Written evidence submitted by About the Royal College of Nursing (RCN)

(TH0030)

 

  1. About the Royal College of Nursing (RCN)

 

1.1. With a membership of over half a million registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

 

  1. Introduction

 

2.2.  The RCN welcomes the Public Accounts Committee (PAC) inquiry into tackling homelessness. We are concerned that rates of homelessness in England are increasing[1] and becoming a problem in areas outside of traditional hotspots. As highlighted by the National Audit Office (NAO) 2024 report into ‘The effectiveness of government in tackling homelessness’, homelessness is now at the highest level since comparable data collection began in the early 2000s.[2]

 

2.3.  Many nursing staff work directly with people experiencing, or at risk of experiencing homelessness and nursing staff working across all settings will likely encounter and care for people experiencing homelessness. One example is homeless hospital discharge nurses who work with people experiencing homelessness to ensure that they get the health care they need while in hospital and help them secure accommodation and ongoing care before they are discharged.

 

2.4.  Tackling homelessness, housing insecurity and supporting people experiencing homelessness are important issues for the nursing profession. At the RCN’s 2024 annual congress, this was underlined by RCN members passing a resolution for the RCN to lobby the Government to mandate specialist accessible health care for people who experience rough sleeping.

 

2.5.  In this submission, we highlight the need to consider health as a key cause and consequence of homelessness, and for health to be prioritised within government strategies and action to tackle homelessness.

 

  1. Health as a cause and consequence of homelessness

 

3.1. There is a strong link between homelessness and ill health (both physical and mental health): ill health can be a contributing factor or cause, and a consequence of homelessness. Our members have highlighted a range of factors at the individual level which can cause homelessness – including job loss, relationship breakdown, substance misuse issues and addiction, mental health illness and at the wider structural level – such as austerity, poor housing provision, a lack of adherence to duty to house, limited wrap around support and a lack of investment in homelessness services.[3]

 

3.2. People experiencing homelessness face significant health inequalities and poorer health outcomes than the general population. Diagnoses of physical and mental health conditions are much higher than the general population and many of those experiencing homelessness face early onset frailty.[4] The average age of death for people experiencing homelessness is 45 for men and 43 for women[5] compared with 79 years for men and 83 years for women in England and Wales in the general population.[6] Homeless people are over nine times more likely to take their own life than the general population.[7] Across all forms of health care needs and access to necessary support, people experiencing homelessness report poorer diagnoses and greater barriers to healthcare than the general population.[8] 

 

3.3. Nursing teams who work with people experiencing homelessness can face significant challenges trying to provide support and services to people sleeping rough and/or in temporary accommodation. Those who are homeless often find it far more difficult to access health care and attend appointments and then often present late with symptoms. RCN members have highlighted that factors affecting access to health and care services include problems with getting to/travelling to services and appointments, compliance with medication regimes, stigma from health professionals and other patients within services, and examples of GP surgeries which require identification and proof of address, and or where they require online or phone appointments which can also serve as a barrier.

 

3.4. A 2024 report from Pathway and Crisis emphasised that in response to rising levels of need, increasing demand for services and reductions in funding, the NHS, housing and social care services are becoming less flexible and also raising their thresholds for people to access support so people have to be sicker, more vulnerable or more distressed to be able to access help and that for people facing homelessness this crisis is a threat to life.[9]

 

3.5. There has been a lack of consistency and coherence across government policy in relation to addressing health inequalities and ensuring that people experiencing homelessness and other inclusion health groups get the support they need. The Pathway and Crisis 2024 report highlights that while there have been examples of the NHS and other Government policy seeking to address health inequalities (for example the NHS Core20PLUS5 approach to addressing inequalities which encourages a focus on inclusion groups including people experiencing homelessness[10]) other areas of government policy (for example in relation to migration, housing and welfare)are actively working against the progress made, ultimately deepening disparities.[11]

 

3.6. There is currently no overarching national strategy for addressing health inequalities in England, and despite consistent rhetoric from consecutive governments about the need to invest in prevention over the last decade,[12] investment in local prevention and public health services in England has been cut significantly.[13] Furthermore the pressures facing the NHS, including underfunding and a workforce crisis, have further hindered progress to ensuring that inclusion health groups, including homeless people, get the health and care support they need.

 

  1. Recommendations for action

 

4.1. The RCN calls for a national cross government strategy to improve health and address health inequalities. This would support greater coherence across government policymaking to address the social determinants of health, reduce inequalities and embed a prevention-focused approach. Alongside this, the Government should embed a health in all policies approach across all departments to ensure that health is considered and prioritised in all policy design, development and implementation. Within this, the Government should prioritise health within strategies to tackle homelessness and across all housing policy.

 

4.2. Alongside this, we urge the Government to ensure that appropriate and accessible specialist health and care services are available across all areas and to all people, with a key focus on inclusion health groups, including people experiencing homelessness. The new 10-year plan for health currently being developed for the NHS[14] is an opportunity for the NHS to mandate every Integrated Care System (ICS) in England to ensure that there are specialist accessible health services available for inclusion health populations, including people experiencing homelessness. These must cover primary care, acute hospital, and community services and be supported by additional funding commitments, given the intense pressure on NHS and social care budgets currently.

 

4.3. We also support the recommendation from Pathway and Crisis that the Care Quality Commission (CQC) should specifically assess for action on inclusion health groups in its ICS inspection regime.[15] The sharing of best practise and learning from the many areas where there are effective specialist services in place between practitioners, services, trusts and ICSs should also be encouraged to support the development of specialist services.

 

4.4. The Government has stated its support for shifting more care from hospitals to the community and from treatment to prevention as part of the planned reforms to the health service in England.[16] Ensuring that there are accessible specialist health services available for inclusion health groups, including those experiencing homelessness, in locations, venues and spaces that best meet their needs and maximise access and uptake must be a core priority within the reforms. Given the significant health inequalities facing people from inclusion health groups, including people experiencing homelessness, a particular focus on prevention within inclusion health groups is critical. Nursing staff will be pivotal to the design and delivery of effective interventions in this space.

 

4.5. Addressing the nursing workforce crisis and increasing investment in health and care services, including local prevention and public health services delivered by local authorities, must be a core focus of the Governments’ work to tackle homelessness and reform the health and care system.

 

4.6. There is a range of guidance and frameworks available to support health and care staff, such as the NHS England Inclusion Health Framework,[17] the Core20PLUS5 approach[18] and the NICE guidance on ‘Integrated health and social care for people experiencing homelessness’.[19] Ensuring that all health and care staff are aware of these tools and have access to appropriate training on how to support inclusion health groups (including people experiencing homelessness) and tackle health inequalities is critical and should be a key priority within the new 10 year plan.

 

November 2024


[1] Statutory homelessness in England: October to December 2023 - GOV.UK

[2] National Audit Office (2024) The effectiveness of government in tackling homelessness

[3] These factors were highlighted by members who responded to an RCN member survey about homelessness in November 2024.

[4] Homeless Link (2022) The Unhealthy State of Homelessness 2022 Findings from the Homeless Health Needs Audit Homeless_Health_Needs_Audit_Report.pdf

[5] Office for National Statistics (2022) Deaths of homeless people in England and Wales - Office for National Statistics

[6] ONS (2023) National life tables – life expectancy in England and Wales - Office for National Statistics

[7] Crisis Homelessness: Causes, Types and Facts | Crisis UK

[8] Health and homelessness | Homeless Link

[9] Pathway & Crisis (2024) Always at the bottom of the pile. Always at the Bottom of the Pile: The Homeless and Inclusion Health Barometer 2024 – Pathway

[10] NHS England » Core20PLUS5 (adults) – an approach to reducing healthcare inequalities

[11] Pathway & Crisis (2024) Always at the bottom of the pile. Always at the Bottom of the Pile: The Homeless and Inclusion Health Barometer 2024 – Pathway

[12] For example, Advancing our health: prevention in the 2020s – consultation document - GOV.UK; Levelling Up the United Kingdom - GOV.UK;

[13] As reported by the Health Foundation (2024) the public health grant has been cut by 28% on a real terms per person basis since 2015/16. Investing in the public health grant

[14] NHS England » Creating a new 10-Year Health Plan

[15] Pathway & Crisis (2024) Always at the bottom of the pile. Always at the Bottom of the Pile: The Homeless and Inclusion Health Barometer 2024 – Pathway

[16] Government issues rallying cry to the nation to help fix NHS - GOV.UK

[17] NHS England » A national framework for NHS – action on inclusion health

[18] NHS England » Core20PLUS5 (adults) – an approach to reducing healthcare inequalities

[19] NICE (2022) Overview | Integrated health and social care for people experiencing homelessness | Guidance | NICE