CONNECT 42: HEALTH MATTERS

connect THE MAGAZINE OF THE HOMELESSNESS SECTOR

Health matters

Counting the cost of cuts

Navigating the new NHS

Beyond polarisation

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

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WELCOME

ConneCt 2011 | issue 42

MICHAEL WHIPPMAN

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: awards@homelesslink.org.uk

www.homeless.org.uk/mw2011 sponsored by:

the deadline for entries is FRIDAy 27 MAy 2011.

SPONSORED by:

creDits : suBscriptions : upcoMinG ABOUT

SUBSCRIPTIONS

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: connect@homelesslink.org.uk

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: editor@homelesslink.org.uk.

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CONNECT 2011 | ISSUE 42

WELCOME

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

4

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

36

WHAT’S ON

39

resources

40 WWW.HOMELESS.ORG.UK

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NEWS

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

telephone referrals.

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

STARTS WORk

www.nosecondnightout.org.uk

the risk of tenancy breakdown and

Within hours of starting work on the

homelessness.

1st april, no second night out was

SHARED ROOM RATE

helping people to stay off the streets

CAUSES CONCERN

homeless link along with Crisis aim

of london.

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

our website.

people when they first arrive on the

restricts the maximum housing benefit

www.homeless.org.uk/our-briefings

streets.

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

4

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NEWS

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

programmes.

women have been recorded in a

continued campaign against the

new oral history project with support

severest.

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

classes.

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

www.mungos.org/streetstories

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

www.homeless.org.uk/snap-2011

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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COMMENT

ConneCt 2011 | issue 42

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

have.

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

vulnerable.

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

vulnerable people.

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

6

england predicted to fall by 16%. Charities fear that day

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COMMENT

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

line staff.

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

tomorrow.

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

homeless people.

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

impact.

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%

50%

45%

45%

40%

40%

35%

35%

30%

30%

25%

25%

20%

20%

15%

15%

10%

10%

5%

5% 0%

0% accommodation services closures

reduction in floating support services staff

reduction in support services

disproportionate cuts

proportionate cuts

protective cuts

WWW.homeless.org.uK

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COMMENT

CONNECT 2011 | ISSUE 42

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

Transforming commissioning

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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COMMENT

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

Routes in

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

health services.

some of these opportunities.

Health and Wellbeing Boards provide an excellent

www.homeless.org.uk/health

opportunity for improving the integration of services and

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COMMENT

CONNECT 2011 | ISSUE 42

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.

hospital stay.

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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COMMENT

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.

practice.

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.

the streets.

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

www.homeless.org.uk/hospitals

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

short periods.

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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FEATURES

CONNECT 2011 | ISSUE 42

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

homeless people.

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

Budget.

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

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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

misuse.

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

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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

services.

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

homeless people.

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

www.homeless.org.uk/health-needs-audit

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

Council says:

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

our clients

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

Birmingham. “

particular, but also with the Homeless Mental Health and Drug and Alcohol Action Teams and Local

Sharing her experiences, Cath Gilliver, CEO of SIFA

Involvement Network.

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

lifestyle advice.

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

people.”

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

constraints.

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

is vital.

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

resettlement.

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

local buildings

area (usually) enhances your credibility, ensures you have local knowledge and enables

based service

the client to come into services once confidence is gained.

Follow up

Getting your client admitted to an acute medical or psychiatric trust is just the beginning.

admissions

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.

Get supervision

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.

chair

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,

levels.

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

Positive

We all need positive relationships in

that where models such as this are in place, increased

relationships

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

delivery.

family.

Increased

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

Working

Informal and formal relationships with

with mental

mental health services, both statutory

health

and within the voluntary sector, are key

practitioners

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.

and wellbeing.

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

practitioners.

titled Looking after number 1 and developed in conjunction with clients and service providers.

www.homeless.org.uk/mental-health-london

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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

timely manner.

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

Moving on

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

nurse-led clinics.

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

www.norfolkcommunityhealthandcare.nhs.uk

on the street.“

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LISTENING, NOT JUDGING...

CITY REACH STORIES Darren, aged 36

Peter, aged 48

Darren reregistered

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

released from

accommodation.

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

previously accessed

was homeless, drinking heavily and neglecting his

its services between

health. He came into the centre after being seen

prison sentences.

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

needed it.

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

22

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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FEATURES

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.

WWW.HOMELESS.ORG.Uk/ANNUAL-CONFERENCE

g

ro

For more information or to book your place: T: 020 7840 4461 E: events@homelesslink.org.uk

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.

WWW.homeless.org.uK

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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

accommodation.

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.

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• 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

FEATURES

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

denied.

death, dying and bereavement. They have produced materials to support people in having conversations

Next steps

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

Connect.

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.

www.stpetrocks.org.uk

www.dyingmatters.org.

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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

Intermediate Care

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

hospital.

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

again.

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FEATURES

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.

structures.

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).

specific conditions.

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

placements.

whole-person health needs and their relationship with social needs. We’ve formed many successful partnerships

Dual Diagnosis

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

homeless people.

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).

problem.

That’s where the peers come in – people with personal

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FEATURES

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

Isoniazid.

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

What’s next?

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

appointments.

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

right signs.”

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

Royal.

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.

everybody’s agenda.

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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FEATURES

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.

there.”

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

distress.

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

service.

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.

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FEATURES

CONNECT 2011 | ISSUE 42

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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FEATURES

MAnAGinG peopLe

Dear Helen,

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

differently.

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

www.broadwaysrealpeople.com WWW.homeless.org.uK

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debate

CONNECT 2011 | ISSUE 42

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

control.

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

committed Christians.

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

people.

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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debate

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

Administering justice

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.

helplessness.

The destructive potential of grace detached

Some of the criticisms of church-based work with

from truth

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

overleaf:

neutral factor - it undermined the positive work we were WWW.HOMELESS.ORG.UK

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Soup runs

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

disrupting it.

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

with.

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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ConneCt 2011 | issue 42

WhAt’s on?

FEATURES

UPCOMING TRAINING AND EvENTS FOR THE HOMELESSNESS SECTOR:

may

June

23

9

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

27

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

14

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: elieu@airecentre.org.uk or call: 020 7 831 4276.

27

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

July 1213

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.

WWW.homeless.org.uK

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COMMENT

CONNECT 2011 | ISSUE 42

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 editor@homelesslink.org.uk.

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

www.homeless.org.uk/health

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

www.homeless.org.uk/toolkits-and-handbooks/

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.

www.homelesspages.org.uk

www.mungos.org/news/influencing_policy/ health

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.

www.endoflifecareforadults.nhs.uk

www.homeless.org.uk/cmtoolkit

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