connect THE MAGAZINE OF THE HOMELESSNESS SECTOR
Counting the cost of cuts
Navigating the new NHS
We map the impact as local councils announce their decisions on homelessness funding.
The health service is changing radically. We ask what “liberating the NHS” means for the sector?
Enough of our differences. Aren’t we all working towards the same thing?
6-7 ISSN 2046-2921
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CONNECT 2011, issue 42 | WWW.HOMELESS.ORG.UK
ConneCt 2011 | issue 42
CLIENT MichAeL WhippMAn INVOLVEMENT cLient inVoLVeMent AWArD 2011 AWARD 2011 The Michael Whippman Award celebrates the contributions of homeless people. It was set up to challenge stereotypes and show people who are homeless that anything is possible. this year the award is focused on finding the best example of an existing campaign or initiative that uses social media to: • raise the profile of homeless people • Broaden the public’s understanding and awareness of homelessness • involve and empower homeless people. We will accept any form of web-based social media from either an individual or group. each entry must however be either led by or involve homeless people. FIND OUT MORE visit: www.homeless.org.uk/mw2011 Call: 020 7840 4461 or email: email@example.com
www.homeless.org.uk/mw2011 sponsored by:
the deadline for entries is FRIDAy 27 MAy 2011.
creDits : suBscriptions : upcoMinG ABOUT
ConneCt magazine is a must-read for anyone working
to subscribe or take out additional subscriptions
with homeless people today. Written for and by
please email: firstname.lastname@example.org
homelessness professionals - ConneCt is a showcase of inspiring projects and best practice.
NExT IN CONNECT: LOCALISM as decision making and commissioning shifts from
EDITORIAL & DESIGN
central government to local communities, we look
Editor martin reed
at the likely impact on homelessness services. What
Editorial Panel Christine spooner, Jessica plant,
challenges does it present? Will it help or hinder what
lindsey horsfield, sarah gorton, helen mathie and
the sector has already achieved?
martin Webber Design new start design (www.newstartdesign.co.uk)
We’re keen to hear your thoughts on this and other
Cover Photo by robert davidson
issues. to contribute, please email: email@example.com.
No42 Spring11 V2.indd 2
CONNECT 2011 | ISSUE 42
Upfront The services you run help
16%. Services are laying off staff and relying more on
thousands of people to rebuild
volunteers. Some projects have already shut and more
their lives. They have taken
expect to do so.
years to develop, but not only does your work transform lives,
So what can we DO as a sector?
research shows that the money
Homeless Link is continuing to lobby central Government
invested pays for itself by
but we are also focussing more effort at a local level.
reducing demands placed on acute services.
Undoubtedly, difficult choices have to be made to tackle the budget deficit but we need to campaign to make
Our sector has been so successful that the UK approach
sure these decisions are made with intelligence and
to combating homelessness is now seen by colleagues
commitment to the most vulnerable.
across the globe as the model to follow. Where this isn’t happening, we need to make our case However, as our report ‘Counting the cost of cuts’ shows,
- lobbying decision makers and challenging decisions.
this message is not being heeded in every area as local
It is particularly important that they hear the voices and
budgets are set.
experiences of the people who rely on services. So please continue to feed back to us on your experiences locally.
While many councils are taking a protective approach to services (reducing their Supporting People budgets by
The people who depend on our work need us to sustain
less than the reduction they receive from government), 4
good services while finding efficiencies, forging new
in 10 plan to cut by more than they have lost.
partnerships that deliver where old ones may have fallen apart and to hone our skills as well informed and
Our survey of 500 homelessness services indicates that
persuasive advocates. It is no small challenge, but given
these cuts risk unravelling the gains of recent years.
what the sector has achieved over the years, it is one I feel confident we can rise to.
On average services expect funding to fall by 25% and we could see the number of bed spaces fall by
Jenny Edwards Chief Executive, Homeless Link
in this issue LATEST NEWS
COMMENT Counting the cost of cuts Navigating the new NHS Admit, treat, discharge – and then?
6 8 10
FEATURES Same world, new landscape Evidencing need, tackling health Street doctors Staying psychologically informed Under one roof Shelter from the Storm
12 14 16 18 20 24
Isn’t it a bit morbid, talking about death? A little bit of clinical Waking up to Capital TB Rehumanising services Enhanced recovery Support under threat Managing people
25 26 28 30 32 34 35
DEBATE Beyond polarisation
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ConneCt 2011 | issue 42
LAtest sector neWs HERE’S A SNAPSHOT OF WHATS BEEN GOING ON SINCE THE LAST ISSUE…
project director, petra salva,
under, but as of January 2012 it will be
said: “soon after we opened a
extended to cover those under 35.
couple of new rough sleepers were helped off the street. the
homeless link has raised the concern
team are already working
of members with government
on reconnecting them to
about the proposals. the plans
services in their home area.
could worsen existing problems
We have also taken a few
with the lack of available shared
accommodation, blocking up of hostel places and difficulty in moving
“it’s early days but on this first
people on from homelessness
NO SECOND NIGHT OUT
day it’s working exactly as it should!”
services. the changes could increase
the risk of tenancy breakdown and
Within hours of starting work on the
1st april, no second night out was
SHARED ROOM RATE
helping people to stay off the streets
homeless link along with Crisis aim
the government announced that
to raise these concerns during the
an extension to the housing benefit
passage of the Welfare reform Bill. in
each week about 40 people are
shared room rate for people aged 25
addition, the social security advisory
seen sleeping rough for the first time
to those under 35 will now take effect
Committee consulted on these
in london.no second night out is a
next from January 2012.
proposals in april 2011. We’ll keep you
six month pilot, running across nine
informed of future developments via
london boroughs, aimed at reaching
the housing benefit shared room rate
people when they first arrive on the
restricts the maximum housing benefit
claimants in the private rented sector
no second night out, working with
can receive to the rate for a single
HOMELESSNESS PREvENTION PAyS
room in a shared house.
youth homelessness charity
other homelessness agencies, offers
depaul uK has launched a key
people help so they do not need to
the shared room rate (srr) currently
piece of research that outlines the
return to the streets.
only applied to people aged 25 and
potential savings local authorities
HOMELESS LINk WELCOMES THE FOLLOWING NEW MEMBERS: Divine Rescue, Weaver vale Housing Trust Limited, Highland Homeless Trust, Maninplace, yMCA – Bedfordshire, Sol Housing Support, Fusion Accommodation and Support Service, Centre 33, Touch A Life, Rhythms Of Life International, The Haven Wolverhampton, Steven Platts, Peterborough Streets, The House of St Barnabas, David Curtis, Sarah Beth James, Diane Elizabeth Smith, Accommodation Concern, StopGap, Connect Centre, Central Eltham youth Project and Ace of Clubs
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spotlight Una Barry MBE, Deputy Chief Executive of Depaul Uk, gives an update from the National Advisory Council. the cuts have arrived in all shapes and sizes, with every local authority area seeing a different impact. some of us are already seeing a dramatic effect on services to homeless people, while in other areas cuts are yet to bite. the advisory Council has been working to feed information to homeless link on what is happening on the ground. this intelligence is could be making if they invested
STREET STORIES FROM ST MUNGO’S
helping to build a picture of the true
in homelessness prevention
the stories of homeless men and
impact of the cuts and is key to the
women have been recorded in a
continued campaign against the
new oral history project with support
the report, ‘Can We afford not to’,
from the heritage lottery fund.
claims that local authorities could
to ensure that the information
save over £9K per person if they
the forty-one autobiographical
you give your regional naC
funded effective homelessness
recordings can be heard on the
representative is as useful as
prevention programmes, such as
st mungo’s website – describing
possible, we agreed at the last
family mediation and parenting
childhood experiences, events
meeting to collect this information
leading to homelessness, survival
earlier in future. We need the views
on the streets of london and the
of homeless link members to shape
the research report says that
struggles of recovery.
naC discussions and the national
homelessness prevention schemes
agenda of homeless link. make
like family mediation are proven to
sure you let us know your views. SNAP 2011 PUBLISHED homeless link’s latest snap (survey
at the last naC meeting we
of needs and provision) study is
also discussed the single Work
available. While uncovering worrying
programme, the government’s new
trends, particularly around funding,
welfare to work scheme.
this annual survey of 500 day centres and accommodation projects also
members are keen to know what
finds many areas in which the sector
role homelessness agencies can
has made huge progress.
play within this scheme. the naC discussions highlighted how little
the full report can be downloaded
information is out there at present.
from the homeless link website.
although we know who may be
leading from the private sector, it is unclear how and indeed if we will
neW Chair for naC prevent homelessness, save money and improve the emotional and physical wellbeing of young people at risk of homelessness. www.depauluk.org
Jon Cox, of member organisation two saints has been elected Chair of the national advisory Council.
have a role to play. homeless link is looking at this policy in more depth and will let members know the findings. visit www.homeless.org.uk/nac to find your naC representative. WWW.homeless.org.uK
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countinG the cost of cuts An interim report from Homeless Link has revealed
Decisions being made by local authorities
‘unjustifiable’ spending cuts being planned by 41% of councils and reveals the impact that many members think reduced spending could have on homelessness services. Report author, Homeless Link’s Drew Lindon, explains the numbers. published in march, ‘Counting the cost of cuts’ aimed
45% reducing budgets by less than the amount lost from central Government
to highlight the extent of cuts being planned by many english councils to funding for housing related support.
41% of councils cutting budgets by more than the amount lost from central Government 14% making like for like cuts
launched at our annual parliamentary reception, an event intended to celebrate innovative services for the homeless, the report details the planned reductions by 84 local authorities to supporting people funding, as well as the impact that 500 homelessness charities think cuts will
made but what the report highlights is the extremely
varied approach being taken by councils. the amount by which local authorities are planning to reduce their
MIxED FUNDING PICTURE
supporting people budgets ranges from 1% - 45%.
in 2010, the government announced that all local council budgets would be cut from 2011/12, but urged
the councils that are protecting services for the most
local budget holders to protect services for the most
vulnerable should be praised but what should concern all
of us are the significant number of local authorities that seem to be making disproportionate cuts.
to help achieve this, the homelessness grant which goes to local authorities was not cut and supporting people
our monitoring of the cuts is ongoing but we aim to
funding was only reduced by 2.7% for 2011/12.
establish the funding situation in every local authority area. Where we do know about disproportionate cuts,
since october, my team have been tracking the
we need to work to change the minds of councillors and
decisions that are being made by the local authorities
commissioners, as well as work with services and clients
who control funds for housing related support and
to ensure appropriate support can still be available for
speaking to local services about what the plans are likely
to mean for them. the findings indicate that: IMPACT ON THE FRONT-LINE 41% of councils are cutting their budgets by more than
according to our survey of 500 homeless service
they have lost from central government;
providers, the planned cuts could result in support for the
14% are making like for like cuts; and
most vulnerable being severely hit in many areas.
45% are reducing their budgets by less than the
amount they have lost from central government.
homelessness organisations are facing an average funding cut of 25%, with the number of bed spaces in
in hard economic times, difficult decisions have to be
england predicted to fall by 16%. Charities fear that day
No42 Spring11 V2.indd 6
ConneCt 2011 | issue 42
centres, accommodation and support services may have
by the government in support, £8.38 of social return
to close and many believe they will have to lay off front-
was derived in reduced health care costs, reduced
welfare benefits expenditure and reduced costs of repeat homelessness.
these cuts come at a time when our latest data indicates
if we are to combat the cuts we need to get across the
that two thirds of accommodation services are running at
economic message that if you invest in homelessness
full capacity, with pressure likely to increase in the current
services today, communities will benefit both today and
climate. We also know that significant gaps in provision
already exist and that services are becoming increasingly WORkING TOGETHER
reliant on volunteers.
the full scale of funding cuts is yet to become clear. MAkING THE ECONOMIC CASE
however, what we all fear is the impact they will have on
in recent years, homelessness charities have made huge
progress in supporting vulnerable homeless people to gain skills and move back into employment and housing.
We need to do more to promote the successful action
there is evidence that this investment pays for itself by
charities and local authorities are taking to minimise this
reducing spending on problems such as substance
misuse, anti-social behaviour, crime and ill health. some local authorities are showing the way, working •
an independent evaluation carried out by Capgemini
hand-in-hand with the voluntary sector to identify and
in 2009 for the government estimated that the
try out new ways to prevent homelessness “upstream”.
national annual investment of £1.6 billion in housing-
others are jointly commissioning services with
related support generated net savings of £3.4 billion
neighbouring councils, extending the length of contracts
by avoiding more costly acute services (subsequently
and reducing administrative demands, so that resources
revised to £1.9 billion by the government in July 2010).
can be redirected to the frontline.
a 2008 report by the Cambridge Centre for housing and planning research concluded that the emmaus
Where this isn’t happening, we all need to work harder
Community saved the state £31,000 per annum for
to make the case, lobbying decision makers and finding
each homeless person moving into work.
champions and, where needed, challenging decisions.
a 2007 evaluation of fab pad, a project run by impact arts to support young homeless people to sustain
To download the report, including a list of local
new tenancies, claimed that for every £1 invested
authorities, visit www.homeless.org.uk/cuts2011.
loCal authorities Budget Cuts 2011-12
serviCes 2011-12 50%
0% accommodation services closures
reduction in floating support services staff
reduction in support services
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NAVIGATING THE NEW NHS Helen Mathie, Homeless Link policy manager, explains Government plans to shake up the NHS With the Government announcing another ‘listening
GPs will have a crucial role to ensure this doesn’t happen.
exercise’ to take into account public concerns over the
To fulfil their duties ‘to promote equality and to assess
Health and Social Care Bill currently in Parliament, what is
progress in reducing health inequalities’, each consortia
clear is that the most radical shake-ups of the NHS since
will have to identify and act on information about the
its foundation is provoking heated debate. And whatever
needs of vulnerable and multiply disadvantaged groups
your role – provider, commissioner, patient or carer – the
in their community. The homelessness sector is well
implications are likely to be significant.
placed to provide additional expertise to ensure the complex, and often costlier health needs of their clients,
Since the Coalition’s white paper, ‘Equity and Excellence,
are not sidelined against other priorities.
Liberating the NHS’, in July 2010, proposals outlining how the vision of the new NHS will be achieved have come
The world of Public Health is also undergoing key
in a steady stream. While the new language of patient
changes. As good public heath is strongly linked to
choice, consortia and Health and Wellbeing Boards is
wider determinants of health such as housing, this is an
becoming more familiar territory, agencies across the
important strategy with which our sector should engage.
homelessness sector are busy examining how these
New reforms will devolve more funding and responsibility
proposals will work in practice for homeless people and
to local authorities. Directors of Public Health working
the services which support them.
with the NHS and other local partners will lead this process at a local level. They will be able to draw on ring-
The changes to the NHS and wider health reform – which
fenced budgets to address public health priorities and a
run across primary and acute care, mental health,
‘premium’ for progress achieved against the proposed
and public health – come against a backdrop where
new outcomes framework.
homeless people persistently experience poor health and inequalities in access to health care. They also come
A new boost for mental health?
at a time where the local policy landscape is shifting at
In February, the government launched ‘No Health without
a great pace. Moves toward welfare reform and cuts to
Mental Health’, their new outcomes strategy which aims
local authority budgets are already having an impact on
to put mental health on a level playing field with physical
services for homeless people. Where do the many health
health. Although overdue, this has been greeted by many
changes fit into all this?
as a welcome change of direction. Along with investment in talking therapies, earlier intervention and measures
to tackle stigma, the strategy explicitly recognises that
Central to the NHS reform is the transfer of commissioning
improvements in services specifically for homeless people
responsibility for the majority of health services away from
with mental health needs are required.
Primary Care Trusts, which will cease to exist, to local GP consortia. While more locally driven commissioning has
It is heartening to see that continued pressure by the
potential to improve responsiveness to local patients, we
sector has helped to keep the mental health needs
know that homeless people traditionally fall beneath the
of homeless people high on the agenda. It remains to
radar in many routine health assessments, making them
be seen how local commissioning plays out though to
less visible to health services and commissioners.
ensure this translates into improvements on the ground, particularly in terms of better access to and integration
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of services at a local level. With many local services
effective joint action to identify and meet local health
undergoing re-organisation and facing competing
and wellbeing needs. A critical factor will be how our
priorities, there will be challenges ahead to make sure the
sector can engage with the process at a local level. This
needs of homeless people are not overlooked.
input will help Health and Wellbeing Boards understand the needs of their local communities, and to build the
effective relationships that are so critical to integrated
One of the routes to help this happen will be the local
local delivery. As these Boards are established Homeless
Joint Strategic Needs Assessment, which each area
Link will continue to work with the Department of Health
must do to assess the health and wellbeing needs of
and other partners to explore how the sector might make
its population. To date, these have not consistently
use of these opportunities.
captured the needs of homeless people and recognised the contribution that housing related support plays in
Across the new NHS reform there is strong support for
meeting the health and wellbeing of the population. We
patient choice. ‘No decision about me without me’
believe each Assessment must systematically review the
has become a new mantra in much of the debate. It is
needs of multiply disadvantaged groups in their local
hard to disagree with the idea of offering more choice.
population and include a clear set of commissioning
However, if it is to benefit everybody it must not exclude
recommendations about how these will be addressed.
those who don’t have a voice in their local community or the means to make their choices known.
In the new system, Local Authorities will have an enhanced role to co-ordinate the Assessment process.
Homeless people can offer a wealth of expertise and
This will be co-ordinated via the local ‘Health and
input. We hope the new Health Watch – the new local
Wellbeing Board’ under new structures intended to lead
body designed to draw together patient involvement and
on improving the strategic coordination of commissioning
replace the current Local Involvement Networks (LINks) -
across NHS, social care, and related children’s and public
will fully engage with the homelessness sector to provide
some of these opportunities.
Health and Wellbeing Boards provide an excellent
opportunity for improving the integration of services and
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ADMIT, TREAT, DISCHARGE – AND THEN? Sarah Gorton, from Homeless Link’s regional team, discusses whether admission to hospital could be used as an opportunity to link people who are homeless into services. The evidence is clear, Homeless people have a high rate
accommodation issues until the point of discharge and
of hospital admission. According to Government statistics,
that NHS staff cannot be expected to know about all the
homeless people can have up to four times as many
services available for homeless people.
admissions as the general population. These issues contribute to a scenario where homeless This trend is confirmed by Homeless Link’s own health
people are discharged to the local direct access hostel
audit work, which draws on the experiences of over
with no communication from the hospital, or to the
700 homeless people. We found that, in the six month
homeless persons unit or directly back to the streets.
period prior to being interviewed, 31% of respondents
None of those options are satisfactory. Hostels where
were admitted to hospital at least once. This is in stark
people can just turn up and expect to get a bed are
contrast with the general population where over a 12
very uncommon - Housing Options need to investigate a
month period it is estimated only 7% will have an inpatient
person’s homelessness before they can make a response.
Moreover, returning someone to the streets from a hospital bed is clearly detrimental to their health and is
There are a number of reasons behind these startling
most likely to result in rapid readmission.
statistics including: • poor access to primary care
These issues are not new. The Department of Health policy
• not seeking help until health conditions are acute
states that all acute hospitals should have admission
• complex health needs
and discharge policies that ensure homeless people
• poor conditions in which to recuperate, and
are identified on admission and linked into services on
• high rates of readmission.
discharge. In 2003, Homeless Link produced a template with the Department for Communities and Local
Making the most of admissions
Government, Department of Health and London Network
Are we missing a trick? In my view yes, admission to
of Nurses to provide guidance on what a protocol to
hospital should be used as an opportunity to link people
prevent homelessness on discharge from hospital would
who are homeless into services and to ensure as far as
look like . This was backed up by a series of fact sheets on
possible that the accommodation and support they are
relevant bits of the law and resources that can be used to
discharged to is an improvement on where they were
find homelessness services.
admitted from. Progress on the ground It is well known that hospitals are under pressure for beds,
Earlier this year, we set out to find out how many areas
that a stay in an acute hospital bed is hugely expensive,
had a protocol in place or were working towards
that people who are homeless may not disclose their
establishing one. We sent out a survey to every local
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CONNECT 2011 | ISSUE 42
authority in and Director of Public Health in England. The
accommodation issues on discharge. Other areas have
141 responses were encouraging:
created strong referral systems and robust links between
• 39% of areas have a protocol
the hospital and the local housing department. Some
• 26% are developing a protocol
areas have a protocol in place that doesn’t work in
• 25% recognised that they need a protocol.
Of those authorities that responded, 90% were engaged
To help, we have published a number of case studies on
in the issue on some level. Emphasis on prevention
our website that explore how different models can work.
has meant that local authorities have become more proactive and see discharge from hospital as part of
It is in the interests of all of us to address this issue,
a necessary homelessness prevention strategy. We
especially the current financial environment. Inpatient
have published examples of existing hospital discharge
costs for homeless people are eight times higher than for
protocols on our website so that other authorities can use
the comparison population (aged 16-64). Appropriate
these as examples.
discharge is likely to cut readmissions. If enquiries can be made while someone is still in hospital, it is better for the
Despite the activity on this issue, our health needs audit
Housing Options service and homeless agencies – who
found only a quarter (27%) of clients admitted to hospital
then don’t feel they are having people with care needs
had help with their housing before they were discharged.
dumped on them. But, above all it results in a better
This shows that there is a long way to go to improve the
outcome for homeless people who are not sent out onto
connections between hospitals and housing agencies.
There is no one size fits all model. It is dependant
If you are aware that hospital discharge of homeless
on the level of homelessness in the area and the
people is an issue in your area do look at the resources on
services available for homeless people. Some areas
our website or get in touch for some support.
have appointed specialist workers to link in with the wards and to take up the cases of people who have
What we need to avoid A male in his late 30’s arrived in the area in 2009.
and the worker did not feel he could commit to
He very quickly came to the attention of the
doing outreach to see if the man could be located
Police due to his behaviour and appearance. The
and assessed. He suggested that he could be
outreach team found it very difficult to engage in
contacted if the client went to the drop in centre
conversation with him and he was adamant he
and could try to assess him then.
would not stay in emergency accommodation. The client was eventually arrested following a Several reports were received that he was crossing
physical attack on a member of the public. Through
the road dangerously and had been lying in the
continued meetings with key agencies it was
road on a couple of occasions. Police were called
agreed that once the individual was released from
but since he was no longer in the road at those
the expected short prison sentence he would be
points they felt they were unable to take him into
sectioned to the psychiatric hospital if still required.
custody for his own safety. He was arrested on a number of occasions but did not see the mental
The client did spend some time in the psychiatric
health social worker as he was detained for very
hospital and was then unfortunately discharged
to the streets with no information given to local accommodation providers. Accommodation was
A homelessness mental health worker made
offered but was refused. The client left the area
appointments for the client, but he did not attend
shortly afterwards and has not returned to date.
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SAME WORLD, NEW LANDSCAPE Esther Sample, policy officer at Drugscope, examines
For homelessness services, one potential positive impact
the ongoing changes to public health service and
is that drug and alcohol services should work more closely
its implications for substance misuse treatment for
together and so homeless clients with substance misuse
problems could receive more coordinated support.
The new Health and Social Care Bill, and the public
We could also see an increased investment in alcohol
health white paper ‘Healthy lives, healthy people’, have
services generally. With more discretion over the
profound implications for the delivery of substance misuse
allocation budgets and a need to respond to local
treatment services in England.
priorities, Directors of Public Health will have an incentive to give greater priority to alcohol issues. Through our
Both pave the way for the absorption of the National
drug, alcohol and homelessness forum in London (run
Treatment Agency for Substance Misuse (NTA) into a new
in partnership with Homeless Link and Shelter), frontline
body called Public Health England. They will also lead to
homelessness workers often report difficulties in getting
the dismantling of existing commissioning structures and
clients into appropriate alcohol treatment .
the potential ending of ring-fenced funding for substance misuse treatment in the form of the Pooled Treatment
Another benefit could be that substance misuse services
are supported to provide broader ‘healthy living services’
It is not yet clear exactly what the new structures will look
Drug and Alcohol Network (LDAN) and DrugScope last
like or what will happen to the local Drug and Alcohol
year, suggested that drug and alcohol service users can
Action Teams, but homelessness services looking to
have difficulty accessing ‘health living’ services despite
engage with the treatment sector will soon have to
the fact that they often have nutritional problems and
grapple with a new landscape.
many are smokers .
The new structure
One LDAN member suggested that ‘drug and alcohol
Under the new proposals, drug and alcohol treatment
misusers may have limited knowledge, access or desire
will sit within and be funded by public health, under
regarding healthy eating and may suffer additional
the responsibility of Local Directors for Public Health,
health issues as a result of this. Training in healthy living -
employed jointly by Public Health England and the local
ie. cooking / nutrition and life skills - is essential’.
for homeless clients. Research undertaken by London
authority. Smoking cessation support was also highlighted as The Government has stated that £1 billion of the
lacking for drug and alcohol service users. An example
projected £4 billion annual public health budget will be
of an organisation working to combat this is Islington NHS
dedicated to drug and alcohol treatment.
Stop Smoking service, which has provided training to the
Directors of Public Health will also sit on local Health and
Islington in ‘Level 1 Stop Smoking’.
staff and service users of drug and alcohol agencies in Wellbeing Boards, which will have a key strategic role for public health, and will also bring together elected
The converse side to these benefits is that, with limited
officials, GP Consortia and Directors of Adult and
resources, there is a risk of disinvestment in substance
Children’s Services. Some services, particularly alcohol
misuse treatment in favour of other areas of Public Health
related, could also be commissioned by GP consortia.
such as obesity and smoking. Another risk of these reforms
No42 Spring11 V2.indd 12
CONNECT 2011 | ISSUE 42
is the potential lack of expertise on substance misuse
awareness among GPs. Another is the Substance Misuse
issues amongst commissioners.
Management in General Practice network, which supports health professionals who work with substance
In drug and alcohol treatment, Directors of Public Health
will take on responsibility for the provision of treatment, aspects of which are not traditionally the preserve of
Busy GP and A&E services are often unable to give
public health. Chief Executive of DrugScope, Martin
sufficient time to the complex health problems that drug
Barnes, suggests: “It will be important to ensure that
and alcohol service users can have. DrugScope members
provision is sufficiently funded and delivered in a manner
have highlighted the need for more appropriate referrals
that is consistent with the NHS principles, constitution and
from thorough and efficient assessments for drug and
NICE clinical standards”. Equally GP Consortia are unlikely
alcohol use and wider associated problems in both GP
to have specialist knowledge in this area.
and A&E services. As in the homelessness sector, provider opinion is varied as to whether it is better to have internal
Our research suggests that substance misuse services
nurse or GP practitioners within services, or for clients to
do not currently work very closely with GPs and broader
be referred out to access this support. However all agreed
health services, and that barriers exist. When interviewed,
that it is essential that these links are in place so that
one GP who had experience of working with drug and
people with drug and alcohol support needs can access
alcohol issues cited prejudice as one of the main barriers
broader health care support.
that prevents people with drug and alcohol problems accessing mainstream heath services. In her experience,
The Health and Social Care reforms which brings
staff make assumptions about clients with drug of alcohol
substance misuse treatment closer to alcohol, healthy
problems and ‘because the client feels they are being
living and broader healthcare services, could necessitate
treated badly, they may behave badly’.
the homelessness and drug sector developing new levels of awareness of the wider health needs of their clients,
She suggests that because of a lack of knowledge, staff
and a greater mutual understanding with the health and
in GP surgeries can feel intimidated and there is a need
social care sector as a whole.
for more training. An example of a service working to combat this issue in London is Health E1 for the homeless,
For DrugScope’s Briefing on Health Service Reform
who provide substance misuse training to try to improve
see: www.drugscope.org.uk WWW.HOMELESS.ORG.UK
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EVIDENCING NEED, TACKLING HEALTH Key to providing the right health services to a community, is understanding what needs the population has in the first place. Homeless Link’s Helen Mathie explains a new tool that can help to do this. We know that homeless people experience poor health
However, the process doesn’t end there. The audit is a
and have some of the worst health outcomes in our
way to encourage action and agencies have been keen
communities. However despite this, they are frequently
to implement practical changes. For example developing
excluded from routine health assessments, which in turn
Health Champions in hostels, improving staff training on
makes them less visible to health commissioners and
mental health or incorporating nutrition into key work
planning to name but a few.
In March 2009, Homeless Link started a project to address
Alongside practical change, we have used the data to
this gap. The Health Needs Audit, developed and piloted
inform strategy, to highlight to commissioners and Joint
with a range of national and local partners, provides
Strategic Needs Assessment leads the health needs that
a way to evidence the health needs of homeless
exist and how these can be effectively met.
people in a local area. It then supports commissioners, voluntary sector agencies and local authorities to use this
The audit tool is now available for wider use. As
information to make more informed decisions about the
responsibilities for assessing and delivering services
development of health services and related activity for
shift, the need for evidence will be even more crucial to
underpin commissioning structures and lobby for service development in the future.
Meeting the health needs of homeless people is the responsibility of agencies across sectors, at a local and
national level. The tool aims to capitalise on this and encourage joint approaches to conducting an audit and taking forward the findings. Most importantly, the audit tool captures information directly from service users – the needs, gaps and service outcomes reported come from the clients who use them, which provides a compelling picture to commissioners. Eleven areas have piloted the audit tool with over 1,000 clients. The analysis provides an updated picture of clients’ health: from their access to A&E to rates of GP registration; to the prevalence of mental and physical health needs to rates of screening. As one participant reported, local data is crucial as decisions become more locally driven: “It has helped to collect evidence and data about issues that before we could only make assumptions about based upon national evidence and data.”
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ROAD TESTING IN BIRMINGHAM A number of agencies took part in the Birmingham
for Homeless Link’s Health Audit we were keen to be
pilot of the Health Needs Audit from 2009-2010.
involved along with our partners.
Commenting, Aman Lal, from Birmingham City
“The data from the audit has been very useful as
evidence to give commissioners and to feed into the
“We received over 150 responses from people living
there was a gap between our perceptions ‘on
in short term supported housing and using day
the ground’ and the findings of national research
centre services during the pilot. Key findings from
studies. We now feel our views about unmet local
the health audit have enabled Birmingham to carry
need have got much more weight behind them.
local Joint Strategic Needs Assessment as previously
forward some strategic action points which included: • Consultation with providers to identify referral
“One of the main benefits came through involving
routes into health services across Birmingham for
some of our service users as health champions to
lead the development of homeless health packs
• Development of a service map of all health services • Development of a service map of all housing options for health representatives • Delivery of a health awareness day for staff and service users
and planning for their launch at a health day in November 2010. The health champions had very clear views about the design and content of the pack, as well as the best way to ensure attendance at the Health Day, and this led to a real learning experience for staff, volunteers and service users.
• Supporting the development and implementation of health modules for staff to
“Other local services such as St Anne’s Hostel,
deliver ‘in house’ training to service users part of
Salvation Army and Heart of Birmingham PCT’s
their move on and lifeskills programme
Health Xchange also got involved….and provided
• Supporting the development of health champions within organisations.
additional data to complement the findings from the health audit.
“The information collated will be used to inform
“Another benefit for us came through consolidating
future priorities and commissioning for services in
partnerships with the Council and the PCT in
particular, but also with the Homeless Mental Health and Drug and Alcohol Action Teams and Local
Sharing her experiences, Cath Gilliver, CEO of SIFA
Fireside said: “We want to build on this project by looking at the “We provide day services for homeless people
health needs of particular groups, for example
in Birmingham city centre and we have become
Eastern Europeans, and work is underway to
increasingly aware over the past few years of both
translate information into Polish and to provide
the poor health experienced by our service users
Polish-speaking volunteers at our ongoing health
and the barriers they face in accessing statutory
forums. Another need identified was training in First
health care, health and wellbeing facilities and
Aid for service users and a bid has gone in to fund
this. On a more strategic level we’re making sure we attend consultations and presentations on the new
“We already worked closely with Birmingham
NHS commissioning arrangements so that we can
City Council’s housing department and Heart of
highlight the health inequalities faced by homeless
Birmingham Primary Care Trust...and when we heard
that Birmingham was one of the pilot areas chosen
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STREET DOCTORS Dr Angela Jones took part in a three month pilot of a
range of services. These services go out of their way
‘street doctor’ role in London. Here she shares what
to be welcoming and accessible, and yet, there are
she learned from her experience, and stresses the
entrenched rough sleepers who will not attend.
need for this role in meeting the health needs of rough sleepers, particularly as the NHS is reshaped.
Outreach teams will know that this entrenched group are not only unwilling to engage with health services. It can
There is little doubt that rough sleepers, and in particular
be the work of months or even years to make progress on
entrenched rough sleepers, have poor health. Not only
any aspect of resettlement, be it on accepting benefits,
do they suffer from environmental stresses, such as heat,
accommodation or clothing. The likelihood of this kind
cold, pollution and exposure to danger, that impact on
of client attending buildings-based health provision can
their wellbeing, they also die significantly younger than
be virtually zero. For this reason, it is vital that every area
the general population.
with entrenched rough sleepers has access to a health professional, who is willing to visit entrenched rough
Add to this the fact that the pathway into rough sleeping
sleepers on the street.
may have begun or been exacerbated by a pre-existing physical or mental illness, and been complicated by
It seems logical, yet this idea is frequently met with
dependence on drugs or alcohol, and you have a potent
resistance. Specialist primary care services often
and complex mixture of health-related factors that may
give the reason that they have not been specifically
need addressing during the process of rehabilitating a
commissioned to provide outreach services. I would
person from the streets into accommodation.
argue that, in most cases, special commissioning arrangements are not necessary. It is normal for primary
Despite this, rough sleepers access health care less than
health care professionals to visit patients in their homes
other homeless people. When they do seek help, it is
if they are unable to attend the surgery. For a service
often from emergency departments in hospitals or walk in
specialising in the care of homeless people, it would be
centres rather than from primary care (GP) practices. The
logical to offer visits in the patient’s usual place of abode,
reasons for this, such as competing priorities of obtaining
be it a hostel, a tent or the street, subject to safe practice
food, money and shelter of some kind, are well-rehearsed
but sadly they are also related to the unwelcoming attitudes of some health staff towards rough sleepers. This
Street doctors at work
leads to an understandable reluctance on the part of the
So what would be the criteria for offering a street visit by
rough sleeper to attempt further contact. Unfortunately,
a health professional and what are the safety issues? Any
emergency departments and walk in centres do not have
entrenched rough sleeper would benefit from a ‘welfare’
the facilities or the staff competencies to undertake the
health check by a health professional on a reasonably
ongoing management of long term conditions that is
regular basis. Individual and environmental risk factors
needed by most rough sleepers. Access to primary care
would influence the frequency. For instance a frail elderly
rough sleeper with known physical or mental health issues might merit a more regular visit than a fitter individual.
Providing the right service
Both may need more frequent visiting during cold
In most conurbations in the UK, there is now some kind
weather or if their outreach worker notices something
of tailored healthcare provision for homeless people.
concerning about their health status.
Depending on funding and need, the models range from a dedicated nurse or doctor operating from a
Perhaps this all sounds rather labour intensive, but viewed
day centre right through to multidisciplinary teams
as a preventative action, it is not difficult to imagine
situated in purpose built premises and offering a full
how this kind of working would lead to ongoing health
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savings when more serious illness is avoided. It may even
with outreach, housing and social services around
help to shorten the period of entrenchment and reduce
associated social costs. The key is in the development of a trusting professional relationship between the health
Of course now that the landscape of the NHS is
professional and the outreach worker, and the ability of
changing, those tasked with tackling rough sleeping
the health service to respond flexibly and promptly to
should not need reminding that if they want to get better
concerns raised by outreach staff.
health services in the future, or even to preserve those they already have, they need to start influencing their
There is the question of who should perform this role?
local GP consortia as soon as possible.
Considering rough sleepers present such a wide range of comorbid physical and mental health needs, there is
In many areas, the movers and shakers in the GP
a clear need for either a generalist health professional
community are already identifying themselves and
with a wide range of competencies or access to a whole
gearing up to commission services. If the healthcare
team of professionals who can offer different components
needs of the homeless community, including entrenched
of the management. The NHS manages this by making
rough sleepers, are not identified and
access to healthcare via the GP, who can make an initial
highlighted to the GP consortia,
diagnostic assessment and then either treat or arrange
they will not be factored into
appropriate referral. Although GPs do not always display
the commissioning equation.
a helpful attitude towards homeless people, there is an
There is a real risk that
increasing cadre of specialist GPs working in or with the
services that already exist
specialist primary care teams who can take on this role or
could be downgraded or
support their nursing colleagues to do so.
lost. Equally, if you have previously experienced a
Commissioning the right care
block at commissioner
Every entrenched rough sleeper should have access to a
level, this could be your
‘street doctor’, responsible for monitoring and overseeing
chance to bypass it by
their physical and mental health as well as with liaising
going to the consortia.
Key tips for street doctoring Don’t go alone
Co-visiting with an experienced outreach worker is safer and offers vital background intelligence and mutual support.
Work from a
Being based in / attached to / associated with a buildings-based health service in the
area (usually) enhances your credibility, ensures you have local knowledge and enables
the client to come into services once confidence is gained.
Getting your client admitted to an acute medical or psychiatric trust is just the beginning.
If you do not follow up intensively and advocate for them on the ward, they may be back on the street in no time. In particular, ensure that you are informed if there is a mental health tribunal and have an opportunity to describe your reasons for undertaking compulsory admission.
You will be confronted with complex and distressing ethical and medical issues. It pays to ensure that you can get regular support and supervision to avoid burnout.
Take a folding
Once you gain your client’s confidence, you may need to spend long periods listening.
It’s easier to concentrate if you are sitting in relative comfort.
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STAYING PSYCHOLOGICALLY INFORMED Jessica Plant, Homeless Link’s Innovations Project
One effective model that can bring excellent results
Coordinator, examines what the Coalition’s new
for individuals is that of psychologically informed
mental health strategy, ‘No Health Without Mental
environments, a new concept from the Royal College of
Health’, might mean for our sector.
Psychiatrists Enabling Environments initiative. Evidence suggests its development offers an approach that can
The Coalition’s recognition of mental health services
support and assist complex client groups effectively. As
as fundamental to general health and wellbeing, and
well as encouraging GPs and other medical professionals
the focus on joint delivery and holistic care should be
to work hand in hand, it also offers a framework, an ethos
welcomed. However, the dismantling of Primary Care
and delivery model that is practical on the ground and
Trusts and planned changes to the way services are
can be developed within existing structures at a range of
commissioned and delivered, while funding is being cut,
is a lot for already stretched services to cope with. The key features of this approach according to a recent Unmet need
article by Robin Johnson and Rex Haigh focus on:
Homeless Link’s Health Needs Audit highlights mental health needs as a priority for all homelessness services
• the importance of relationships
with 72% of service users reporting mental distress as an
• responsibility - everyone, staff clients, volunteers take
issue. The role of the sector must be twofold: to continue to seek and strive for appropriate intervention from statutory mental health teams; and to ensure we provide environments that allow individuals to feel safe and nurtured, with a realistic prospect of recovery.
responsibility for the environment and their role in it • equality – everyone is valued equally and supported to contribute effectively; clients, all staff, volunteers • purposeful activity is encouraged and developed together • opportunities for creativity and initiative are acted on
Up to 60% of people accessing homelessness services
• transparent decision making
could be diagnosed with personality disorder according
• power and authority is held to account and open to
to recent research, compared with 10% of the general population. However, as our health audit shows, only 5% are actually diagnosed.
discussion • formal rules and expectations of behaviour are explained with support • behaviour, even when potentially disruptive, is seen as
So what can be done?
meaningful, as a communication to be understood.
Mental health professionals need be able to work more holistically with homeless people through diagnosis and
Potential culture change may be necessary to create
treatment. While we can try and influence this process
successful psychologically informed environments within
via the Joint Strategic Needs Assessment, we need to
existing services. Staff are asked to work more openly and
find practical ways to work with these complex needs
holistically and question their role and responses more
cases on a day to day basis. This can be challenging and
critically. This model links in with person centred planning,
requires a considered approach to practice.
personalisation and positive risk taking.
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Our recent work on evictions and abandonment found
We all need positive relationships in
that where models such as this are in place, increased
our lives to grow and be fulfilled. Our
participation was evident and few evictions and
role in a hostel should be to: foster
abandonments occurred. St Mungo’s has adopted this
positive relationship with clients;
approach in both the development of their Life Works
promote opportunities for positive social
programme, which provides psychotherapy sessions
engagement; and develop mechanisms
with excellent results, and more generally by adopting
to support clients to build and rebuild
a ‘reflective practice’ model to key work and service
important relationships with friends and
Developing such models requires commitment and
Provide learning and creative
participation opportunities in house - film and book
an understanding of complex behaviour, which can
groups, exercise, talks, volunteering
be daunting when staff are not trained professionally
opportunities and client involvement
within the mental health field. However, that doesn’t
in decision making. Ensure the
discount our responsibility and ability to develop effective
opportunities you provide encompass
‘enabling environments’ for clients through learning and
and promote wellbeing.
sharing effective practice. An operational paper about
Ensure you have excellent links with the
how to deliver such services will be available soon from
community so clients are included and
Homeless Link, along with a range of case studies
represented where they live.
A full analysis of psychologically informed environments is available from www.rjaconsultancy.org.uk. Good practice
Informal and formal relationships with
mental health services, both statutory
and within the voluntary sector, are key
to ensuring that appropriate and timely interventions can and do happen.
In developing a psychologically informed environment
Understanding diagnostic language
there are a few ideas and key areas for homelessness
and pathways will help you get clients
services to focus on in promoting improved mental health
the support they are entitled to.
PROMOTING WELLBEING IN PRACTICE Wellbeing Resource Pack
Homeless Link and City Bridge Trust
As part of our ongoing work to improve mental
Homeless Link has been working directly with a
health and wellbeing amongst homeless people,
number of services to improve mental health and
Homeless Link is developing a wellbeing resources
wellbeing for individuals living in hostels across
pack for clients.
London. This has involved working with a number of projects and looking practical interventions
The aim of the resources is to reduce stigma around
that have an impact on clients’ wellbeing and
accessing mental health support and to break down
mental health by implementing aspects of the PIEs
barriers around discussing wellbeing and mental
approach. Effective interventions have included:
health – a key factor in ensuring the appropriate
developing reflective practice models, building
support for homeless people.
partnerships with community mental health teams, increasing awareness and reducing stigma with
Traditionally, resources aren’t specifically targeted
clients and staff via awareness days, workshops,
at this client group, so we are developing these
newsletters and setting up meetings with relevant
resources based on ten top tips for wellbeing in pack
titled Looking after number 1 and developed in conjunction with clients and service providers.
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UNDER ONE ROOF From homeless health to holistic healthcare - 10 years of City Reach Health Services This year an innovative NHS healthcare service aimed
patients who found it difficult to access appropriate
at supporting the homeless, vulnerable and hard
healthcare. They realised it was essential to establish a
to reach groups is celebrating its 10th anniversary.
primary health care service for this local population and
Christine Spooner, Homeless Link’s Regional Manager
to enable them to access appropriate health care in a
for the East of England, explains how the service has
evolved and the impact it is having. City Reach Manager, Kevin Hanner explains: “Primary During the past decade City Reach has provided GP
care services are everything you might expect to
services and support to thousands of vulnerable people
receive from your GP - chronic disease management,
who may not normally access this type of healthcare,
immunisations, medical certificates and referrals to local
due to isolation, their sometimes chaotic lifestyle, aversion
secondary care services.”
to authority, or even a lack of awareness of the NHS care available to support them.
With no set base and only limited resources, the team was technically homeless itself back in 2001, but with a lot
Based in the city of Norwich, the service is led by Norfolk
of creativity it managed to provide regular primary care
Community Health and Care NHS Trust, and has an expert
clinics in a concoction of rooms within local day centres,
team of NHS staff made up of GPs, nurses and support
hostels, traveller sites and out on the streets.
workers. Its patients and clients include homeless people, former prisoners and sex workers, as well as refugees,
As well as services for homeless people, it developed the
asylum seekers, people from travelling communities and
care it provides to meet the needs of other communities
from migrant populations.
in need of primary healthcare, but who may also find it difficult to establish themselves within a single GP
The service sees around 40-50 new patients every month
practice, or mainstream healthcare, such as travelling
and to ensure these ‘hard to reach’ communities can get
communities, and refugees.
to the care they need, its staff work out on the streets, in refuges, hostels, and from a range of health and support
“As well as providing all aspects of primary health care
buildings. To mark its 10th year, I visited City Reach to find
that you can find in what are described as ‘mainstream
out how the service began and how it has found its home
services’,” says Kevin, “our team has specialist interest
in the heart of hard to reach communities.
and expertise in mental health, problematic substance misuse, blood-borne viruses, sexual health and dual
Hard to reach
diagnosis. We also act as a signposting service for our
City Reach Health Services was launched as a pilot
patients to be referred to more specialist care, such as
project in 2001, commissioned by the local NHS, and
appointments at general hospitals, social care services
staffed by a group of enthusiastic and committed health
and so on.”
workers from GP surgeries across Norwich. A new base The team was set up after a group of local GPs identified
After nine years of being a team always on the move,
that there was a growing number of ‘hard to reach’
City Reach Health Services finally picked up the keys to its
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Kevin Hanner, Operations Manager at City Reach
own base in early 2010, moving from cramped premises
neighbouring a GP practice to a purpose-built health
Kevin explains that to cope with this level of new referrals
centre in Westwick Street, right in the heart of Norwich.
the team also has to help its existing patients move on to mainstream services, when they are ready.
“Our new clinic is set up within a multi-service centre called Under-1-Roof. This centre, provided by St Martins
“We now have a support worker who is able to help
Housing Trust, serves as a one-stop centre for vulnerable
patients through this challenging time, while the patients
people who require housing support, medical care and
settle in at a new GP surgery. This is essential in reducing
support in finding work.”
the risk of people falling back out of the mainstream services they need and their health deteriorating.”
The new premises has enabled City Reach to offer more regular specialist clinics around substance misuse and
Kevin recognises that with the commissioning or ‘buying’
mental health, fast-track access to counselling and
of NHS services expected to be handed over to GPs from
regular TB screening clinics, alongside its daily GP and
2013, their relationship with local GPs will develop even
further. There may be challenges, but there will also be opportunities. They know they will have to be innovative.
The permanent base and the team’s close work with its patients, always asking what they need and want, has
“We are actively encouraging our patients to ensure their
also enabled people to have direct access to a wider
voice is fully heard and to become members, or even
range of health services, including first aid and healthy
governors, of our foundation trust, to help direct how our
lifestyle courses, dance classes, and relapse prevention
services develop in the future to better meet their needs.
groups. “One of our key pledges is to improve the lives of our “The Under-1-Roof project shows a huge commitment
patients, wherever and however they need us, and that
by the local NHS and St Martins to offer our patients a
we aim to deliver care equally to all. I’m pretty confident
recognised centre of support. But our outreach work is
that at City Reach we do everything we can to fulfil this
still essential to make sure we make contact with people
pledge every day, and that really makes us proud to do
who need our services – around 40-50 new referrals each
the work we do.”
month. And so we continue to provide daily sessions too at places like hostels, day centres, refuges, the Big Issue or
on the street.“
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LISTENING, NOT JUDGING... CITY REACH STORIES Darren, aged 36
Peter, aged 48
Peter battled with alcohol for many years, which
with the City Reach
resulted in him ‘living in a bubble’, drifting in a
service after being
circle of homelessness, prison and temporary
prison in July 2008. However, he was
Having been released from prison in October 2010,
known to the team
he found his way to the new service based at the
since 2003 and had
Under-1-Roof project. Arriving at a time of crisis, Peter
was homeless, drinking heavily and neglecting his
its services between
health. He came into the centre after being seen
on an outreach basis by the City Reach team and started to come in on a daily basis for showers,
He has a history of sporadic contact with health
clothing and housing support as well as health
services, including substance misuse services and
care. This holistic approach of having a range of
mental health services dating back many years.
services available in one building was essential in his
But after coming back to the service in 2008, Darren
accessing the support he needed, at a time that he
has maintained regular contact, has been linked
into substance misuse services, and has taken up tenancy of his own home.
“I couldn’t ask for anything better. I’ve found a doctor who will listen, not judge, and who takes
He has also registered at a mainstream local GP
the time to explain my symptoms and options,”
practice, and used its services since City Reach
Peter said. “I had previously experienced doctors
helped him to make the move in 2010.
looking to blame me rather than help. This left me disillusioned and resulted in me walking out.”
“I wasn’t bothered about accessing healthcare when I came out of prison as I had other priorities.
Since making contact with City Reach, Peter has
However, in hindsight I needed medical advice and
been supported in accessing accommodation
the outreach nurses found me.”
through St Martins Housing Trust and been linked in with mental health, counselling and substance
“The best thing about City Reach was the support
misuse services at Under-1-Roof. He is now in
worker. They supported me attending hospital
settled accommodation, is not using alcohol and is
appointments and gave me the confidence to
engaging well with a range of services.
access a normal surgery,” he said. Peter reports that the City Reach GP’s attitude, and
Having successfully settled into his own flat, Darren is
how easy he has found it to access services, has
now keen to use his experience to help others and is
been of paramount importance in his successful
exploring options through the local faith groups.
move away from alcohol abuse and homelessness.
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hoMeLess LinK AnnuAL conference 13 JULy 2011 | THE UNIvERSITy OF WARWICk
HOMELESSNESS IS A LOCAL ISSUE. IF WE ARE TO END HOMELESSNESS AND IMPROvE THE LIvES OF THE MOST vULNERABLE, WE NEED TO GAIN THE SUPPORT OF LOCAL COMMUNITIES, POLITICIANS AND SERvICES. this practical one day event, aims to help you understand the new ‘localism’ landscape, the threats and opportunities that exist and who you need to engage to achieve change. the conference will explore how you can continue to end homelessness locally, by looking at how to: •
prevent further destitution in the uK
reduce re-offending locally
improve the health of homeless people under the new structure
campaign locally to maintain support for your service
support individuals with no recourse to public funds
reduce unemployment locally for your clients
work together to address multiple exclusion
offer a personalised approach in your service
influence the local community to ensure support for your service
use sport to engage with the community and change perception of homeless people
end rough sleeping locally.
if you work with homeless people or are interested in ending homelessness, then this is the event for you.
For more information or to book your place: T: 020 7840 4461 E: firstname.lastname@example.org
u 02 av p d 0 ai i s C 78 la o 4 0 Bl u n ts 44 e 61
Join the homelessness community.
No42 Spring11 V2.indd 23
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Shelter from the Storm Identifying the needs of rough sleepers with alcohol problems St Petrocks and ARTEC recently conducted research to gain a better understanding of the link between dependent and hazardous drinking and rough sleeping in Exeter. We look at what they learned and how those findings can be used in practice. The Shelter from the Storm research project involved eleven in-depth interviews with street homeless heavy drinkers, with the aim of shedding light on this often hidden group. Respondents were invited to talk about their individual experiences at length. Local professionals who had regular contact with the subjects - including workers from St Petrock’s, the street homeless outreach team, and representatives from local alcohol and drug services - took part in a focus group,
• Significant alcohol problems had mainly pre-dated
which aimed to highlight the challenges, dilemmas and
the transition to homelessness. Another crisis, often
issues when working with this group.
involving a significant relationship breakdown triggered a decline into a pattern of rough sleeping
The research highlighted a number of emerging themes: • Level and type of alcohol use
and drinking. • Respondents described various levels of willingness
• Routes into alcohol use
or capacity to change. Most respondents described
• Routes to rough sleeping
their use of alcohol as a way of managing pain over
• The risks of living on the streets
long periods of time and a number linked the onset of
• Experiences of services
alcohol dependence to early family difficulties.
• Why people stay on the streets: motivation to change. • Some respondents expressed a feeling that they had What WAS learned
been on the streets so long they could not move into
A number of key findings emerged from both the
individual interviews and the professional focus group. • Those who did express a need for change were often • There is a comparatively small but persistent group of local alcohol using rough sleepers who maintain very
older and felt that they were going to have to change because of the deterioration in their health.
high levels of alcohol use, and who have long histories of homelessness and rough sleeping.
• Respondents described detailed and highly routine
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filled days from rising in the morning to settling down to sleep. • There was awareness throughout the day of where and how the next drink would be obtained, with choice that was invariably based on cost and strength. • Risks in relation to withdrawal - for instance hypothermia - were seen to be high, particularly in winter months. So too were threats, intimidation and
Isn’t it a bit morbid, talking about death?
possible violence, especially at night. Dying Matters is about to publish resources to assist • A definite theme that emerged from the focus group was the effectiveness of small positive steps
in talking to homeless people about what they would like to happen in the event of their death.
and approaches that chipped away at resistance to change or engagement. Short and less formal
Homeless people often die young. Whilst homeless
contacts often provided the springboard for
people may have few possessions and little contact with
real change in respondents’ lives. It was noted
family, they may have particular wishes around what
that St Petrock’s provided an ideal backdrop for
happens to them at the end of life. Support workers often
such contacts and interactions as this was an
need to trace next of kin, and want to give residents a
environment where the group felt comfortable,
good send off and uphold their wishes.
trusted and safe. Death seems to be our last taboo. Many of us struggle to • The flexibility and freedom to think creatively in
talk about it, and we often find it difficult to know how to
terms of offering support was seen as vital when
speak to someone who’s been bereaved. However, we
working with this group and recognised as key if
all have the right to make choices around what happens
meaningful change was to be achieved.
at the end of our life. But if we can’t talk about it, our choices are less likely to be upheld and those left behind
• Inter-agency working was seen as largely positive
can be left with regrets or unanswered questions.
and in particular the range of drop-ins provided at St Petrock’s allowed this group access to a range of
Dying Matters is a national coalition with just over 14,000
vital services that they may otherwise have been
members, which seeks to reduce the taboo around
death, dying and bereavement. They have produced materials to support people in having conversations
around this difficult area.
Since publication, Shelter from the Storm has already started to have an impact on how services are
Dying Matters are producing two free leaflets, specifically
tailored to this group. In particular the local council
relevant to homeless people. One is for homeless people,
have taken the key findings on board and are looking
outlining the choices available to them at the end of life.
at the possibility of small accommodation units. It is
The other is aimed at staff, to support them in initiating
envisaged that this would include an element of peer
and having conversations with residents about their
support in order to sustain the tenancies alongside
end of life wishes. Both have been produced as a result
more formal floating support.
of discussions with homeless people and support staff. Copies will be circulated with the July 2011 edition of
Crucially, the structure will encourage existing
supportive street friendships to continue into accommodation, effectively removing an identified
Join Dying Matters for free to access materials and
and considerable barrier to progress.
information. To find out more, contact Jo Black involvement Manager, Dying Matters: 020 7697 1520.
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A little bit of clinical The health needs of homeless communities are significant and complex, yet health providers often don’t have the structures to engage with them. Peter Cockersell, St Mungo’s Director of Health and Recovery, looks at how more creative solutions and partnerships are needed – and how when they’re in place they change lives dramatically. Among the people who use St
prescribing service and needle exchange at Endell Street,
Mungo’s services there are high
feeding into a semi-structured reduction programme.
levels of substance dependency, mental health and physical
Not only did the service surpasses all its clinical targets
health problems; there are high
in its first six months, successfully engaging, referring and
levels of chronic trauma; and there are high levels of self-
retaining ‘hard to engage’ drug users, but the needle
neglect, self-harm and attempted suicide.
exchange alone led to participants having a 28% increase in general engagement in other activities within
In our Intermediate Care service, 24% of residents tested
the hostel. This small amount of clinical care had a big
HIV positive, 34% had Hepatitis B, 84% had Hepatitis
impact across the board.
C, 83% were intravenous drug users, 74% were alcohol dependent, and 88% had mental health problems. Across
all our provision, 37% of our residents have mental health,
It is not acceptable for people to be discharged from
physical health and substance abuse issues.
hospital wards straight onto the streets or into hostels poorly suited to looking after someone with significant
So even before you look at the homelessness itself you
healthcare problems. Yet that practice is all too often the
can see that this is a community of people with complex
case. It hinders and prevents full recovery. In some cases
health needs. Research in one hostel in 2004 showed
it results in preventable deaths.
that residents had an average of 6 to 8 untreated health conditions, and almost all were intravenous drug users.
Our Intermediate Care Project launched at the Cedars
Yet in spite of their health issues (and often because of
Road Hostel in Clapham in 2009. With a full time nurse, a
them) this community does not easily engage with health
dedicated health support worker, and close ties to a GP,
services via the usual routes of GP referrals.
the project offers intermediate support for 10-15 people for six to twelve weeks following their discharge from
So if they won’t go to health services, we need to bring
health services to them. To describe them as ‘hard to engage’ is an oversimplification. They just need the
In 2008, there had been 7 deaths among this target
opportunity to be engaged more creatively.
group in our hostels. With the Intermediate Care Project
What we’ve demonstrated with a series of projects is that
ambulance use; a 52% reduction in A&E visits and a 77%
a relatively small amount of investment can really help to
reduction in hospital admissions.
in place there were none. There was a 67% reduction in
turn lives around, not by degrees, but dramatically. And again, people became more broadly engaged with Health Action Zone
other activities in the hostels. They found a point to life
In 2004, we introduced the first ever hostel-based onsite
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Lifeworks This psychotherapy service works across several hostels, two psychiatric wards, and three community-based mental health services, offering access to fully-qualified psychotherapists regardless of diagnosis. It is a fully inclusive offering – the only referral criterion is that a client wants to take part in the 25 weekly sessions. It is about how not whether to work with them. Possibly because of this accessible approach, there are particularly high levels of attendance. Of those who
who haven’t been particularly well-served by existing
came to the first session, 70% kept coming.
Based on SLAM’s (South London and Maudsley Mental
We are keen on the idea of Health and Wellbeing Boards,
Health Trust) evidence-based Mental Wellbeing Impact
provided those boards are formed with a makeup
Assessment Measure we saw a 75% positive change. Our
that can accurately reflect the needs of excluded
Outcomes Star data, showed that people who attended
communities. The Joint Strategic Needs Assessment
sessions were three times more likely to progress from not
is potentially useful too, but it must look at specific
wishing to change (a pre-contemplative phase) to being
communities of people as well as regional clusters of
motivated to make their own changes (an active phase).
Lifeworks has no employment goals, but by the end of 25
I believe that GP commissioning could work well,
sessions, 42% of people were in training or employment
because GPs generally have a better understanding of
whole-person health needs and their relationship with social needs. We’ve formed many successful partnerships
with GP practices over the years, and hope to do so with
Our Brent Dual Diagnosis service offers accommodation
the new GP Consortia.
to people discharged from psychiatric hospitals with mental health issues, such as bipolar disorder and
The key is in the implementation of these changes. How
schizophrenia, alongside substance addictions. A
they are planned, managed and delivered will decide
psychotherapist and a substance abuse specialist are
how effective the new structures are for tackling the
incorporated into the support team, providing 1-1’s
health needs of homeless people. Our concern now is
for the residents, and group reflective practice for the
that more and more attention is being focussed on the
staff. During the first three years there have been no
architecture and less on the treatment outcomes. We
rehospitalisations and 17 out of 18 people moved on
badly need to see health inequalities and inclusive health
successfully to lower support projects.
take more centre stage so that the NHS can deliver on its founding pledge to provide Universal Healthcare.
New challenges We have achieved a great deal with these projects, but
We are in the business of promoting change and
we are going through a period of considerable change
providing opportunities for change, so that homeless and
at the moment - changes to funding as well as changes
vulnerable people can move closer to achieving their
to the way health provision is offered. Cuts to Supporting
aspirations. There is a woman who, prior to using Lifeworks,
People funding are being mirrored by cuts to health
had been in and out of psychiatric institutions for 22
services in general, and together risk the capacity to
years. In all that time she had had resettlement support
provide the necessary levels of treatment and support.
packages, but had never before been offered talking
We need to keep quoting our success stories to make sure
therapies. Now she is living independently. How’s that for
the balance of health and keyworker expertise continues
change? After 22 years, a few months of psychotherapy,
to be recognised. That close work is essential.
just that little bit of clinical added to the resettlement support, has quite literally transformed her life.
As for the proposed NHS changes – actually, we hope that they could have some benefit for homeless people,
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Waking up to Capital TB London is “the TB capital of Europe”, The Daily Telegraph reported as recently as December 2010. Britain is now the only nation in Western Europe with rising levels of tuberculosis, with more than 9,000 cases diagnosed annually. Alistair Story, Clinical Lead at Find and Treat, gives an overview of tuberculosis in this country and describes the challenges for his organisation and the Mobile X-ray Unit in tackling tuberculosis among hard to reach groups. By the 1980s tuberculosis was considered to be almost
Find and Treat
eradicated in the UK. However, this has changed with
Established in 2007 on the back of 2 years NHS funding of
increases in travel and migration. Poor living conditions
the Mobile X-Ray Unit, Find and Treat has recently secured
experienced by certain population groups have led to a
another year of funding until 2012 – this after a period of
gradual re-emergence of tuberculosis as a public health
uncertainty. We screen between 8,000 and 10,000 people
problem in Europe. London now accounts for almost 40%
a year, mainly homeless people and those with drug
of all tuberculosis cases in the UK.
and alcohol problems. The service doesn’t have a huge capacity, so the focus is on larger congregations of the
Tuberculosis is a curable disease, as long as a prolonged
target groups, with visits to hostels, day centres, drop-ins
course of antibiotics is followed. However, as with any
and drug and alcohol projects across London.
antibiotic treatment, failure to complete a full course can lead to the development of antibiotic resistant strains of
Getting screened takes just 2 minutes. It is confidential,
bacteria. The drug-resistant form is developing among
safe, there is no need to undress and the clients get the
results immediately. On an average day we will screen around 60 people.
TB and homelessness Cases of tuberculosis amongst homeless people is on the
The attitude to the van depends on whether health is on
rise – both diagnosed and undiagnosed.
the agenda of the hostel. Some see the van as disruptive, but the more progressive hostels see it as an opportunity
There are many factors: diagnosis is often delayed by
to down tools and focus on health matters.
a reluctance to access health care; poor nutrition and weakened immunity increases the risk of initial infection;
Active case finding is critical
high alcohol intake has a direct effect on immunity;
We work with more than 223 partners – probation,
hard drug use, especially smoking crack cocaine, can
police, tuberculosis clinics, CHAIN, prison services,
mask tuberculosis symptoms; taking ongoing treatment
agencies – to find individuals and plug them into
for at least six months is often very difficult for people
services. Of 225 people who have been lost prior to
living chaotic lives; and a prevalence of drug resistant
treatment completion, we have re-engaged with 75% of
tuberculosis among homeless people, which is much
them. We often feel overwhelmed by the clinical case
harder to treat and infectious for longer.
management and social care required for the lengthy treatment.
View these factors together, and you can easily see the need for a dedicated effort to target this growing
It can be difficult to get people on board (literally).
That’s where the peers come in – people with personal
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experience of tuberculosis and homelessness, or of alcohol or drug dependency. They’re people who have been through the full course of treatment, so they are in a unique position to convey the importance of screening, diagnosis and treatment to people in similar situations. Since 2007, we have recruited 7 former tuberculosis patients as peer educators. The peers are far better at raising awareness and encouraging higher turnout than any alternative effort. If an X-ray reveals something is going on, it is critical that we don’t lose the individual and that he or she is supported through the diagnosis. A peer goes to the hospital and accompanies the individual to see the
Find and Treat’s Mobile X-ray Unit
nurse, effectively reducing the likelihood of the person going missing. Acting as the patient’s ‘buddy’ they help ensure that person sticks with the process.
approach. The typical clinical model doesn’t work with highly vulnerable people as many have negative
Treatment – the challenge continues
experiences of accessing hospital services. Other
The key to reducing levels of tuberculosis is early diagnosis
countries have been more proactive in implementing
and appropriate treatment. Isoniazid is the main first line
directly observed therapy.
drug in the treatment of tuberculosis. In fact no new drug has been found for 45 years. It is very effective, but, if
Critically, partners need to be able to support
the treatment is not completed, the disease may come
tuberculosis patients in the hostels. Hostels used to have
back in a drug resistant form. Treatment lasts at least 6
medical units where people with low level health issues
months and can last up to 18 months, which would be
could recover. But some time ago, we hit the wilderness
demanding ask for anyone. It is a particular challenge
years when hostel workers were suddenly not sure about
for individuals with chaotic lifestyles. Figures show that in
the legalities of holding or providing medication on site.
2009, nearly 7% of new tuberculosis cases were resistant to
Now hostels are putting health care on the agenda
again as a condition for meaningful occupation
National tuberculosis treatment guidelines strongly
treatment in hospital or treatment on the street, we try to
recommend using a patient-centered case management
get patients admitted into hospital to give them time to
approach, including directly observed therapy, when
sort out accommodation and a plan of care. But many
treating people with active tuberculosis disease. This
self discharge and there is an absence of intermediary
involves a trained health care worker or other designated
accommodation following initial treatment, and those
individual providing the prescribed tuberculosis drugs
who stay are often kept in a side room in hospital for 5 or 6
and watching the patient swallow every dose.
months which is very expensive – the equivalent of 2 years
and independent living. If the alternative is between
in bed and breakfast accommodation. The real triumph is the coordinated care within the community. We engage with hostels, pharmacists, street
outreach and other specialist advice workers, such as
We are really keen to build on the services we provide.
human rights lawyers, particularly in the case of people
We have demonstrated that we can reach large numbers
with no recourse to public funds who can be treated,
of clients effectively. We have a great opportunity to find
but not accommodated. The prerequisite is that patients
active tuberculosis, but perhaps we could be extending
have somewhere reasonable for recovery to take
our diagnostic capability to finding other long term
place, food and somewhere to attend clinical follow up
conditions such as HIV and diabetes. We need a real
investment in technology if we are to achieve our dream of becoming a one stop screening service.
Why the TB capital of Europe? As a country we have been late in devising an effective
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Rehumanising care Paul Connery of Homeless Link looks at how the efforts of Liverpool Royal Hospital to work with homeless people have been completely transformed during the past few years – from ill equipped to award winning. The goal of meeting the needs of homeless people when
“The hospital trust is really on board and will be flexible to
accessing hospital services has proved elusive in many
ensure that everybody has a safe discharge,” says Carol.
areas across England. Only a few years ago Liverpool
“There are link workers on each ward who are crucial to
Royal Hospital was typical of many - ill equipped to
early referrals and now hospital staff know who to call if
respond to the complex and multiple needs of homeless
necessary and ask the right questions and look for the
people, many of whom would prefer to travel to hospitals
outside the city to avoid it. Ian believes that the close location of the key agencies in Yet in 2010 the specialist nursing team based at the Royal
the city centre helps to ensure continuity of care needed
won the prestigious National Nursing Times Award for
so that if a homeless person presents at A&E Carol can
their work around homelessness, substance misuse and
refer them to the Brownlow Health, which is based not far
safeguarding. The judges said that the service provided
from the Royal, or to one of two nearby voluntary sector
“an integrated response to achieve better outcomes.
day centres - the Whitechapel Centre or the Basement
They have rehumanised these patient groups.”
Drop In. To enhance this service further, the Basement Drop In employs Joan, a hospital outreach worker in the
Ian Harrison is the lead homelessness nurse based at
Brownlow Health, an inner city centre GP practice that runs the local enhanced service for homeless patients.
As Ian says, “Joan is amazing. Apart from her expertise on
Carol Holt is the emergency nurse practitioner with a
non health related issues she has the time, which hospital
specialism in homelessness, based in A&E at the Royal.
staff don’t have, to spend with the patients.”
They both agree that a number of key factors have helped bring about this remarkable transformation
Carol agrees: “She is invaluable and can navigate her
ensuring that homeless people have continuity of care
way through a system which most hospital staff aren’t
when accessing health services in the city.
aware of. “
The Royal, alongside the local authority, developed
The city’s complex needs panel brings together decision
an admission and discharge protocol which ensures
makers from the key agencies in health, mental health,
that a person’s housing status is asked on admission to
housing, the voluntary sector, police and social workers.
hospital. “This protocol raised awareness of issues around
They bind all this work together to ensure that positive
homelessness within the hospital and was instrumental in
solutions are found for individuals who will be on
bringing hospital and housing staff together,” says Carol.
In support of this, training is provided to staff within the hospital, in addition to which homelessness training is
The health service provided to homeless people in
now on the syllabus for both student nurses and medical
Liverpool has been further enhanced by the PCT funding
students to ensure that they are fully aware of issues that
a treatment room in the Basement Drop In which
may arise when working with homeless people.
ensures that people can access health services in an
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From left to right: Ian Harrison (Homelessness Nurse Co-ordinator), Carol Holt (Emergency Nurse Practioner / Homelessness Nurse) and Carol Hamlett (Coordinator Basement Drop In)
environment and at a time they are comfortable with.
It is obvious from meeting the key individuals involved that one common characteristic they all possess
The service has started to specialise in support which
is a passion and commitment to working with and
caters for the needs of homeless people, specifically
addressing the issues of homeless people. Parts of this
the funding of a GP consortium pilot for vascular and
work could be replicated elsewhere but without this drive
leg ulcer issues, which are associated with intravenous
it would be unlikely to succeed.
drug use. “This has enabled people to receive treatment regularly and before their condition worsens. Redirecting
Another key gauge to the success of this work in
from accessing A&E and will reduce costs in the long
Liverpool is the fact that people who are homeless
term for the health service,” says Ian.
no longer travel to other hospitals but are now happy
With GP commissioning set to dominate the health
continuity and communication across health and
sector, this kind of collaborative working could provide
other sectors, they will receive an effective and non
opportunities for the homelessness sector to engage in
judgemental service. As Ian says: “Now they feel safe
delivering health services in the future.
to access the Royal. They know that, because of the
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Enhanced recovery Sarah Ward is Homelessness and Substance Misuse
At St Pauls, we are able to offer, what can be described
Manager at BCHA in Bournemouth. She describes how
as a health A&E service. St Pauls offers accommodation
BCHA’s supportive, nurturing, yet practical assistance
for up to 40 individuals or couples and also provides a
for clients achieves such positive outcomes for the
direct access day centre. The Day Centre offers an array
people they work with.
of services, from a daily GP practice, to Blood Bourne Virus nurse, podiatry, dentistry, needle exchange, and
It is a sad but well known statistic that being homeless
Community Psychiatric Nurse. The health advice and
means average life expectancy might be as low as
support is often the door which opens up a range of other
45. The combination of poor diet, damp, cold, and
options for our clients.
unhygienic conditions, the effects of substance misuse, and the impact of all of these things on what may already be fragile mental health, surely means that for those people who find themselves homeless, easy access to health services is crucial.
Williams story When William arrived at St Pauls he had been
At BCHA, we have been providing services for people
sleeping rough following family breakdown
who are homeless for 42 years and have for a long time
some years previously.
put health interventions at the centre of our service delivery. In doing this, we have also found that offering
William was encouraged to visit the GP as
health services is often a way of enabling us to engage
he stated he had been suffering from terrible
with clients who may otherwise not access services at all.
nightmares and other symptoms of mental
This type of delivery can be seen at its most powerful at
two of our Bournemouth services: St Pauls Direct Access Service and Hannah House, our alcohol intervention
On speaking with the GP he was referred to a
psychologist who diagnosed ‘post-traumatic stress’. This had developed as a result of William being in a hotel fire years previously which resulted in him jumping from a window and in which many other people had died. With the right psychological support William was able to put his life back together. He moved into his own flat and was able to re-build links with his family, including his daughter. The turning point in all of this was, William says, the moment he walked into the GP surgery at St Pauls.
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Megan’s story When Megan came to Hannah House she was long term street homeless, had suffered periods of domestic abuse, and had a history of heroin addiction and alcohol dependency. As a result of all of these issues she also had chronic health needs including conditions which affected her cognition. Staff worked with Megan to register with a GP and supported her to keep appointments. A lot of work was carried out with Megan around healthy eating as she was also suffering from an enlarged liver and suffered from episodes of pancreatitis. Megan was encouraged to change from drinking sherry to larger. She also agreed, with support to have her teeth removed in hospital, as they were totally At Hannah House, we accommodate and support
decayed due to substance misuse. She also
up to 13 men and women who have ongoing alcohol
experienced severe discomfort with her feet.
dependency issues. This type of addiction, combined with a history of rough sleeping nearly always results
When she was ready to consider treatment for
in chronic health issues. The clients we support at
her substance misuse issues, staff were able to
Hannah House are helped in a way which provides
work with agencies to ensure that pre-treatment
an atmosphere of safety and dignity where they can
meetings were held at Hannah House.
continue to drink, but work towards reducing their use. Often the first stage of engaging in this process will be
Megan eventually left the service to go into
through addressing health issues, sometimes long before
treatment. She now lives drug and alcohol free
the clients are ready to start addressing their alcohol
with her family.
use. Chronic health conditions caused by alcohol can often lead to a spiralling of use as a way of managing the effects and pain caused. This in turn causes overall health conditions to deteriorate further. By addressing health as
William and Megan’s stories illustrate how important it
a priority we have often seen clients who are then able to
is for clients experiencing homelessness and substance
start making changes to their alcohol use.
misuse issues to be able to address their health needs as an absolute priority and in the most convenient,
Within Hannah House this is done in the context of a
accessible and supported way possible.
nurturing, supportive environment, which comes from the staff, volunteers and most importantly between
When this is achieved within an environment where
peers. There are opportunities to grow produce in the
people retain dignity and human warmth, the outcomes
allotment on site as well as collect fresh eggs from the
can be truly life enhancing and life changing.
‘rescue’ battery hens living in the garden and cared for by the clients. All of these elements go towards improving
BCHA help people find a way forward and start
the mental and physical wellbeing of people living and
accessing the right housing, health, learning and work
working at Hannah.
opportunities, visit www.bcha.org.uk. WWW.HOMELESS.ORG.UK
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Support under threat In 2009/2010 Places of Change investment enabled Two Saints day centre in Southampton to incorporate proper facilities for GPs and nurses. This year, because of funding cuts, the future of the service is in question. Sophie Sharman and Natalie Wagstaff look at the ways in which Two Saints and the Homeless Healthcare team offer a truly supportive service for clients. The Two Saints day centre in Southampton opened in 1962, providing homeless people with a range of services. Staff from the day centre saw the significant effects of a lack of mental and physical healthcare and began lobbying for specific healthcare provision for the people
professionals at points of crisis, for instance when being
in their care. This resulted in the development of the
sectioned or during accident and emergency visits.
Homeless Healthcare Team in 1992. In 2009/2010 Places
Without the proactive efforts at the day centre and with
of Change investment enabled the development of a
this level of engagement from the Homeless Healthcare
proper facility where GPs and nurses run surgeries.
Team, the mental and physical health needs of these people would go unnoticed.
Due to the considerable number of extremely vulnerable people with untreated mental or physical health needs
The way in which Two Saints and the Homeless Healthcare
who have been homeless or living in poor quality housing,
Team work together allows for a longer term approach
there was a real need to bring healthcare directly to
that can truly focus on individual and their needs.
them. The day centre allowed people to seek medical
Without the day centre and their services, the Homeless
advice in a comfortable environment. The Centre
Healthcare Team believe they would have to spend a
provides various services, which include giving homeless
lot more time advocating for people and not focusing
people somewhere to have a shower, clean their clothes,
specifically on health.
have a meal and explore housing options. They also offer help and advice on benefits and other issues, including
Due to the many services it provides, The day centre is
access to training and employment.
extremely valuable to the local community. Now facing funding uncertainty as a result of local government
Whilst homeless people are at the day centre, members
cuts, there is a risk the facilities and support on offer will
of staff are able to informally assess their behaviour and
be significantly affected. Funding for the work of the
general wellbeing and raise concerns with the Homeless
Homeless Healthcare Team is secure, and Two Saints is
Healthcare Team staff. They also encourage people to
working hard with all its partners to secure the future of
engage with the Healthcare team which can, over time,
the day centre with these healthcare facilities.
build their trust and confidence, so they will consent to a consultation with a doctor or nurse.
Without services like the day centre, there is a risk that hard to reach, vulnerable people will once again,
Without the Healthcare Team, the majority of these
become invisible and their health needs will be
people would only come into contact with healthcare
overlooked and untreated.
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Helen Giles, Managing Director of Broadway’s Real People HR Consultancy, now has a regular column in Connect aimed at helping you to make the most of your most important resource – your staff teams. This edition focuses on staff health. if people’s jobs are changing as a result of cuts and reconfiguration of services and job roles, you must do a risk assessment to ensure that you are putting in place measures to protect staff health and safety. it won’t do to cut posts then pile endless amounts of additional
Wit h all the a d ditional pre ssu re s we’ re u nder every one in ou r orga nisation seems to be do ing more for le ss. I’m worr ied that peop le’s healt h will su ffer. One work er in particular s eems to be so fraz z led that I’m worr ied a bo ut his mental he alt h a nd wond er if I should tell him to go hom e a nd get himse lf sig ned off s ick.
work on those who are left. Work and services need to be reorganised to ensure that people are not trying to
ever you have anxieties about a staff member’s
do absolutely everything they did before and all the rest
health, and certainly if they say they feel stressed as a
on top. some things will have to be dropped or done
result of work, you should immediately make a referral to
occupational health. they will see the employee and then advise both them and you on the best course of
if commissioners will only pay a certain amount for certain
action to manage the situation.
services, then the ways those services are run needs some radical and innovative re-thinking. hopefully ideas about
also, if your organisation doesn’t already have an
new service models will be something that homelessness
employee assistance programme, it is well worth
organisations will be prepared to share as this is a
considering if you can afford to buy into one. this is a
challenge for all of us.
relatively low cost benefit for staff, but the impact where people have anxieties – whether personal or work-related
you need to ensure that all staff members have regular
– can be tremendously positive, so the scheme can more
supervision sessions with their line manager and that
than pay for itself. the line manager and the organisation
line managers proactively ask staff how they are
retain responsibility for checking that people are well and
feeling about their work and their workloads and take
enjoy a good working environment. however, it is really
appropriate action where problems are identified.
beneficial for employees to be able to access practical or counselling support from an impartial third party
as for your frazzled staff member, we should never put
service when they are feeling troubled, or even if they
ourselves in the role of ‘manager as doctor’ making
need practical advice on things like managing debt or
assumptions on what we see or hear and then prescribing
tenancy or family issues.
action. Whatever the size of your organisation, it’s essential to be signed up with a good occupational
Helen Giles is HR Director of Broadway and Managing
health service – no organisation can hope to manage
Director of Broadway’s Real People HR consultancy
health and attendance issues properly without one. if
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beyond polarisation Approaches to tackling homelessness often couldn’t be more different when comparing state funded organisations and community based projects. Jon Kuhrt, Executive Director of Social Work for the West London Mission, explains that if more effort is not made by services to close the divide, it will be to the detriment of those who rely on their support. Homelessness is just one area
agencies are depicted as having sold their soul to the lure
of social care where there are
of government funding and have become tools of state
tensions between the larger state
funded organisations and smaller community based initiatives.
This gap is damaging and needs bridging. Why? Because
On the one side you have agencies commissioned
the gap does no good to the people who should be at
by local authorities to run hostels, larger day centres,
the centre of this issue – the homeless people we are
coordinate outreach and also increasingly to address
seeking to help.
‘street life’ activity and associated anti-social behaviour. On the other side there are many smaller community
Resources to bridge the gap
organisations, often still church-based, running drop in
It is interesting to consider that so many homelessness
sessions at church halls, lunch clubs, night shelters and a
agencies, whether large or small, have Christian roots.
wide range of more informal support services.
The Salvation Army and Connection at St Martin’s are obvious examples, but dig deeper and you realise
The gap between the two approaches to working
that Centrepoint and Shelter were also established by
with homeless people is, more than ever, in danger
of widening and deepening. The recent furore over Westminster Council’s proposed ban on rough sleeping
I think this ‘Christian DNA’ that exists within many homeless
and soup runs in the Victoria area are the perfect case
organisations can provide important resources when it
in point. Some larger state funded agencies have
comes to bridging the gap - because Christian theology
come out in support of Westminster’s proposed byelaw
has much to say about human transformation. I realise
whilst some of the most vocal opposition has come from
that the very mention of theology runs a risk of causing
churches. Over recent weeks a passionate debate has
many readers, whether Christian or not, to switch off.
taken place on TV, radio in the press and especially
Surely theology is the last thing we need – surely it smacks
on-line – often represented as a debate between harsh
of narrow dogma, arcane debates and irrelevance? Well,
enforcement versus indiscriminate compassion. It was a
sometimes it does. But that does not mean it should.
prime example of the polarising that so easily breaks out when discussing the best approach to helping homeless
In this article I want to use the two theological concepts
of grace and truth as a framework for the discussion. One of the ways that Jesus is described in the Bible is that
One of sad aspects is how both sides lapse into
he was ‘full of grace and truth’ (John 1:14) and I believe
caricature of each other. Churches are patronised as
these two themes are very relevant to practical work with
naïve do-gooders, locked in an ‘old school’ approach
homeless people. The chart below sets out some of the
which is simply out of date and inappropriate. Larger
inherent tensions that many of us work within.
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The gap between the two approaches to working with homeless people is, more than ever, in danger of widening and deepening.
Emphasis on grace Unconditional acceptance Giving another chance Showing compassion Providing support and care Upholding legal rights Voluntary and charitable
Emphasis on truth
trying to do. I will never forget the response of one honest
Enforcement of rules
resident who we were urging to stay in one evening and
Maintenance of boundaries
leaving he turned and said to me “I’ll tell you what, if you
lounge and drop fivers and pound coins in my lap - then
Challenging and empowering Encouraging personal responsibility Professional and statutory services
get involved in an event we had organised. As he was get members of the public to walk through the hostel I’ll stay in”. There is no doubt that members of the public were trying to help these young people and show grace to them – but what they were doing was not actually helping them. In many ways the problem was one of truth – because the young people were presenting a false picture of their
Managing these issues will always be an on-going tension
situation. And this meant that on the street they could
rather than a dichotomy because all transformative work
easily receive the last thing they needed – an incentive
with vulnerable people requires a certain amount from
to remain in the downward spiral of addiction and
both sides of the chart.
The destructive potential of grace detached
Some of the criticisms of church-based work with
homeless people are that there is too much focus on
Just over ten years ago I was Manager of a sixty-bed
giving free meals, free accommodation, love and
cold weather shelter for young homeless people in Soho.
acceptance rather than empowering them to face
After a few days of opening we would see our residents
reality and take responsibility. A person with a destructive
begging right outside the hostel, using our duvets to give
lifestyle can be simply be maintained in that situation.
the impression that they were rough sleepers. We used
We have to face the uncomfortable challenge that
to overhear them saying that they could not afford any
sometimes an over-emphasis on grace, detached from
of the hostels round here’ and that ‘no one would help
truth, can actually be destructive and damaging, rather
them to people who stopped to talk with them. Often the
than liberating and healing.
passers-by listened with real concern and would hand over cash. The only people who really benefited from this
Bridging the gap
exchange were Soho’s many crack and heroin dealers.
I believe the balance of the tensions between grace and truth is relevant to the contemporary homelessness issues
The ease of getting money through begging was not a
neutral factor - it undermined the positive work we were WWW.HOMELESS.ORG.UK
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commitment that so many Christians and churches have
I am sympathetic to the concerns that have been
towards evolving new services for homeless people.
raised about how soup runs operate would always urge
They have been particularly effective with those who are
churches to support vulnerable people locally in their
unemployed foreign nationals who have no recourse to
own communities. The street-based nature of soup
public funds. I would urge that all shelter schemes seek to
runs perpetuate the impression that the street is where
work as closely as they can with the established agencies
help, generosity and kindness can be accessed and this
and ensure a good and effective flow of communication
inevitably draws a wide range of people who are in real
to ensure that they enhance and complement the year-
need of these things. I think it would be better for soup
round work of other agencies, rather than unintentionally
runs to become social and recreational groups working
from churches or other buildings. Where there is no bridge between the established agencies and the soup
A major role FOR THE CHURCHES
runs, it is easy for the soup run volunteers to believe that
It is worth reinforcing the clear reality that churches
‘nothing is being done’ for those they serve when often
has a major role to play in combating homelessness. A
this is not true.
member of the rough sleepers team at Westminster City Council said to me that ‘What the churches do is such a
Sharing information and coordination between
strong ingredient in the overall recipe to address rough
agencies (CHAIN database)
sleeping, it’s important that they do it right.’ We need
The CHAIN database is an on-line system where different
to have confidence in what we can do – the kind of
homeless agencies can upload information on the
confidence that allows us to critique our own practice
case work that is happening for clients and make this
with humility, adapt it as needed and be willing to build
information available to others. In essence this is a
bridges with other agencies and acknowledge the ways
mechanism for truth and I think that Christian agencies
in which our aims and purposes overlap.
should warmly endorse this kind of progress because it helps build the kind of unity that improves the services
In order to be as specific as possible, I will end with the
offered. Also it can help staff challenge clients when they
following recommendations for further discussion:
insist that nothing is being done for them when actually it
• Transformative work with homeless people will always
is their behaviour or some other blockage that is the key issue.
need to blend the elements of truth and grace. • All agencies should encourage all initiatives which help the truth emerge about someone’s real situation.
The No Second Night Out initiative
• Churches and smaller agencies need to affirm the
This is a recently launched initiative driven by the London
good work that the government and commissioned
Delivery Board of the Greater London Authority (GLA)
agencies are doing and work as closely as they can
which is aiming to ensure that new rough sleepers do not spend more than one night out on the streets by targeting and coordinating resources even more tightly.
with them • Churches should not duplicate the work of commissioned agencies, but instead consider what we can do better than anyone else and how we might
In a sense this is a key moment in this whole discussion. This initiative tightens the ‘noose’ of truth around each person’s situation. If the system works well this could be
add value? • Lastly, churches should be more confident to offer activities which help homeless people explore themes
a great opportunity to prevent new rough sleepers from
of Christian spirituality. Issues such as identity, loss,
becoming entrenched into a street lifestyle. However,
forgiveness, hope and faith are very significant for
it could also be a harsh and blunt system. I believe it is
many homeless people.
important that churches support this initiative and give it a chance to work but alongside this monitor closely what
I hope that Christian groups can work as well as we can
is happening to the rough sleepers they are in contact
with others to fulfil our shared the aims of bringing hope
and transformation to people who end up sleeping on the streets of our rich but needy nation.
Church Night-shelters The growth of the Church Night-shelter initiatives across
An earlier version of this article was published by The
London and beyond are testimony to the impressive
Christian Socialist Movement.
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UPCOMING TRAINING AND EvENTS FOR THE HOMELESSNESS SECTOR:
HOME AGAIN: THE NATIONAL EMPTy HOMES CONFERENCE home again is a comprehensive one day event on empty homes. With house building in the doldrums, there has never been greater interest in creating homes from empty property. the coalition government has introduced new powers and funding, and at the same time new and exciting ideas are emerging. www.emptyhomes.com
lemos & Crane present this one day event on responding to reform and rethinking policy and practice on tenancies, rent, and anti-social behaviour. www.lemosandcrane.co.uk
THE ANTI-TRAFFICkING LEGAL PROJECT AND THE AIRE CENTRE free conference for non lawyers who are providing support to people who have been trafficked.
REDUCING EvICTIONS AND ABANDONMENTS this free event will focus on the role of commissioners in reducing evictions and abandonment. the event will focus on how commissioners can improve quality without increasing cost, and will share learning from those involved in pilot projects to reduce evictions and abandonment across london in 2010. www.homeless.org.uk/eace2011
email: email@example.com or call: 020 7 831 4276.
DELIvERING CHANGE IN HOUSING MANAGEMENT
MICHAEL WHIPPMAN AWARD 2011 DEADLINE this year, the award is focused on fi nding the best example of an existing campaign or initiative using social media that raises the profi le of homeless people and homelessness amongst the public, broadens the public’s understanding of homelessness, and involves homeless people and empowers them to make a contribution. www.homeless.org.uk/mw2011
HOMELESS LINk ANNUAL CONFERENCE 2011 The University of Warwick homelessness is a local issue. if we are to end homelessness and improve the lives of the most vulnerable, we need to gain the support of the local communities, politicians and services. this practical event aims to help you understand the new ‘localism’ landscape, the threats and opportunities that exist and who you need to engage to achieve change. www.homeless.org.uk/ac2011
you can’t support the people who depend on your service if your client recording doesn’t support you every day, more than 3000 staff in frontline homelessness organisations of all sizes* use homeless link’s in-form client recording system to reflect the needs of the thousands of people they support and to measure the outcomes they achieve. in-form is designed to fit into your organisation, intuitively and functionally, leaving you to focus on what matters. to find out how in-form could support you, call 0207 840 4443 or visit the website.
www.homeless.org.uk/in-form * in-form customers include depaul uK, thames reach, Centrepoint, framework ha, Bournemouth Churches ha, norcare, the Cyrenians, Worthing Churches homeless projects and the m25 housing and support group.
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RESOURCES We’ve pulled together a list of health and homelessness related resources and research. If you have any information you would like to share with our member organisations, please write to firstname.lastname@example.org.
Homeless Link information
DEPARTMENT OF HEALTH PUBLICATIONS
Health and homelessness – where to start looking for more on this topic on the Homeless Link website.
Equity and excellence: Liberating the NHS
The July 2010 white paper setting out the Coalition’s long-term vision for the future of the
Health Needs Audit Toolkit – The Health Needs
National Health Service.
Audit is a way to gather information about the health of people who are homeless in your local
No health without mental health
area. It can be used by local authorities, voluntary
This strategy, published in February 2011, “sets out
sector agencies and health services in partnership.
six shared objectives to improve the mental health
This toolkit provides the materials needed to
and well-being of the nation, and to improve
undertake an audit in your local area.
outcomes for people with mental health problems
through high quality services.”
health-needs-audit www.dh.gov.uk Homeless UK – the leading source of information about advice, support, hostels and supported accommodation for homeless people and those at risk of homelessness. www.homelessuk.org
ST MUNGO’S ON HEALTH St Mungo’s has long sought to highlight the clear
Homeless Pages – find the latest publications and
links between health and homelessness, and how
research on health and homelessness.
one continually exacerbates the other.
NHS End of life care – a publication from the National
NEW: CRITICAL MASS TOOLKIT
End of Life Care Programme: “A practical guide
Advice and guidance on data collection, using
to implementing high quality end of life care for
your data to influence funders, and the ethics of
homeless people in our communities”.
using operational data for research purposes.
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The health needs of homeless communities are significant and complex, yet health providers often don’t have the structures to engage with th...