Homelessness and the causes of homelessness are complex
The term encompasses people sleeping rough, single homeless individuals and families living in emergency and temporary supported accommodation, including asylum seekers and other vulnerable migrants; statutorily homeless households who are seeking housing assistance from local authorities; and ‘hidden homelessness’ (e.g. ‘sofa surfing’).
Individuals who face homelessness are more likely to have experienced childhood trauma, physical and mental ill health, substance misuse and experiences of the care system, institutional care and those who have served in the armed forces. People who are homeless face significant increased risk of serious abuse, exploitation and neglect as well as an escalation of their health and care needs and a reduction to their life expectancy. Long term homelessness is characterised by tri-morbidity (the combination of mental ill health, physical ill health, and drug or alcohol misuse). This can lead to premature ageing and frailty. The average age of death of a person who is rough sleeping is around 30 years earlier than the rest of the population.
Experiencing homelessness should not mean that someone is unable to access the healthcare they need or that we accept poorer health outcomes and growing health inequalities. Safeguarding Adult Reviews (SARs) undertaken in relation to deaths where homelessness was a factor highlight circumstances where agencies may have missed opportunities to protect adults at risk. Concerns raised include a lack of leadership and coordination between agencies, challenges in performing and interpreting mental capacity assessments, a lack of professional curiosity or normalisation of risk, a lack of suitable accommodation provision and poor hospital discharge arrangements.
Research1 highlights that 1 in 3 deaths among people discharged from hospital could have been prevented with more timely access to health and care services. There is a need to challenge poor practices such as discharging people back to the street or ‘signposting’ people to the local housing authority without an appointment.
Both these circumstances can lead to neglect through the failure to provide access to appropriate health, care and support. It is important that the decision to transfer someone from hospital is underpinned by a multidisciplinary team decision that the person is both ‘clinically optimised’ and ‘safe to transfer’ (i.e. that all necessary housing, care and support services are in place including step-down or interim accommodation).
Resource: Safe and effective discharge of homeless hospital patients checklist
The Homelessness Reduction Act 2017 significantly reformed England’s homelessness legislation by placing duties on local housing authorities to intervene at earlier stages to prevent homelessness in their areas, and to provide homelessness services to all those who are eligible.
Additionally, the Act introduced a duty on specified public authorities (including hospitals) to refer service users who they think may be homeless or threatened with homelessness to local authority homelessness/housing options teams.
Guidance on the duty as it applies to healthcare
The duty to refer will help to ensure that services are working together effectively to prevent homelessness by ensuring that peoples’ housing needs are considered when they come into contact with public authorities. It is also anticipated that it will encourage local housing authorities and other public authorities to build strong partnerships which enable them to work together to intervene earlier to prevent homelessness through increasingly integrated services.
NHS and other staff must seek the permission of the person before a referral is made to the local housing authority. Staff should use ‘concerned curiosity’ and be mindful of how they ask questions as adults who are homeless may feel stigmatised by their circumstances.
If you are concerned that someone who is homeless may be at risk of abuse or neglect, you can refer to the ‘Multiple Needs Safeguarding ToolKit’ and to your local safeguarding children and/or adults partnerships multi-agency safeguarding policies and procedures.
The following questions may be helpful in informing the decision to raise a safeguarding concern:
Mental capacity assessments can be particularly challenging where adults have background cognition and addiction issues and may require an expert to undertake them.
Guidance on undertaking mental capacity assessments.
Some people have additional support needs to acquire and sustain accommodation. The most common support need for households with children is those at risk of or those who have experienced domestic abuse3. A person, and those who are reasonably expected to live with them, whose accommodation is unreasonable to occupy because of violence or domestic abuse cannot be found intentionally homeless from that accommodation. A person who is homeless as a result of domestic abuse is automatically in priority need. Chapter 21 of the Homelessness Code of Guidance4 states that a person whose accommodation is unreasonable to occupy because of violence or domestic abuse cannot be found intentionally homeless from that accommodation.
Safeguarding and NRPF is a complex area. Individuals who are subject to immigration control have no entitlement to welfare benefits or public housing. This includes homelessness assistance.
However, access to other publicly funded provision may still be available, including adult social care. Some individuals with NRPF may be given assistance under the Care Act 2014 if their eligible needs are the result of disability, illness or a mental health condition, or if the local authority exercises its power to meet non-eligible needs. Put another way, their needs must not be the result solely of destitution.
Provision can include accommodation owing to the individual’s need for care and support if support is necessary to prevent a breach of their human rights, especially the right to live free of inhuman and degrading treatment (Article 3, European Convention on Human Rights).
Reducing health inequalities remains a key priority for the NHS. Many of our migrant population are among the most deprived members of our communities and face barriers to accessing healthcare alongside particular vulnerabilities to abuse, neglect and exploitation. Regardless of immigration status, everyone is entitled to register with a GP and do not need to provide proof of address of identity5.
Unaccompanied children face additional vulnerabilities and inequalities in addition to those experienced by children in care, there are a number of resources to support health and safeguarding at www.uaschealth.org.
We can improve health outcomes and safeguarding for all migrant populations by working together. The British Medical Association (BMA) have produced this helpful toolkit that can support planning and responding to migrant health issues.
References
1Transforming out-of-hospital care for people who are homeless. Support Tool & Briefing Notes: complementing the High Impact Change Model for transfers between hospital and home
PDF, 1200kb, 48 pages
3Statutory Homelessness Annual Report 2021-22, England
PDF, 5000kb, 47 pages