Homeless people often access health care only when a crisis arises (Martins, 2008). According to Deloitte (2012), the lack of a permanent address is one of the barriers for homeless people accessing community-based health care and primary care services. In addition, it has been reported that they often feel they negatively stand out, are not welcome, and are not treated equally to the general population in certain healthcare settings (Quilgars and Pleace, 2003). As a result, paramedics working in urgent and emergency care settings may well be the first and only health professionals accessed by homeless people. It must be recognised therefore that this healthcare encounter could be the key opportunity to improve the life course for this person.
This comment provides information on homelessness for paramedics to consider when treating this vulnerable population. It describes the challenges present in the healthcare system in providing adequate care, and outlines the implications of the relatively recent Homelessness Reduction Act 2017 for paramedic practice.
Key facts on homelessness
The full extent of homelessness and rough sleeping in the UK is difficult to describe. Homelessness is recorded differently in each nation, and not all homeless people show up in official statistics. However, it is clear that homelessness and rough sleeping have been increasing substantially since a low point between 2009 and 2010.
Statutory homelessness statistics reported that the local authorities in England had duty to accommodate just over 59 000 households in 2016–2017. This is a 48% increase on the 40 020 reported in 2009–2010. In addition, the estimated numbers of people who sleep rough have increased by 169% since 2010 to 4751 (Ministry of Housing, Communities and Local Government, 2018a; 2018b).
What is homelessness?
The legal definition of homelessness is that an individual has no home in the UK or anywhere else in the world, which is available and reasonable to occupy. A home is a place that provides security and links to a community and a support network (Public Health England, 2018). Rough sleeping is one of the most obvious examples of homelessness, but many people are still classified as homeless even if they are staying in an accommodation because they do not have rights to stay where they are or they live in unsuitable housing such as:
Cause of homelessness
The cause of homelessness is often multifactorial. Ill health can be both a cause and a consequence of homelessness, although it is not always recognised as the trigger. Ill health may contribute to job loss, relationship breakdown or financial difficulties, which in turn can result in homelessness.
Preventing homelessness
Preventing homelessness and providing for the healthcare needs of the homeless population affords a significant challenge for individual organisations and for the healthcare economy. The need to provide physical health care often coincides with the need for housing support, social support, addiction support, and community mental health care at a point of crisis in the individual's life. The responsibility of organisations to identify individuals who require this support and to respond to their needs in a timely manner has been highlighted by new legislation.
Health inequality
The health and wellbeing of people who experience homelessness is worse than that of the general population. They often experience the most significant health inequalities. Those classed as homeless have a greatly reduced life expectancy compared with the population average, at 47 for men and 43 for women (Thomas, 2012). The longer a person experiences homelessness, particularly from young adulthood, the more likely it is that their health and wellbeing will be at risk. The homeless population have poorer self-ratings of mental, physical and overall health status, and reduced use of non-emergency health services, particularly within primary care.
Homeless people are more than twice as likely to have a health issue compared with the general public. This applies to both physical and mental health issues. A Health Needs Audit by Homeless Link (2016) showed that 78% of homeless people report having a physical health condition compared with 37% for the general population. In addition, 44% of homeless people have a mental health diagnosis, in comparison with 23% of the general population. Furthermore, 21% of homeless people report having an alcohol problem, and over 40% report having used drugs.
Comorbidities combined with the complex health and social care needs within the homeless population could be significant challenges for paramedics who are treating these people. The lack of awareness of health inequalities within this population could mean housing and underlying long-term health problems are not addressed when the person is discharged.
Duty to refer
The Homelessness Reduction Act 2017 came into force on 3 April 2018, with the final section (s.10: duty to refer), introduced on 1 October 2018. It is one of the biggest changes to the rights of homeless people in England in 15 years. The Act places new legal duties on local housing authorities (LHAs) and amends the existing homelessness legislation in the Housing Act 1996 (Gallagher, 2017).
The Act places renewed emphasis on the prevention of homelessness with the introduction of the new ‘prevention’ duty. The Homelessness Reduction Act 2017 extends the period during which an individual is considered at risk of homelessness from 28 days to 56 days. This gives authorities more opportunities to prevent homelessness and a longer window to respond adequately to the individual's needs. Additionally, the Act legally obliges local authorities to provide more meaningful assistance to all people who are eligible and homeless, or threatened with homelessness, irrespective of their priority need status.
The ‘prevention’ duty of local housing authorities outlined in the Act can be summarised as ‘information on preventing homelessness, securing accommodation when homeless and how to access that help’.
Furthermore, Section 10 of the Homelessness Reduction Act:
The specified public authorities subject to the duty to refer are (in England only):
Some public authorities which are often accessed by homeless people, such as police, fire, ambulance services and primary care are not subject to the duty to refer. However, it would still be beneficial to refer the individuals to the LHA, and the individual will be entitled to the same assistance. Referrals to LHAs must include the individual's name, contact details, and the agreed reason for the individual being referred to the LHA. It is important to have the individual's consent before referring them to the LHA and share the minimum details required to make a worthwhile referral. However, referrals without consent may be made in order to safeguard children or vulnerable adults, in accordance with local safeguarding procedures.
What does this mean?
Paramedics who are working in the public authorities specified in the Homelessness Reduction Act (2017) should consider how homeless people could be identified and referred in their practice settings. It may be beneficial to discuss this new duty to refer at the local team meeting.
Anecdotally, many health professionals providing care in these areas are unaware of the new duty. Paramedics who do not work in a public authority with the statutory duty to refer should establish an appropriate referral method to their LHAs, and be aware of the services which are available in the local area for this group of vulnerable individuals.