Although nearly a quarter of a century apart, both these reports focus on the same problem: the reasons why people who are homeless can experience access to NHS services that is poor, disorganised or non-existent, when free, universal health care is supposed to be available for anyone.
In 1996 we found bureaucratic barriers, with GP surgeries only allowing registration by home address, and that negative attitudes or hostile looks from other people in a waiting room, could stop people who were homeless using the NHS. People experiencing homelessness often could not access all the services they needed, as those services were often not co-ordinated, or did not provide the specialist support that someone with high and complex needs required. We also found examples of self-sacrificing, highly committed individuals working within the NHS, arguing for – and winning – the case for specialist homelessness services.
So where are we now? Having been reduced in the early 2000s, rough sleeping in England has dramatically increased since 2010. We know that when people have long-term or repeated experience of rough sleeping, it is often associated with high and complex needs, such as severe mental illness and addiction. Policy attention has become focused on how to prevent and reduce rough sleeping and given the health needs of this group, health services play a pivotal role in meeting that challenge.
Through our latest research, we saw how collaboration between homelessness services, the NHS, local authorities and other services can improve results. If services share data, combine and refine their referral systems and build systems that provide suitable homes, while ensuring that those with complex needs get the treatment and the other help that they need, real progress is possible.
We know that the health needs of people sleeping rough must be addressed alongside their need for a home. Effective health care and effective prevention and reduction of rough sleeping requires a clear, quick and sustainable route to having your own front door, security of tenure and a rent you can afford, as well as both the privacy and the connections to family, friends and community that come from having a home of your own. As we used to say back in 1996, you cannot (effectively) treat someone living in a cardboard box.
The most effective services, like Housing First, support people by focusing on securing a settled home as the first priority, then providing the support needed to sustain that home, with individuals choosing where, when and how support is provided. Services are provided that fit the individual rather than trying to get the individual to fit a service. Importantly, housing is not dependent on someone continuing to use the support. Housing First also works alongside other services to provide an integrated package of suitable housing, treatment and support.
We know that models like Housing First, alongside the innovative practice developed within the NHS itself, such as specialist homeless health services, can be effective in enabling people to exit rough sleeping. The challenges can be met, but in order to do that we have to work to ensure that effective good practice is used consistently. This means meeting housing, support and health care needs of people experiencing long-term and repeated rough sleeping, in an organised, co-ordinated way, using the right mix of services. For some, the main requirement is for a settled home with lighter-touch services, while others with more complex needs may require intensive supported housing services. In addition to this, we need as much attention being paid to preventing rough sleeping as on the mix of services designed to reduce it.
Guidance and sharing of good practice are an important part of the answer. So too is the quality of leadership across a local area. The new work with The King’s Fund has again shown how much depends on individual clinicians and commissioners within the NHS and local authorities, social housing and homelessness services arguing for, experimenting with and delivering effective health services. People sleeping rough need leaders from across health, care and housing to take shared responsibility for improving the support on offer locally. We also need to recognise that treatment and care needs among people sleeping rough cannot be addressed by NHS services alone, no matter how those services are designed and commissioned; settled homes and support to sustain those homes are as essential as providing effective treatment.
We have also learned something else in more than 30 years of working to reduce rough sleeping. Services and systems that listen to people who have experience of sleeping rough and work with them, recognising and respecting them as fellow human beings who have often been through a great deal, work better than those that do not listen to them. Our latest research reminds us not to make assumptions about how people who sleep rough want to access health and care services. One size will not fit all, and any successful strategy requires careful and repeated conversations with people who are sleeping rough.