relationships are lost as well. Having to start again from scratch in situations like this is extremely inefficient.

Rather than a constant stream of time-limited pilots, we need to fund the services, interventions and systems that we already know to be effective. This would represent a more efficient use of public money.

 

 

 

 

Collaboration, integrated working and system leadership

Recommendations from NICE[24] and NHSE[25] focus on improving integrated and collaborative working between public sector agencies (e.g. health, housing, social care, safeguarding, welfare) in tackling homelessness. However, despite some improvement, responses to homelessness are still characterized by disjointed and inefficient working across different public services.

Rather than working together collaboratively, different services often pass responsibility between them, with people falling through the cracks. This is partially due to the pressures that public sector services are under, but also due to the lack of systemic incentives to work collaboratively to address peoples’ homelessness and issues with information sharing. Improving system collaboration would represent a more efficient way to address homelessness.

The success of the ‘Everyone In’ programme during COVID showed the positive impact of effective collaborative working across government and the public sector. However, the lack of effective coordination following COVID is one of the reasons why homelessness has risen during the period, as evidenced by multiple sources.[26] [27]

November 2024

 

 

 

 

 


[1] https://www.england.nhs.uk/long-read/a-national-framework-for-nhs-action-on-inclusion-health/

[2] https://www.nice.org.uk/guidance/ng214

[3] https://www.pathway.org.uk/partnership-programme/why-were-needed/

[4] https://jech.bmj.com/content/jech/75/7/681.full.pdf

[5] https://www.pathway.org.uk/resources/barometer2024/

[6] https://england.shelter.org.uk/professional_resources/policy_and_research/policy_library/still_living_in_limbo

[7] https://www.pathway.org.uk/resources/barometer2024/

[8] https://www.pathway.org.uk/resources/barometer2024/

[9] https://www.pathway.org.uk/resources/barometer2024/

[10] https://www.independent.co.uk/news/uk/home-news/homeless-nhs-hospital-discharge-beds-rough-sleeping-b2507850.html

[11] https://www.kcl.ac.uk/research/oohcm-evaluation

[12] https://www.pathway.org.uk/resources/barometer2024/

[13] https://www.kcl.ac.uk/research/oohcm-evaluation

 

[14] https://www.carnallfarrar.com/the-unseen-struggle-the-invisibility-of-homelessness-in-nhs-data-cf/

[15] https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/emergency-care-data-set-ecds

[16] https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/mental-health-services-data-set

[17] https://www.carnallfarrar.com/the-unseen-struggle-the-invisibility-of-homelessness-in-nhs-data-cf/

 

[18] https://www.pathway.org.uk/resources/barometer2024/

[19] https://www.nhsconfed.org/publications/putting-money-where-our-mouth-health-inequalities-funding

[20] https://groundswell.org.uk/wp-content/uploads/2023/09/Improving-the-health-of-people-living-in-Temporary-Accommodation-in-London-Sep23.pdf

[21] https://groundswell.org.uk/wp-content/uploads/2023/09/Improving-the-health-of-people-living-in-Temporary-Accommodation-in-London-Sep23.pdf

[22] https://homeless.org.uk/knowledge-hub/unhealthy-state-of-homelessness-2022-findings-from-the-homeless-health-needs-audit/

[23] https://www.kcl.ac.uk/research/oohcm-evaluation

 

[24] https://www.nice.org.uk/guidance/ng214

[25] https://www.england.nhs.uk/long-read/a-national-framework-for-nhs-action-on-inclusion-health/

[26] https://www.gov.uk/government/collections/homelessness-statistics#statutory-homelessness

[27] https://www.gov.uk/government/statistics/rough-sleeping-snapshot-in-england-autumn-2023/rough-sleeping-snapshot-in-england-autumn-2023