Written evidence submitted by Devon County Council [IOC 173]

Introduction

I am the Chief Officer for CoPHEP (Communities, Public Health, Environment and Prosperity) for Devon County Council and am also the statutory Director of Public Health. We are submitting evidence to this enquiry because both because we have a commissioning responsibility for substance misuse services and also work closely with partners to improve health and reduce inequalities across our population, including people experiencing homelessness.

The Committee invites written evidence on the impact of COVID-19 on homelessness, rough sleeping, and the private rented sector, as well as any other connected issues. In particular, the Committee is interesting in finding out:

•             How effective has the support provided by MHCLG and other Government departments in addressing the impact of COVID-19 on those in the private rented sector, rough sleepers, and the homeless?

Everyone In

'Everyone In' was a welcome step in providing support to rough sleepers to help them protect themselves against COVID-19. It has provided a focal point for multi-agency partnerships to rally support and coordination the response for homeless/rough sleepers. However, the funding provided to councils does not cover the costs incurred of housing people during this time. Wider support needs such as clothing and laundry add to the overall costs. There have also been challenges with finding enough appropriate accommodation, especially as there are also demands for housing from prison releases and people leaving domestic violence situations.

Guidance

Guidance for this sector has lagged behind other sectors such as care homes. The Healthy London Partnership, NHSE and PHE have done an excellent job in developing and sharing resources, but having official guidance directed at this sector sooner would have been helpful. There are specific challenges for this sector, for example outreach workers are not always able to ascertain in advance in someone is symptomatic, and social distancing is not always easy in emergency accommodation, so acknowledgement of these types of scenarios in guidance would be really helpful. Final guidance is still awaited on how to develop drug and alcohol protocols to meet the needs of this group, for example preventing people who are alcohol dependent from sudden withdrawal if they become ill and need to self-isolate.

As part of the recovery process, there now needs to be clear strategic direction and resources to help local authorities support the homeless community through stepdown and the next phase of the pandemic - not just in the immediate lockdown period.

•             What problems remain a current and immediate concern for these groups?

Cohorting

The recommendation to cohort people into COVID-Protect, COVID-Care and the asymptomatic, low-risk was based on sound public health principles, but has been more challenging to implement in some areas than others, with plans constrained by the speed with which the 'Everyone In' drive was announced, availability of appropriate accommodation locally, and clinical/community capacity to coordinate. The shielded group have been prioritised in self-contained accommodation wherever possible, but many areas are co-hosting different groups on the same sites, and do not have the facilities to move people who are symptomatic into separate accommodation. Preventing outbreaks will depend on rigorous infection prevention and control measures in those co-hosted sites.

Clinical and social vulnerability

A higher proportion of rough sleepers fall into the vulnerable and extremely vulnerable (shielded) categories for COVID-19, compared to the general population. Many live complex lives, facing challenges such as addiction, trauma, multiple comorbidities, mental health issues, low self-esteem and self-efficacy meaning self-care and following health advice are not easy to do.

Access to healthcare

In urban centres with specialist GPs, many people are registered with the GP so links with primary care are strong, but some get missed, and in rural areas there's even more chance of people not accessing healthcare when they need to. The general public have been advised to self-care at home if they develop COVID symptoms, and to seek help if more severe symptoms develop. Both of these steps are harder for the homeless community.

Challenges to social distancing and self-isolation

There are practical challenges to practising social distancing and self-isolation. Living in lockdown is hard for everyone, but it's even harder if you have few resources and multiple social disadvantage. Some funds and donations are emerging to provide ipads, books, toiletries, clothes, phones, distraction packs etc., but the need is immediate. People need practical, psychological and social support to deal with the stress, anxiety and boredom of life in lockdown and to find meaningful ways to spend the time.

Substance misuse

There are challenges for people with drug and alcohol addiction. Usual sources of income are unavailable so people have less money. Providers are working hard to get people onto benefits but there can be delays. For people who are alcohol dependent, the priority is to keep them stable and avoid sudden drops in intake - this can be very dangerous and lead to severe illness or death. Alcohol harm minimisation guidance is in place and plans are being developed to ensure people are still able to access alcohol if they have to self-isolate or shield, to avoid risks of unplanned detoxification. The substance misuse provider is working hard with primary care to get people into treatment.

Anecdotally, the drug market is changing, as usual sources become more difficult to access. Methadone, prescribed through opiate substitution therapy (OST) is becoming a higher value commodity, and there are reports of people having their prescriptions stolen. It is also being prescribed in greater quantities (7 days at once instead of more frequently) to reduce pharmacy contact, which makes individuals – or, for those who are shielding or self-isolating, nominated proxies/services who are collecting them on their behalf - even more of a target. Some properties have been risk assessed as not safe for OST to be delivered to because of concerns about interception. Additionally, some rough sleepers living with addictions have felt vulnerable when having to wait in queues at pharmacies for their medication as drug dealers/others have taken these opportunities to exploit their vulnerabilities

Smoking

Up to 80% of homeless people smoke, compared to 15% of the general population in the UK.[1] People who smoke are more likely to contract COVID-19, due to the hand to mouth action increasing the opportunity for the virus to enter the body, and are more likely to develop severe complications, due to impaired respiratory function. It is common for rough sleepers to share cigarette butts found on the street, increasing infection risk.[2] Homeless organisations are linking with stop smoking services to support people to quit and to pilot the use of e-cigarettes, both as a harm reduction option, and to support people to follow the rules of non-smoking emergency hotel accommodations, helping them to stay housed and maintain social distancing/self-isolation.

•             What might be the immediate post-lockdown impacts for these groups, and what action is needed to help with these?

Post 'Everyone In' – outbreak risk and wider healthcare needs

Significant resources will be needed to get people into onward accommodation and support them to stay off the streets if 'Everyone In' ends. If onward accommodation cannot be found, homeless/rough sleepers will remain highly vulnerable while there is not yet a vaccine or treatment for COVID-19 – particularly those in shielding/higher risk groups who need to be prioritised. If there are further waves of the virus, outbreaks in rough sleeping communities could be hard to contain, and there could be a high case fatality rate due to the vulnerability of the community. One solution to this would be to have, as a minimum, COVID-care facilities on standby, so anyone who becomes mildly symptomatic could safely self-isolate and be cared for. Testing for these groups would also help identify people who need to self-isolate, including people who are positive but asymptomatic. 

There could also be risks of overdose as street drug supply increases and individuals increase their intake again without realising their tolerance has decreased during lockdown. Naloxone will need to be widely available. Before COVID-19, there had been local and national outbreaks of wound infections including invasive group A streptococcus (IGAS). With less face to face observation and care of drug users, there are risk of repeated outbreaks in this group. Therefore, action is needed to protect and resource the services who serve these groups, including substance misuse services, council and voluntary sector services, as well as investment in primary care and mental health services to meet the needs of these groups throughout the pandemic and beyond.

Action will also be needed to prevent more people becoming homeless due to the economic pressures COVID-19 is causing.

Coproduction and recovery

Continued effort is needed to listen to people experiencing homelessness, understand the challenges they face, and to do things 'with' them not 'to' them, using principles of coproduction. COVID-19 is an unprecedented crisis, but also an unprecedented opportunity. Organisations and communities are coming together to support the most vulnerable in society and new partnerships are forming. Despite the challenges, this situation has provided an extraordinary chance to engage with people who are often labelled as 'hard to reach'. As we move into recovery, we should be aiming to 'Build Back Better'.[3] Lockdown provision should be the beginning of a new chapter in homeless healthcare, as described by the Kings Fund - 'going above and beyond' to deliver healthcare for people who sleep rough.[4]

May 2020