Tackling poor health outcomes: the role of trauma-informed care

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Part of Health and care services for people sleeping rough

Over the past few months I’ve been interviewing, reading and writing about the provision of health and care services to people who sleep rough. One concept has particularly stood out to me from what I’ve heard: trauma. It’s something I’ve been hearing more about recently, both in this research and in other health and care contexts.

Our understanding of the breadth of the definition of trauma is growing. One well-used definition comes from the US Substance Abuse and Mental Health Service Administration:

The concept of adverse childhood experiences (ACEs), is one that researchers and policy makers are using to think about the impacts of trauma. ACEs are potentially traumatic events experienced before reaching the age of 18, including but not limited to abuse or neglect in childhood and distressing family events such as witnessing domestic violence or a parent going to prison. It’s estimated that almost half of the adult population of England have experienced at least one ACE, while 9 per cent have experienced four or more. ACEs are therefore far from rare.

'We heard about how people who were sleeping rough with substance misuse problems were also often dealing with longstanding trauma, but that health services were often not set up to recognise or meet this need.'

People who are homeless are more likely to have experienced trauma than the general population, and homeless people with the highest support needs are also the most likely to have experienced multiple ACEs. In our research, some interviewees described the impact of trauma on people (not) accessing services, while others highlighted the importance of an approach in services for homeless people that recognises the impact of trauma. For example, we heard about how people who were sleeping rough with substance misuse problems were also often dealing with longstanding trauma, but that health services were often not set up to recognise or meet this need. If services don’t take trauma into account, given that people who have experienced trauma may be reluctant to engage with health care in the first place, there is a risk that some will not receive the support they need.

This is not just an issue for services supporting people who are homeless. Multiple ACEs are also associated with higher risks of a range of poor health outcomes. Additionally, they are not evenly distributed: higher ACE counts are associated with living in a deprived area or being female. For all these reasons, it’s important to consider how services across the health system respond to people who have experienced trauma.

A trauma-informed approach to healthcare aims to provide an environment where a person who has experienced trauma feels safe and can develop trust. This might look like a health care provider explaining why they are asking sensitive questions, responding with compassion when a person refuses a medical exam or test, or enabling the person to take control, for example, asking them to share what they’ve found helpful or harmful in similar situations in the past. Lots of research in this area focuses on mental health services because of established links between trauma and mental distress. The NHS long-term plan commits to developing trauma-informed care in relation to a community offer for people with severe mental health problems, but also a service for vulnerable young people in contact with the youth justice system. Additionally, an expectation of trauma-informed approaches in mental health services accessed by people sleeping rough is included in the NHS mental health implementation plan.

'This work requires a cultural shift, not simply a behavioural one – a change in the way front-line staff understand the impact of trauma, which in turn influences their practice.'

Given that people who have experienced trauma will interact with a range of services throughout their lives, it makes sense that front-line staff across sectors have at least a working knowledge of the impacts of trauma. The Scottish Government are aiming to develop understanding of trauma across the workforce – including not only mental health but also the physical health, social care, education, and justice sectors. They commissioned NHS Education for Scotland to produce a knowledge and skills framework that sets out different levels of expected expertise depending on an individual’s particular role. As of this year, 3,000 front-line workers had been given some form of training. There is also work being undertaken in Wales. Public Health Wales have published a number of reports examining ACEs and their impacts on the Welsh population to inform a focus on ACEs and addressing them across public services.

This work requires a cultural shift, not simply a behavioural one – a change in the way front-line staff understand the impact of trauma, which in turn influences their practice. Training is a good place to start, but there are many competing asks on NHS staff time. Initiatives to promote trauma-informed approaches need to ensure a focus on the system-level change needed to deliver them, not simply relying on changing individual practice.

Finally, it’s important to remember that while anyone can use a service that is trauma-informed, services that are not trauma-informed risk excluding people who have experienced trauma. As well as enabling a more person-centred approach for anyone who uses a service, this is a change with potential to improve healthcare for people who currently face poor outcomes.

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Jacqui Jobson

Director of Advocacy,
Connected Voice
Comment date
18 November 2019

I found this a really interesting read and very important to raise the issue of trauma informed practice across health and social care. As an Independent Advocacy service, far too often we see the result of service users being excluded from systems that are not able to meet their needs. looking through a trauma informed lens is not only of great benefit to service users but would also save on much wasted time and resources, when people do not engage. Also I think it is worth looking at the impact of "Minority Stress"; a lot of work has been done in the US and Canada evidencing the impact this has in terms of PTSD and trauma and the resulting health inequalities.

Deborah Fenney

The King's Fund
Comment date
21 November 2019

Thanks for your comment, Jacqui - it's really interesting to hear from your experience in independent advocacy . And I agree, the work on Minority Stress is really interesting too - sadly there were so many things I couldn't squeeze into this blog!

Simon James

Chief Executive,
Interlink RCT
Comment date
04 December 2019

We are looking at how we take a community development approach to tackling trauma / ACES. But it seems many public services are designed to protect the system by stigmatising the most vulnerable and putting barriers in the way of care and support. Not sure how you tackle systemic problems without leadership that can acknowedge and address the problem is the system not the person rewuiring support.

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