Homeless Health Network
Better health services for people experiencing homelessness
National Survey
Summary of Findings 2014
August 2014
Background
Improving healthcare for people experiencing homelessness
The Homeless Health Network is a network of over 700 community nurses and other
health professionals interested in better healthcare for people experiencing
homelessness.
The network is co-ordinated by The Queens Nursing Institute (QNI), and started in
2006 in response to the need for professionals to share evidence and work together
to improve practice, and as a means of mutual support. You can find out more and
sign up to the network for free on the QNI website.
Better data
Health professionals are a rich source of data on access to, provision of and
experience of healthcare for the most marginalised patients, including those
experiencing homelessness. Community nurses and homeless health specialists are
particularly well positioned to give valuable information, given the frequency and
nature of their interactions with their patients.
In May 2014, informed by nurses, the QNI produced a national survey to capture:
The reach of health professionals
The challenges faced by homeless patients accessing healthcare
Essential development and structural needs for the homeless health sector
This document summarises a full Report that will follow later this year. The QNI will
repeat the survey each year (currently the project is funded until 2017) to capture
and track changes in data over time and report on changes to inform policy
recommendations.
Content
This summary includes a brief breakdown of some of the key findings from analysis
with specific reference to:
Healthcare access issues
Improving hospital discharge for homeless patients
Where further learning could improve prevention, screening, treating and
managing conditions
Self-evaluating performance of health services across 5 criteria, as a means
of benchmarking
Intended Audience
This summary is intended to improve knowledge of key issues relating to healthcare
for patients experiencing homelessness and is intended for use by:
policy makers
nurses and other health / public health professionals
commissioners
housing organisations
national umbrella bodies
charities
media
Key findings
Survey reach
There were 184 respondents to the survey covering a wide diversity of job roles in
community nursing, general practice and public health across England, Wales and
Northern Ireland.
The sector
Structure of teams
79% of teams had fewer than 15 staff, with 31% reporting fewer than 5 staff in
their team.
48% had homeless healthcare as a dedicated role, for 52% it was part of their
wider role.
46% were multidisciplinary teams, 54% were not.
40% were non-medical prescribers, 60% were not.
Screening tools
In total, there were 67 different patient health assessments reported in use. Notably the
highest number of respondents used no assessment at all, or a self-designed assessment.
The importance of collecting specific health data for this group is critical and should become
a priority for NHS England, commissioners and frontline professionals, to improve the
evidence base and ensure services that best improve patient outcomes are commissioned.
The QNI Response
The QNI will:
Develop a health assessment tool with nurses suitable for comprehensive
health screening
Map current homeless health provision across England, Wales and Northern Ireland
The patients
Patients encountered
On average respondents encountered 128 patients every month. This figure may indicate
the high number of repeat appointments, part-time working in the sector, longer than
average appointment times, or the nature of drop-in clinics where attendance is not
guaranteed. If this figure translated evenly across the Homeless Health Network there would
be 1,021,500 patient contacts per year, 94% of which were classified as homeless.
Complexity of patients backgrounds and circumstances
166 respondents (90%) worked with drug and alcohol dependent patients
108 respondents (73%) worked with patients who had committed a criminal offence
97 respondents (66%) worked with Asylum Seekers and Refugees
90 respondents (61%) worked with patients who had engaged in Sex Work
89 respondents (60%) worked with people with learning disabilities
43 respondents (29%) worked with Gypsy and Traveller Communities
43 respondents (29%) worked with those trafficked for work or sexual exploitation
Current living conditions
34% of patients were staying in a B&B or Hostel
11% were rough sleeping
11% were sofa surfing
5% were staying in a Wet House
4% were staying in a Refuge
3% were in a Bail Hostel
2% were in squats, 2% were in a rehabilitation unit, 2% were in an immigration unit
1% were in prison, 1% were in a young offenders institute, 1% on a travellers site
12% were listed as other
Hearing the patients voice
18% of services had developed a service user group
2% of services had patients as volunteers, or employed a patient experience worker
The most common form of hearing the patients voice, was through feedback forms
(26%)
The QNI Response
The QNI will:
Share examples of good practice commissioning, proactive community healthcare
and services that have integrated patient involvement
Accessing healthcare
The Homeless Health Network reported the big challenges faced by people experiencing
homelessness when trying to access health care services. The biggest access barrier
reported was inaccessible services. This included:
Services located outside of city centres
Long waiting times for appointments
Telephone or online-only appointment booking systems
29% felt that lack of service was a top problem, including:
Not enough flexible or out of hours care
Over subscription to services so patients cannot get an appointment
No specialised services at all
25% felt that the patients own attitudes could prevent them from accessing services,
including:
Fear of professional organisations
How they might be treated
Negative past experiences
Not prioritising health over addictions
Being aggressive or non-compliant
Mental health issues that prevent patients from being in the right frame of mind to
access services or engage with services once they were there.
The QNI Response
The QNI will:
Share good practice examples that have developed holistic, long term care
partnerships with patients.
Share examples delivered in accessible community locations, directly in hostels,
on the streets or in deprived communities.
Share examples that have open rather than rigid access requirements.
Write targeted letters to MPs to raise these issues and call for action.
Share the work of other organisations, calling for improved healthcare access,
such as Pathway.
Work with St Mungos Broadway to survey local Health and Wellbeing Boards,
Directors of Public Health and Clinical Commissioning Groups about their
intentions for dealing with healthcare access for patients experiencing
homelessness.
Develop a yearly survey to track changes in these key issues.
Hospital discharge
Problems identified
Not enough appropriate accommodation
o People who need ongoing care being discharged back onto the streets
o Lack of respite care for people who still needed regular care
o People being housed in accommodation that was unfit for purpose
o No place to go back to leading to social isolation
Not enough communication between services
o Primary care/ housing staff not informed when a homeless person was being
discharged
o A lack of forward planning for discharge when a homeless person is first
admitted
Difficulty following up
o Did not attend appointments
o contact was lost due to unstable accommodation
o Difficulty accessing primary care for patients
o Difficulty with GP registrations
Other process issues
o Not enough training for hospital staff on discharging patients experiencing
homelessness
o A patient being discharged after one routine medical issue was resolved
without addressing other underlying mental health conditions or addictions.
This makes re-admittance to hospital more likely.
o Inappropriate discharge when patient still needed care
o Too much bureaucracy surrounding discharge
Negative attitudes of other patients or staff
Quotes
A patient can present at an A-E Department, experiencing suicidal ideas, triggered by
accommodation problems. They are admitted and that trigger is reduced, they are
discharged with no fixed arrangements in place and so the same problem arises.
Hotels, temporary accommodation, or staying with friends may not provide suitable bed or
private space to provide often complex health and social care need especially if patients are
palliative or end of life.
Solutions identified
Early discharge planning
o Including early identification of homeless status, contacting other service
providers and ensuring that patients have a discharge plan before they leave
hospital.
Pathway Programme a hospital discharge process
Integration between all health and housing services to ensure continuous care
Communication and sharing of information
o Including informing primary care services when a patient is going to be
discharged.
Dedicated respite care for patients needing on-going treatment
Training health sector staff to understand the needs of homeless people and the right
support services to contact.
Ensuring GP registration on discharge
Electronic record keeping
Palliative care tailored to the needs of people experiencing homelessness.
Taking a public health/prevention model by performing more health checks on
homeless patients when they are in-patients.
The QNI Response
The QNI will:
Publish What Nurses Say About Hospital Discharge for Patients Experiencing
Homelessness.
Share our learning and resources across all health professionals in the Homeless
Health Network, whether community or hospital based.
Improving conditions management
The QNI asked the network to report which health conditions they needed more knowledge
on to improve their delivery of public health, self-care, screening, prevention, aftercare
following treatment and widening access for patients experiencing homelessness, with the
following results:
Public Health and Self-Care
The top 5 conditions the network wanted to know more on were:
1. Substance Misuse (including alcohol withdrawal)
2. Mental Health
3. Alcohol-Related Dementia
4. Blood Borne Viruses
5. Nutrition
Screening and Prevention
The top 5 conditions the network wanted to know more on were:
1. Alcohol-Related Dementia
2. Substance Misuse (Inc. managing alcohol withdrawal)
3. Mental Health
4. Blood Borne Viruses
5. Tuberculosis
After Care Following Treatment
The top 5 conditions the network wanted to know more on were:
1. Alcohol-Related Dementia
2. End of Life Planning
3. Long Term Conditions (e.g. Diabetes, Hypertension)
4. Substance Misuse (Inc. managing alcohol withdrawal)
5. Blood Borne Viruses
Widening Access to Services
The top 5 conditions the network wanted to know more on were:
1. Cancers
2. Alcohol-Related Dementia
3. Immunisations
4. End of Life Planning
5. Blood Borne Viruses
The QNI Response
The QNI will:
Include conditions profiles in each issue of Homeless Health News
Theme learning events and guidance according to demand
Produce and share good practice public health documents
Performance evaluation
Self-assessment quality of service
Respondents were asked to score the quality of their homeless health service in terms of
removing barriers, assessing of patients general needs, treatment, aftercare, ability to deliver
public health messages and use of IT.
Breaking down barriers to accessing healthcare
Breaking down barriers
Score out of
10
Percentage who selected the score
10
28
8
22
9
18
7
13
6
7
5
7
4
2
1
2
2
0
28% of respondents scored their own services as 10/10. 22% scored 8/10 and 18% scored
9/10. This indicates that on average respondents felt this was a general strength of their
services as homeless health specialist services. It is a subjective measure and so more
evidence from patient satisfaction and reach of service needs to be acquired.
Screening patients general health needs
Screening homeless for their most common
health problems
Score out of
Percentage who selected the
10
score
10
9
8
7
6
5
2
3
4
1
23
21
16
12
7
6
6
4
3
2
23% of respondents scored their own services as 10/10 and over 70% scored a 7 or over.
21% scored 5 or under and so there is plenty more work to do to ensure nurses have the
time and resources to assess patients general health needs during appointments.
Delivering public health and self-care messages
Delivering public health and self-care
Score out of
Percentage who selected the
10
score
8
9
5
6
10
7
3
4
2
1
20
16
15
12
10
10
6
5
3
2
The most common score was 8/10, favoured by 20%. Only 10% of respondents scored a 10
in this area, and 31% scored a 5 or under. It is important that public health campaigns are
designed in a way that reaches vulnerable patients, to reach our aim of health equality.
Treating health conditions
Treatment
Score out of
10
9
10
8
6
7
5
4
1
2
3
Percentage who selected the
score
28
16
14
9
8
8
5
5
3
3
58% scored an 8 or over for their treatment quality, though over a third scored a 6 or under.
The complexity of working with multiple health conditions concurrently and resource issues
may account for this, though further evidence is needed.
Providing aftercare
Aftercare
Score out of
10
9
8
7
10
5
6
4
3
2
1
Percentage who selected the score
18
16
16
12
11
7
5
5
5
4
62% scored a 7 or over for care following a course of treatment. Over 1 in 10 scored 5 /10
and so there are clear improvements that can be made in some areas, particularly as noted
in effective discharge from hospital.
Embracing latest IT
Embracing the latest IT
Score out of
Percentage who selected the
10
score
1
7
6
5
3
8
4
2
10
9
18
13
12
12
11
9
8
7
5
5
The most frequent response for using IT effectively was 1/10 as selected by18% of
respondents. The least frequent responses were 9/10 and 10/10. This indicates that more
attention needs to be focused on the use of up-to-date effective IT to offer the best patient
experience for people experiencing homelessness.
The QNI response
The QNI will:
Publish information and hold practice sharing events as a means of raising quality
across the system.
Develop with nurses a Health Assessment Tool, suitable for general screening.
Continue to share innovations and invite applications from nurses for the QNIs Fund
for Innovation Programme to encourage better use of technology.
Feedback and get involved
These issues need tackling together.
To share your practice
Feedback on this summary
Add your evidence to the evidence base
Get in touch with our network
Ask about joint/partnership working
Or if you want me to speak about these issues at your event
Contact: David Parker-Radford, [Link]-radford@[Link] / 020 7549 1400
Acknowledgements
Kind thanks to the Homeless Health Network, with particular thanks to Pamela Campbell,
Tracey Campbell, Janet Keauffling MBE, and the Healthwatch England team, and for the
staff and Council at The QNI, with particular thanks to Joanna Boughtflower for data
analysis. Thank you for reading this report and please share with those in your network.
Kind thanks to our funders:
Terms explained
The Queens Nursing Institute - The Queens Nursing Institute is a registered
charity dedicated to improving the nursing care of people in the community.
Homeless Health Network The national collaborative network for homeless health,
providing health professionals with news, research, workshops, and e-learning tools.
Fund for Innovation Since 1990 The Queens Nursing Institute has supported
hundreds of nurse-led projects through the Fund for Innovation. These projects are
help community nurses to deliver improvements in patient care. Dissemination of
project results also helps nurses in other areas to implement new ideas.
Sofa surfing those who are without a permanent address and are staying
temporarily at different addresses e.g. with friends.
Refuge a place of temporary refuge and support for women escaping violent or
abusive situations, such as rape and domestic violence.
Bail hostel a place to allow convicted criminals to begin the process of
reintegration with society, while still providing monitoring and support.
Wet House A unit that allows the drinking of alcohol.
Sex Work The exchange of sexual services for money.
Hospital discharge When a patient who has been spent time in hospital, has
clearance from medical staff to leave hospital.
Pathway A charity with a focus on improving healthcare arrangements for people
experiencing homelessness.
Healthwatch England Healthwatch England is the latest reorganisation of
arrangements to involve patients and the public in the running of the NHS in England.
Health and Wellbeing Boards - Statutory bodies introduced in England under the
Health and Social Care Act 2012. Their aim is to improve integration between
practitioners in local health care, social care, public health and related public services
so that patients and other service-users experience more "joined up" care,
particularly in transitions between health care and social care. The boards are also
responsible for leading locally on reducing health inequalities.
Clinical commissioning groups (CCGs) - NHS organisations set up by the Health
and Social Care Act 2012 to organise the delivery of NHS services in England. CCGs
operate by commissioning (or buying) healthcare services including:
Elective hospital care, Rehabilitation care, Urgent and emergency care, Most
community health services, Mental health and learning disability services.