New 'duty to refer' homeless act emphasises role of nurses
Initiating change in the care of a homeless person is hard, but can be done
Initiating change in the care of a homeless person is hard, but can be done writes Samantha Dorney-Smith
The annual cost of unscheduled care for homeless patients is eight times that of the housed population (Department of Health 2010) and homeless patients are over-represented among frequent attenders at emergency departments (EDs).
Yet despite this expenditure, patients have a reduced quality of life caused by multi-morbidity and the average lifespan of homeless men is 47 (Crisis 2011).
More recently, researchers found that the standardised mortality rate among the homeless, prisoners, sex workers, and individuals with substance use disorders in high-income countries, was nearly eight times higher than the population average for men, and nearly 12 times for women (Aldridge et al 2018).
One reason for these poor outcomes is ‘tri-morbidity’, or the co-concurrence of physical healthcare, mental healthcare and addiction problems (Hewett et al 2012).
'The opportunity to intervene around homelessness can be missed'
Homeless Link (2014) reported that 80% of homeless people self-reported a mental health condition, although only 45% had been diagnosed with one, and 36% reported taking illicit drugs in the last month compared to 5% of the general population.
Homeless people are nine times more likely to commit suicide than the general population (Crisis 2011).
However, when homeless people attend healthcare services, their homelessness status is often not apparent to the healthcare provider.
Many types of homelessness, such as living in a homeless hostel, ‘sofa surfing’ with friends and family, or living in temporary accommodation are hidden because the person or family can give a current address.
This means that an opportunity to ask pertinent health screening questions is often missed, as well as the opportunity to intervene around homelessness.
In 2015, 22 hospitals across the UK and Ireland participated in an audit on the quality of care of homeless patients in EDs (RCEM 2015). While much of the care proved to be good, around half of homeless patients were not registered with a local GP and clinicians failed to signpost for GP registration in 83% of cases.
Additionally, a drug and alcohol history was documented in only 60% of cases and only 25% of patients were referred to specialist services where drug or alcohol use was the direct cause for presentation. Acute mental health problems were identified in 15% of patients, yet over a quarter of these patients were not referred to a psychiatric liaison team.
The good news is that changes are afoot.
The Homelessness Reduction Act came into force in April 2018, and conveys a new ‘duty to refer’ on many statutory authorities. These authorities will have a responsibility to refer patients experiencing homelessness for appropriate housing support from this month.
This applies to emergency departments and inpatient services, although many healthcare professionals providing care in these areas may be unaware of this new duty.
'You might want to think about whether your department is able to identify homelessness effectively'
Work is also being done to improve health assessment for people experiencing homelessness. The charity Pathway works to improve the healthcare delivered to all people experiencing homelessness.
As part of its work, the charity has recently worked with EMIS Health to produce a digital homeless health-screening template, which is now available to primary care services nationally, and is also being used by many hospital-based homelessness teams.
The vision is that one day the template will form part of a national homeless health data set which can be rolled out across healthcare.
The charity is also working with EMIS Health and NHS Digital to enable better data sharing so people’s stories don’t have to be repeated again and again – a common complaint from people experiencing homelessness.
What can you do?
In the meantime, you might want to think about whether your department is able to identify homelessness effectively, and if not, what could be done to achieve this.
The RCEM audit is a good place to start or you can join the Faculty of Homeless and Inclusion Health, run by Pathway, and find out about the template and data sharing project.
A small change can make the world of difference, and that change can be initiated by you.
- Aldridge R, Story A, Hwang S et al (2017) Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance misuse disorders in high-income countries: a systematic review and meta-analysis. The Lancet.
- Crisis (2011) Homelessness: A Silent Killer.
- Department of Health (2010) Healthcare for Single Homeless People. DH, London.
- Hewett N, Halligan A, Boyce T (2012) A general practitioner and nurse led approach to improving hospital care for homeless people. British Medical Journal.
- Homeless Link (2014) The Unhealthy State of Homelessness. Health Audit Results 2014.
- Royal College of Emergency Medicine (2015) Inclusion Health Clinical Audit 2015-16.
About the author
Samantha Dorney-Smith is nursing fellow at Pathway Homeless Charity, London.