The number of people sleeping rough in England has risen substantially over the past decade. People who are homeless have some of the worst health outcomes in England, and are more likely to experience and die from preventable and treatable medical conditions and to have multiple and complex health needs. Many people who sleep rough experience a combination of physical and mental ill health and drug or alcohol dependency.
Alongside these needs, people who sleep rough face barriers to accessing health and care services, including attitudes of some staff, complex administration processes and previous negative experiences. This means continuity of care is a challenge and health issues may not be picked up until they become acute.
Multiple services are involved in meeting the health needs of people sleeping rough (see diagram). Many people sleeping rough will require support from several of these services at once and the effectiveness of any one service is dependent on that of the others.
This complex service landscape requires multiple stakeholders to work together: how services manage the handovers and links between them is crucial. Services therefore need to provide a coordinated, joined-up approach, recognising the breadth of health needs that a person sleeping rough might be experiencing.
Ultimately, a person cannot achieve good physical and mental health without a safe and stable home. However, health problems can also be a cause of homelessness or a barrier to exiting rough sleeping. Health, housing and wider support needs are deeply interconnected – there is a need for an integrated response across a wide range of partners including health services, local government and the voluntary, community and social enterprise sector (VCSE), as well as a range of other organisations such as the police, the wider local economy and the local community.
This work was commissioned by the Department of Health and Social Care and the Ministry of Housing, Communities and Local Government. We looked at what four nominated areas were doing to improve health outcomes for people sleeping rough repeatedly or on a routine basis and explore what insights they might offer to other areas.
We interviewed a set of key individuals in each area, which included commissioners and managers of health services, clinicians, public health, housing and adult social care, VCSE providers and elected councillors. Our research partners at the University of York conducted one focus group in each area with people who have lived experience of sleeping rough.
Across the four areas, we identified five common principles of delivering effective health care to people sleeping rough that other areas may find useful to learn from.
Find and engage people sleeping rough
Because many people who sleep rough have high and complex needs, as well as facing barriers to accessing services, systems need to identify and address unmet need and design services that people who sleep rough can and want to use. People with lived experience were involved in the design and evaluation of many of these services in the four areas we looked at.
Each contact that someone has with any service provides an opportunity to establish a relationship, build trust and connect them to services that can help meet their needs. Our case study sites recognised both primary care and acute hospital visits as key opportunities for connecting people who sleep rough to community health services, mental health services, social care and housing support. Some areas embedded workers from these services into acute hospital discharge teams.
Multifaceted approaches to outreach, combining street outreach with ‘inreach’ in a range of settings, increased the range of opportunities that services had to engage people. Health workers were embedded in VCSE and local authority outreach teams. Peer advocates were commissioned to help people navigate the system and access the care they needed.
Some areas explicitly took an asset-based approach to care, enabling and training their staff to adapt to the specific circumstances and priorities of the individuals being treated. Some areas provided training to improve understanding and promote positive attitudes about people who sleep rough among staff in mainstream health services, including video training for GP receptionists.
Build and support the workforce to go above and beyond
Local areas are not yet functioning in a way that meets the needs of people sleeping rough. Staff often have to work around systems, rules and procedures rather than through them. Across sectors, staff working with this group have high levels of passion and knowledge. Leaders should work to nurture, sustain and capitalise on this.
Developing a shared sense of purpose across a system can bring people together and form a basis for integrated working. We saw senior leaders raising the profile of this issue and setting high expectations about service delivery. Different services came together to agree a common vision and approach, setting the tone for staff delivering services to work together towards a shared goal.
Giving staff permission to flex the system enabled people sleeping rough to access effective support. Senior leaders helped to foster a safe, supportive, ‘no blame’ approach: one that asks staff to use reasonable flexibility in the client’s best interests.
The provision of ongoing support to staff enabled them to maintain the understanding, confidence and resilience needed to work effectively with this population. Across our case study sites this ranged from investment in staff wellbeing, to training across the local workforce to engage with people sleeping rough at any contact point. Specialist training for those in regular contact with people who slept rough often focused on trauma-informed approaches and reflective practice.
People who sleep rough may not use conventional routes to access support. Staff need to connect individuals quickly across different services spanning housing, social care and health. This works best when staff know each other personally. Staff also need to be able to trust others when flexing normal practices to fit services around an individual.
Senior leaders modelled collaborative working and helped shape organisational cultures in which positive relationships were prioritised. This included demonstrating commitment to collective leadership in cross-organisational partnerships, and agreeing shared visions that resonated with staff.
Formal mechanisms for staff at all levels to build relationships face-to-face included co-locating teams, designing pilot projects that encouraged joint working, and both strategic and operational multi-agency meetings.
Tailor the response
Effective, joined-up services need to reflect place-specific characteristics, including local needs, assets and geographies. A generic, ‘off-the shelf’ approach to improving health and care outcomes for people sleeping rough will not work.
Our case study areas sought to develop thorough local insights about who was sleeping rough, their needs, their interactions with services, and how these changed over time. Decisions were informed by insights from people who had lived experience of sleeping rough and staff in homelessness services. Conducting specific health needs assessments for people experiencing homelessness created an opportunity to draw together existing data and get owners talking to each other about how to use and share it. Employing analysts to develop data collection and use made data significantly more powerful. Leaders played a critical role in shaping the approach to rough sleeping, and yet many interviewees struggled to identify where overall leadership and accountability sat for meeting the health needs of this group. Active engagement with elected politicians and the public helped to cultivate and harness their support.
Co-ordinated local and regional approaches were at various stages of development. Some neighbouring areas worked together to facilitate a flexible response to people moving across boundaries. They focused on a duty of care to individuals in need, rather than eligibility criteria for services based on geography. One sustainability and transformation partnership had prioritised this area, framing it in terms of its role in tackling health inequalities and using it as an opportunity to bring partners across health and local government together.
Use the power of commissioning
Commissioners have a range of powers to bring about improvements in services and how people work together across a system. Commissioners should work together across the NHS and local authorities to deliver integrated services that truly address the complexity of need among the population who sleep rough.
Dedicated resources and inter-agency commissioning helped to create a momentum for change. All four areas had successfully accessed additional central funding for this work. Flexible contracts enabled providers to adapt to changing need and facilitated bottom-up innovation by frontline staff.
Contracts were designed to encourage specialist services, where they existed, to play a system leadership role. Some included an expectation of supporting mainstream services to work with people who sleep rough, including through advocacy, training and advice. We also saw contracts in which key performance indicators included numbers of patients discharged from specialist to mainstream services.
Retendering offered key opportunities to better co-ordinate and integrate care. Commissioners worked together to ensure that pathways joined up across services. In some areas, commissioners also had a process by which they could review and amend contracts and service specifications to prevent incompatible thresholds or eligibility criteria across service pathways.
There is no blueprint for how to improve the health of people sleeping rough, but these findings point to multiple ways that local and national leaders can support individuals to get better access to health and care. Local leaders need to understand the importance of leadership across a local system, with shared ownership for ending rough sleeping and responsibility for their individual roles in driving improvements. They should be committed to collaboration and clear accountability across health, housing and social care. They need to gain political buy-in and support, as well as asking themselves how well, as a team, they hear and act on the views of people sleeping rough. Finally, local leaders should develop the capacity of others and support them to lead change.
Government departments and arm’s length bodies also have a key role to play in encouraging wider progress. Building on its commitments in the long-term plan for the NHS, NHS England and Improvement needs to support sustainability and transformation partnerships’ and integrated care systems’ plans to join up services and set local goals for improving the health of people sleeping rough, as well as ensuring rough sleeping is part of the measure of accountability for reducing health inequalities. Across departments, government needs to ensure secure and sustainable resources to deliver the Rough Sleeping Strategy, with a focus on upstream prevention. Attention also needs to be paid to the issue of local connection.
Public Health England is already developing new guidance for commissioners and demonstrator sites should also be considered to help draw out learning from applying this guidance in practice. The Ministry of Housing, Communities and Local Government and the Department of Health and Social Care could also support learning across areas through developing learning networks. The Ministry of Housing, Communities and Local Government needs to co-ordinate with other partners to embed core capabilities consistently across the workforce for frontline health and care staff working with people sleeping rough.
Finally, while recent funding commitments are welcomed, there is a need to ensure new funding is sufficient for the task and that areas are equipped to use it effectively. This also means ensuring a more strategic approach to funding with longer time frames and more flexibility for adaption to the local context.
- What are these ten prompts?
What are these ten prompts?
These prompts are designed to support local systems to improve the health and care outcomes of people sleeping rough. They are aimed particularly at those in leadership roles (such as commissioners, managers and clinicians) across health, public health, housing, social care and the voluntary and community sector in a local area.They are designed to prompt system leaders on whether they have the right relationships, leadership and infrastructure in place to respond effectively to the needs of their rough sleeping population.These prompts are drawn from The King’s Fund research on what four local areas in England shared about how to improve outcomes for people sleeping rough. The need for collaboration across health, housing and social care – and across the NHS, local government and the voluntary and community sector – was one of the key findings emerging from this work. We highlight some of the approaches local areas have used to make improvements. Further information can be found in the report.
Why use these prompts?
People who sleep rough experience some of the worst health outcomes in our society. The NHS long-term plan recognises the health inequalities that this group faces, and all local areas are expected to have a plan in place to improve support for people who sleep rough to access mental health services.The solutions to reducing poor health outcomes for people sleeping rough do not rest with the NHS alone. Local authorities, the voluntary and community sector and the NHS need to work together as a system to improve access to physical and mental health, care and housing support.
How can you get the most out these prompts?
Most areas will be able to recognise activity that they currently do under each of the prompts. But stopping there would be to miss the point of the exercise: these questions are an opportunity for you to reflect on what more you could do collectively and how you could make existing activity better and system-wide. Success depends on leaders taking shared ownership for ending rough sleeping. Please adapt and use these prompts in a way that works best for your local area.
- Part one: make it easier for people who sleep rough to access and engage with services
Examples of approaches that local areas valued
1. How do we use every contact a person has – and across all services – as an opportunity to establish a relationship with people experiencing rough sleeping and offer ongoing support?
Outreach staff (on the street and embedded in other services, such as housing workers in hospitals or mental health nurses in hostels) build strong relationships based on trust.
Champions actively advocate for people sleeping rough, for example a discharge team working with hospital ward staff to raise awareness.
Trauma-informed approaches – where care is delivered with an understanding of the impact of trauma, including that experienced in early life – were valued highly by staff although they are not yet mainstream.
2. How do we understand the paths that people take through our system, and identify any barriers, gaps or sticking points?
- Mapping of services (access and referral routes).
- Specialist mental health teams, working on the street and in hostels.
- Dedicated support for people with complex and co-occurring mental health needs and drug and alcohol dependency, such as dual diagnosis workers, formal protocols for referral, and joint clinics.
- Peer advocates or link workers commissioned to help people navigate the system and access support.
- Reciprocal arrangements and strong partnerships across geographical boundaries.
3. Do we all make the most of key opportunities to improve health outcomes?
- Primary care taking on a key role in the strategy to improve access to all (health and non-health) services. Examples include:
- a focus on increasing GP registrations, eg hostel key performance indicators included registration with a GP
- contract renewals used strategically to shape primary care provision for people sleeping rough
- GPs taking on a system leadership role (and built into the contract), with clinical leaders challenging system leaders – and also training other primary care staff
- housing, drug and alcohol, and mental health services embedded with GPs.
- Acute hospital visits (accident and emergency and/or admission) recognised as a key opportunity for connecting people to community health, mental health, social care and housing support as part of discharge planning. Examples include:
- specialist workers (from health, social worker and housing) embedded into acute hospitals
- weekly multidisciplinary meetings, including the voluntary and community sector, support discharge planning and connections with other services
- step-down provision gave staff the time to sort housing and benefits and care once someone is medically fit to be discharged.
Read section 4 in the full report for further examples and insight.
- Part two: how can we build and support the workforce to ‘do the right thing’
Examples of approaches that local areas valued
4. Is there a shared understanding of what ‘doing the right thing’ for a person sleeping rough looks like, with staff confident they have the permission to flex the system to achieve this?
- Senior leaders raise the profile of rough sleeping and set high expectations about service delivery.
- Staff use reasonable flexibility in the client’s best interests; recognising that there is no easy way to manage sometimes incompatible eligibility criteria.
- Opportunities for staff to develop a shared understanding about different professional approaches, and how to work effectively together.
5. How do we provide support for staff carrying out a demanding role?
- Staff wellbeing built into provider contracts, including psychological support.
- Training to raise awareness, eg training for GP reception staff, and specialised training for those working with people sleeping rough (mental health and mental capacity legislation and developing reflective practice).
6. How do we model collaborative, compassionate leadership and show staff that spending time building relationships with each other across the local system is valued and expected?
- Senior leaders model collaborative working and demonstrate the value of partnerships across the system.
- Leaders support staff to prioritise and attend regular multi-agency meetings to discuss how to best support specific individuals sleeping rough.
Read sections 5 and 6 in the full report for further examples and insight.
- Part three: fit the response to the local population and the local geography
Examples of approaches that local areas valued
7. Are our local insights on this population good enough to shape decision-making?
- People with lived experience of sleeping rough involved and heard – even small sample sizes had a powerful impact.
- A deep and regular commitment to understanding who is sleeping rough, and how the health and care needs of this group change, including a health needs assessment.
- Dedicated analysts to make full use of the data they collected.
- Commissioning decisions informed by insights from outreach/frontline staff.
- Learning from incidents (such as deaths on the street, drug overdose in hostels, detention under the Mental Health Act, multiple ambulance call outs, and hospital discharge to the street) to improve access and co-ordination of care across a system.
8. Do we spend enough time together understanding how services fit together – both at a local and regional level?
- Key staff who got to know their counterparts in neighbouring areas who they might need to negotiate with over eligibility or no local connection.
- Commissioners across sectors review and co-ordinate service specifications for retendering, and move towards alignment of commissioning cycles.
- Using broad area-wide strategies such as integration or prevention to focus attention on the needs of people sleeping rough.
9. What is our local narrative and how do we engage local politicians and the public over the long term?
- Leaders invest time in building relationships with elected politicians and the wider public.
- Leaders take responsibility for sharing a strong and relentless message that this group is part of the local community – and should not be left out or ignored.
10. Where does overall leadership and accountability sit within our system?
- Shared accountability for ending rough sleeping across health, social care and housing, and directors from health, social care, housing and public health included on overall governance boards.
- Clear expectations about the commitment to collective leadership that goes far beyond signing a strategy.
- Rough sleeping prioritised at a sustainability and transformation partnership/integrated care system level in plans to address health inequalities, and close engagement of local authorities.
- A lead person with the authority to drive improvements and hold other leaders to account for their contribution.
Read sections 7 and 8 in the full report for further examples and insight.
- Share your examples
What approaches have worked in your local area? Share your examples in the comments section below.
We have just competed a "pop up" GP clinic in a local hostel and day centre. We have provided a GP and a receptionist for a weekly clinic at the day centre over the winter months Dec, Jan and Feb. The clinic has been well received and we have seen people needing treatment for chest infections and quite a lot of dermatology. We also provided "pop up" flu vaccination clinics in October.
We have all gained from this and we have seen and registered people who would not have been given medical help otherwise.
The main barrier to us continuing to provide this service is cost. As a practice we could only afford 3 month's provision. We asked for reimbursement for the flu vaccinations from our commissioners but this request was rejected so we had to fund the staff costs and the cost of the vaccines ourselves.
If there were ways in which commissioners were able to fund pilots and then evaluate their effectiveness that would be great.
As it is - we will write up the through put of the "pop up" and approach our commissioners to consider funding for next year.
Gosport open doors project ran for 2 months. Totally unfunded. 4 church halls rotated put up 12 beds every night. A facility opened in morning so showers and clothes could be had.
Foodbank gave food which was cooked every evening. Dinner at 8pm.
GPs and volunteers ate with homeless. Real relationships, good conversations were had over dinner,. Trust was built. All got library cards- place of safety in day and access to internet. Help with filling in forms and communicating with "authority". Results- two were rehoused, 2 more starting detox. But all felt cared for for a short time. This was a truly moving and personally rewarding scheme to involved in. All it took was an idea, leadership and "will anyone help?"- 200 came to first meeting. This helped more than the homeless people.
We run a Community Market Garden, which sits alongside a hostel for homeless people, rough sleepers & vulnerable adults in rural Somerset/Mendip area. We're also registered with Health Connections Mendip as a Well-being Garden for Social Prescription & we're an approved work placement for a local Special Needs school for their 45 sixth form students with learning & sensory difficulties. The garden is also open to the local community, so we can work along side people who may be recently bereaved, socially isolated through lack of public transport & people who find themselves on the fringes of society. We're not receiving any funding from the government or NHS as a provider & constantly under pressure to generate our own cash sales & look for grant opportunities. I would welcome any help & advice on how we can navigate our way towards financial support for the essential care, support & teaching we offer to ensure the service we offer is sustainable going forwards. www.rootconnections.co.uk
Very good report. I would emphasise 'Commissioners should work together across the NHS and local authorities to deliver integrated services that truly address the complexity of need among the population who sleep rough. Dedicated resources and inter-agency commissioning helped to create a momentum for change. All four areas had successfully accessed additional central funding for this work. Flexible contracts enabled providers to adapt to changing need and facilitated bottom-up innovation by frontline staff.'
Yes, Money should follow the patient, All social interventions (such as gym membership, yogs classes) should be free at the point of use, under social prescribing, Teachers should be paid on receipt of the used prescription form, as pharmacists are paid for drugs.