A review of the health needs and healthcare costs of rough sleepers in
the London boroughs of Hammersmith and Fulham,
Kensington and Chelsea, and Westminster
Rough sleepers needs assessment
 The review includes three work streams:

Literature review - to set the scene, understand the
health needs, and identify interventions to support
rough sleepers

Qualitative research - interviews to understand the
barriers to healthcare (undertaken by Broadway)

Analysis of hospital data to understand the healthcare
utilisation
Setting the scene (literature review)
• Health needs – most common are alcohol or drug dependence, mental
illness, and dual diagnosis. Homelessness is associated with tri-morbidity
• Service use – greater use of A&E and hospital services than general
population. Rough sleepers face a range of barriers to accessing services
• Costs - homeless people consume about 4 times more acute hospital services
than the general population, costing £85m. Very little cost effectiveness research
– although some economic evidence for intermediate care
• Effectiveness of interventions - overall lack of good quality research,
although some evidence for case management for mental health and substance
misuse, and that housing should be provided as part of integrated model.
• Models of service delivery - models of care range from mainstream practices
providing homeless services to fully coordinated primary and secondary care.
Discharge planning should be a component of an integrated model to prevent
inappropriate discharge back on to the streets and reduce emergency
readmissions
Reducing barriers to accessing healthcare
(qualitative research)
As identified in the qualitative study, there are
examples of practice which could enhance access to
health services and improve health outcomes:
 health services removing barriers to access and
enhancing patient experiences
 using homelessness support services to enhance access
to health services
 taking services to where homeless people are
 services coming together to improve joint working
Examples to support access to health services
(qualitative research)
 Enabling access





Specialist homeless GPs
GPs registering people without the need for proof of identity
Local accommodation projects which have a health focus
Accompaniment to appointments, eg Groundswell peer health advocates
Open referral system to secondary healthcare, eg UCL Pathway team
 Bringing services to the patient
 Day centres where health services are brought in
 Outreach e.g. outreach team that are accompanied by a mental health
social worker and in nurses from GP practices going out with the homeless
outreach teams
 Hostel in-reach
 One stop shops, eg a supported accommodation projects offering regular
‘health MOT’ sessions
 Working across service and organisational boundaries
 Find and treat tuberculosis services
 Dual diagnosis outreach worker
Discharge from hospital
(qualitative research)
Concerns include:
 Early discharge before patient feels health needs have been fully met.
 Discharge to the street either because homelessness is not identified or
hospital staff do not make the necessary referrals following the
disclosure of homelessness.
 Poor communication between service providers upon discharge.
 Discharge without clothing or transport.
Suggested improvements:
 The provision of respite accommodation with adequate healthcare.
 A system of care coordination for every homeless person to ensure that
all their health and social care needs have been fully addressed
Analysis of hospital data
 3450 individuals confirmed to be rough sleepers was identified from the
CHAIN (Combined Homelessness and Information Network) system and
matched with NHS general practice registered data.
 Those rough sleepers from CHAIN were identified between January 2010
and December 2011.
 933 patients had NHS numbers within Health services data.
 For those rough sleepers:
 High proportion of 30-59 age population compared with INWL general
population
 Common countries of birth: UK (49%), Poland (12%), Ireland (4%),
Lithuania (4%), Romania (3%), Portugal (2%), Rest from 76 other
countries
More than half of rough sleepers had contacts
with a hospital
Out of 933 patients that
registered with a GP
practice in INWL GP
practice 555 patients had
contacts with acute NHS
hospital.
Nearly 40% of rough
sleepers attended all
three types of hospital
services (A&E,
outpatients and
inpatients)
Hospital Activity ratios for rough sleepers,
compared with INWL general population
Rough sleepers have
significantly high
hospital activities
compared with
general population
Total cost of services for rough sleeping
population, split by hospital service per year
Excess hospital cost of rough sleeping per year = (real cost of rough sleeping per year –
Estimated cost for 933 patients from Inner North West London with same age and
gender
Rough sleepers have high rates of did not
attends (DNA) to hospitals
One Westminster based GP said:
‘We need to be as concerned with the people who do not attend
the service as the people who do, cause often the ones who are
not attending us have the greater need.’
Accumulative cost of hospital care (£)
10% of rough sleepers contribute to 50% of
health care cost
£2,400,000
£2,200,000
£2,000,000
£1,800,000
£1,600,000
£1,400,000
£1,200,000
£1,000,000
£800,000
£600,000
£400,000
£200,000
£0
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Percentage of rough sleepers accessing hospitals
Other findings (data analysis)
 Increase in trends in hospital activity: 2 fold increase in rate of
hospital activity from 2010 Jan- 2011 Dec to 2012 Jan- 2012 June period.
 Outpatient activity: Rough sleepers have high number of attendance
due to mental illnesses, trauma & orthopaedics and alcohol related
attendance
 Inpatient activity: Rough sleepers have significantly high emergency
rates while low rates elective admissions compared with general
population.
 Inpatient activity: Main diagnosis for admissions for rough sleepers
are mental illnesses, injuries, poisoning, alcohol related problems and
musculoskeletal problems.
Number of rough sleepers in Westminster
by ward location of GP practice
Ward location of GP practice
St James's
West End
Warwick
Westbourne
Harrow Road
Vincent Square
Church Street
Little Venice
Maida Vale
Queen's Park
Marylebone High Street
Churchill
Hyde Park
Knightsbridge and Belgravia
Tachbrook
Abbey Road
Bayswater
Lancaster Gate
Bryanston and Dorset Square
Regent's Park
Number of rough sleepers
312
59
40
36
26
25
18
13
11
9
8
7
6
5
5
<5
<5
<5
<5
<5
Final Summary
 Hospital utilisation and hospital cost for rough sleepers are significantly higher than
the tri-borough general population
 Rough sleepers have a high proportion of co-morbidities and a high frequency of
attendances/ admissions. A small sub group of rough sleepers have a particularly
high level of need - 10% of the rough sleepers accessing hospital services consume
approximately 50% of the total cost of hospital services
 Commonest diseases for these rough sleepers are Mental illnesses, Alcohol related
diseases, Trauma & Orthopaedics.
 Rough sleepers have high rates of DNA (did not attends)
 Access to healthcare is problematic and rough sleepers face many barriers e.g. GP
registration
 Integrated model of service delivery needs to ensure access to a package of care
which links health, social care, housing, and voluntary sector provided ser vices.
Discharge planning following a hospital admission requires joint working and an
agreed process.
Next Steps
 Central London CCG programme of work:
- Targeted health promotion with ‘Groundswell’: peer
advocacy to support the highest users of secondary
care
- Nurse outreach service
- Community hepatitis C treatment service
Commissioning cycle