Crisis’ response to the Department of Health’s ‘Healthy Lives,
Health People’ consultation
March 2011
Introduction
Crisis, the national charity for single homeless people, broadly welcomes the white
paper Healthy Lives, Healthy People and the two accompanying documents,
Consultation on the funding and commissioning routes for public health and
Transparency in Outcomes: proposals for a new public health outcomes framework.
In particular, we welcome the recognition of the importance of reducing health
inequalities. We are pleased with the extra responsibility being given to local
authorities to promote public health and prevention measures. Prevention must be at
the core of a successful health service. Our homeless client group in particular would
benefit enormously from a greater emphasis being placed on preventative
interventions as this could avoid relatively minor conditions becoming more serious.
Homeless people experience significantly worse health outcomes than the general
public, and so any public health strategy must take account of the specific needs that
they have.
Health and homelessness
Homeless people have long been failed by health provision. Rough sleepers in
particular have especially poor health outcomes. The average life expectancy for a
rough sleeper is only 421, compared with the national average of 76 for men and 79
for women. However rough sleeping is only the most obvious manifestation of
homelessness, and staying in hostels, overcrowded, temporary or substandard
accommodation can have a damaging effect on a person’s physical wellbeing.
Common health problems include respiratory conditions, with one in ten people
diagnosed with TB having a history of homelessness, foot conditions and dental
problems.
Homeless people often face particular difficulties accessing mainstream healthcare
services and mental health services. One in three homeless people has a health
condition for which they are not currently receiving treatment2. We would like to see a
widening of access to primary health care, through making mainstream services
more flexible such as increasing the availability of drop-in sessions. More specialised
services should also be provided including within existing homelessness services,
such as hostels and day centres. Improving access and take up of health services
could have a huge impact on reducing health inequalities for homeless people.
Mental health problems can be both a cause and consequence of homelessness.
People with mental health problems can become unable to cope with day to day life
and sustain their tenancies. One in four tenants with mental health problems have
serious arrears and are at risk of losing their home.3 Homelessness itself is an
isolating, lonely experience which erodes confidence and self esteem. This in turn
can cause or exacerbate mental health conditions. 32%4 of clients of homelessness
services in England have mental health needs and 14%5 have a personality disorder.
35%6 of those sleeping rough in London have mental health support needs and 18%
1
Crisis (2006) Still Dying for a Home
St Mungo’s (2005) Sick of Suffering Briefing
3 Social Exclusion Task Force (2003), Mental Health and Social Exclusion
4 Homeless Link (2009) Survey of Needs and Provision (SNAP)
5 Broadway (2009) Street to Home, Annual Report for London, 1st April 2008 to 31st March 2009
6 Crisis (1996) Still Dying for a Home
2
have a mental health need combined with a substance misuse issue (dual
diagnosis).7 Rough sleepers are 35 times more likely to commit suicide than the
general population8.
It is also important to point out that the Government’s proposed welfare changes are
widely predicted to lead to an increase in homelessness. This is likely to put
additional pressure on health services trying to respond to the needs of a growing
homeless population. Therefore it is particularly important that full consideration is
given to ways to include homeless people in existing service provision and to provide
appropriate and targeted care.
Funding and Commissioning
Crisis welcomes the commitment to reducing health inequalities, and the
acknowledgement of the effects of wider social issues on health and health
inequalities. We are pleased that ensuring the health and care system works to
address health inequalities is part of both the Secretary of State for Health and the
Director of Public Health’s roles. We also welcome that another part of the Director of
Public Health’s role will be to work with NHS colleagues to ensure the provision of
services for diverse and potentially excluded groups, such as people with mental
health problems and homeless people.
We support the move to tackle health inequalities using the health premium.
However, further details will be needed on how the health premium is to be
calculated before we are satisfied that it will really reward councils working with the
most vulnerable people. Decisions as to which areas will receive the highest funding
levels must include an assessment of housing need and homelessness. Vulnerable
housing and homelessness can be hard to measure, so wide indicators such as the
demand for homelessness services and number of hostel bed spaces should be
used.
We have some concerns about payment by results particularly as it is often hard to
measure outcomes when working with particularly people. There must be a
recognition that some people will have further to go to achieve good health, and that
good health will mean different things to different people. Payment by results is to be
introduced in a number of areas, such as rehabilitation of offenders, but it has not yet
been properly evaluated. It is important that further evaluation takes place in order to
determine whether payment by results is effective in obtaining the desired outcomes
in health. There is a real risk that local authorities may focus on working with those
who are easiest to help, as this may deliver better results. It is therefore important
that appropriate outcome indicators are developed to take these difficulties into
account.
We welcome the proposal to increase integration and partnership between public
health and other services, such as housing, transport and social care, in order to
improve health and well-being and reduce health inequalities. It is important that
knowledge and best-practice on working with homeless people is shared between
different agencies.
It is important that all public health promotion and information is accessible to all, and
that public health professionals actively target vulnerable groups, such as homeless
people. Health information sessions and leaflets should be made available within
homelessness services, such as hostels and day-centres. Health information should
7
8
Broadway (2009) Profiling London’s Rough Sleepers
Crisis (2009) Mental Ill Health in the Adult Single Homeless Population: a review of the literature
also be tailored to meet the needs and priorities of vulnerable groups, ensuring it is
relevant and useful to them.
Health And Wellbeing Boards are an important development, but it is important that
they are easily accessible and representative. They should certainly be strongly
encouraged to engage with the voluntary sector and make use of their expertise. We
would ideally like to see membership being opened up to third sector partners so
they can fully contribute. Frontline agencies working with homeless people are very
well placed to offer advice on engaging with homeless people, and on the demand
for services in their local areas. This expertise should be drawn upon. We would also
recommend that those involved in housing and tackling homelessness are included
in the Health and Wellbeing Boards, such as the strategic lead for housing within the
local authority.
Whilst we recognise there could be some merit in the move to commission public
health services at local authority level, we would advise caution in two areas. Firstly,
although the current PCT structure is not perfect, many PCTs have built up
significant bodies of knowledge in commissioning health services for vulnerable
people. It is vital that this expertise is not lost. Secondly, some services will need to
be commissioned on a ‘supra-local’ level, as the consultation acknowledges. The
new commissioning framework must allow for communication and sharing of
resources across local authority boundaries. For some specialised services, budgets
could be pooled and services jointly commissioned on a regional or sub-regional
basis. Services such as domestic violence services may not be required in every
local authority area, but on a regional or sub-regional basis there is likely to be a
need. This is particularly important in large cities such as London where people
frequently move between boroughs and can find it hard to access continuing support.
It also provides an efficient way for commissioners to invest in higher cost services
for a relatively small number of patients without risking either duplication or gaps in
provision.
Outcomes Framework
Crisis is pleased to see such a wide range of health determinants and indicators
included in the Outcomes Framework. We would suggest that the following indicators
are included to provide an even more comprehensive structure.
In Domain 2, Tackling the wider determinants of ill health, we strongly support the
inclusion of indicators based on housing and poverty. While it is important that
statutory homeless figures are used as an area of improvement, there are many
vulnerable, homeless people who are not included in these figures. Many single
homeless people sleep rough or live out of sight in hostels, bed and breakfasts,
squats or on family and friends’ sofas and all of these vulnerable housing situations
can impact on health. Consideration needs to be given as to how to count people in
these situations who are often not included in official statistics. This could include
rough sleeper counts, statistics for people deemed homeless but not in priority need,
hostel bed spaces, numbers of people in temporary accommodation, or consultation
with local housing and homelessness service providers.
In Domain 4, Prevention of Ill-health, we believe it is important to build in some
recognition that homeless people are particularly likely to live with preventable health
conditions. In tackling many of the indicators, such as emergency readmissions, local
authorities will need to specifically address ways in which they can support homeless
people to access the treatment they need at the right time to prevent relatively minor
health conditions snowballing.
Finally, we would suggest that an indicator on mortality rates among people with no
fixed abode is included in Domain 5, Healthy life-expectancy and preventable
mortality. Due to the extremely low life expectancy for rough sleepers, it is important
that local authorities tackle mortality of homeless people as a priority.
Conclusion
It is clear that homeless people suffer far worse health than the general population
and real difficulties in accessing services. We very much welcome the recognition of
health inequalities as a major problem. We hope that the introduction of a health
premium will incentivise local authorities to tackle homelessness health care
problems, but we would like to see more details as to how this would work. For the
Outcomes Framework to be truly effective, it must take non-statutory homelessness
into account as well as other homelessness related health issues. As mental health is
a particular problem for homeless people, there can be no effective public health
strategy that does not take this into account. Finally, voluntary agencies which have
valuable experience working with vulnerable groups must be encouraged to feed into
the public health commissioning process as part of the Health and Wellbeing Boards.
About Crisis
Crisis is the national charity for single homeless people. We are dedicated to ending
homelessness by delivering life-changing services and campaigning for change.
Our innovative education, employment, housing and well-being services address
individual needs and help homeless people to transform their lives. We are
determined campaigners, working to prevent people from becoming homeless and
advocating solutions informed by research and our direct experience.
Within our Crisis Skylight centres, we offer a range of health services to homeless
and vulnerably housed individuals. This includes workshops such as Yoga, Karate,
Tai Chi and Pilates to improve physical health and well-being, and regular Health
Days which offer free health MOTs, eye tests, First Aid training and link people up
with health services throughout the year. We have recently successfully piloted a
new mental health scheme which we will roll out to our Crisis Skylight centres At
Crisis Christmas centres our guests can access a full range of medical services
including TB Screening, dental treatment and podiatry.
We have commissioned and delivered a number of research projects over the years
to better understand the links between homelessness and poor physical and mental
health. We use this evidence to make policy recommendations and campaign for
innovative solutions.
Company Number: 4024938 | Charity Numbers: England and Wales 1082947,
Scotland
SC040094
For further information or briefings on issues related to homelessness, please
contact:
Katharine Sacks-Jones
Policy Manager
Crisis
66 Commercial Street
London E1 6LT
Tel: 020 7426 5668
Katharine.sacksjones@crisis.org.uk