LUTON HOMELESS PEOPLE HEALTH NEEDS ASSESSMENT

Transcription

1 LUTON HOMELESS PEOPLE HEALTH NEEDS ASSESSMENT Innocent Muza Health Improvement Specialist NHS Luton Nightingale House 94 Inker man Street Luton LU1 1JD Tel: Web:

2 ACKNOWLEDGEMENTS Adult facing Chronic Exclusion- Community Psychiatric Nurse BLPT Mental Health Partnership Bedfordshire Police-Domestic Violence Unit Bedfordshire Dental Service (Yee Lee & Sam Davis) CARA Housing Association Centre for All Families Positive Health Dr Rieger & Partners -Church field Medical Centre Dr Janet Biezik- Fordam M-NHS Bedfordshire Heads Together Homeless People Steering Group LBC- Housing Needs Performance Service Luton-Mind LAMP-Luton Access & Move on Project Luton Borough Council Floating Support Team Luton Borough Council Homeless Champion Luton Borough Council Housing Needs Manager Luton Borough Council Housing Policy & Strategy Luton & Dunstable Discharge Unit Luton Walk in Centre Luton Community Housing Association Luton and Dunstable Discharge and Planning Team Mary Seacole Housing Association NOAH Enterprise- NOAH -Outreach Services NHS Luton Community Services. - Child Protection/Domestic Abuse Advisor. NHS Luton- Drug and Alcohol Partnership St John s Ambulance Severe Winter Weather Shelter Staff The Foyer Walk In Centre Local healthcare Solutions (Ltd)

3 Executive Summary Introduction This Health Needs Assessment (HNA) was carried out as part of NHS Luton s 5-year strategic plan. Part of this plan is to understand the needs of the marginalized groups as identified in Strategic Health Authority (SHA) pledge 9. The pledge seeks to ensure that access to health services is available to the homeless people as it is to the rest of the Luton population. The life expectancy for someone sleeping rough is 42 (lower than Ethiopia or the Republic of Congo). According to a report, Still Dying for a Home, among homeless people across the UK 47% possess qualifications; of those 48% have GCSEs, 16% have A levels, 15% have a degree and 13% have professional qualifications (Crisis, 1996). Methodology The information for this HNA was obtained through interviews with at least 30 stakeholders or their representatives. The stakeholders included agencies and health services that provide health care, and support homeless people. What enriched this process was the involvement of 27 people experiencing homelessness through three separate focus groups. In addition, we analysed 63% health survey questionnaires completed, and returned by homeless people. Underlying this engagement was a review of existing policies and literature on health and homeless (see section 2.0). Scope of Homelessness in Luton For health delivery purposes, this report identified two categories of homelessness. The non-statutory and statutory homeless people (section 1.2). The risk of ill health falls most on rough sleepers and children living in insecure or temporary accommodation (section 1.4). The description of a homeless person is one that encompasses populations in series of unsatisfactory housing ranging from rough sleepers through to long-term hostel dwellers including those people living in temporary and insecure accommodation. As at 30 November 2010, Luton had 562 homeless households in temporary accommodation awaiting settlement, of these 459 are households with children and 1

4 103 are those with no children. The total number of children living in temporary accommodation is 808 (DCLG, 2010). Luton Borough Council last conducted a rough sleeper s count on 4 November 2005 this count determined that there were three (3) people classified as rough sleepers within the borough (LBC, ). However, based on the recent use of the severe winter weather shelter, it is estimated that 17 people are sleeping rough. In addition, The Luton Drug and Alcohol Partnership estimated that there are 47 sofa surfers. Health and homeless services in Luton NHS-Luton and Luton Borough Council have services in place convenient for the Homeless people (section ). The health services include outreach GP services; GP Service based in the town centre, a Nurse led Walk in Clinic, Health Visiting Services, vulnerability assessment service, emergency first aiders, and dental service. Furthermore, few GP services have homeless people in their registers. Luton has a range of hostel providers, a day centre, and an emergency night shelter facility. Most health services for homeless people operate in partnership with the day centre (NOAH) (see section 3.4). Improving the health and general situation of homeless people requires that NHS Luton efforts be coordinated and complemented with social house owners, LBC social services and the voluntary sector. Homeless people supporting agencies expressed that partnership with health services was essential to improve access to health services. Both homeless people and their agencies supporting them noted that access to health services was generally poor. The poor coordination between social housing services, the NHS and community care services has a potential of causing people falling out of the health care system. Improving coordination or communication among homeless agencies and health services has the prospects of increasing access to health services. Findings Stakeholders and members of the focus groups shared a view that services for homeless people with mental health, drug, and alcohol problems were unsatisfactory. The main challenge was lack of clarity on the care pathway for this sub group of homeless people. Some had strong views about the frustration they encounter when trying to facilitate access to mental health assessment and or crisis services. This 2

5 HNA recommends a review of mental health services or commissioning of mental health services suitable to homeless individuals as opposed to use of a criteria based services. Such service can be developed in the same lines as that of ACE project model (section 3.7, and 7.4). This HNA identified that dual diagnosis of Drug and Alcohol dependency seem to present barriers to mental health assessment and treatment services. Some homeless people noted that GPs were reluctant to prescribe certain drugs because of concerns that they would not use `them as prescribed. Evidence from focus groups and stakeholders consultation suggest that some Luton Homeless people have a history of rough sleeping and are likely to have medical conditions that may go untreated ( Chart # 6). Some homeless people in Luton have underlying long-term conditions such as chronic obstructive pulmonary disease (COPD), diabetes, cardiovascular (CVD) diseases, cancer, mental health, drug, and alcohol. Yet they are on the high risk of falling out the health system if not properly identified and signposted. An analysis of health survey questionnaire confirmed that multiple health needs are insidious in the lives of single individuals who are homeless (section 5.3.1). The majority (52 out of 76), of respondents to the health survey questionnaire are registered with a GP; yet fewer than 40 respondents did not visit their GP in the last 12 months. Access to mainstream and GP services for homeless people is poor in Luton, although there are some variations between categories of homeless people (Chart 8). Some homeless people in Luton prefer specialist services, as there is a perception that they are convenient and empathetic to their situation. In addition, homeless people are on the high risk of falling out the health system if not properly identified and directed into appropriate services. Reasons cited include difficult in accessing health care and or lack of awareness of the opportunities to obtain treatment. Even though, some of GPs in Luton town are prepared to register homeless people using their addresses. The severe winter weather is an opportunity to engage with some of the rough sleepers in Luton. The government advices local authorities to provide an emergency night shelter to accommodate homeless people during the periods of severe winter weather. During this HNA, the facility opened at least 10 times during 2009/10 winter season. St John s Ambulance team provided emergency first aid care at the shelter. 3

6 In line with improving access to health services agenda, there is an opportunity for NHS Luton to ensure that, qualified clinical staff will help with appropriate diagnosis and treatment at severe weather night shelters. Some health care professionals reflected a view that people sleeping rough would be unsettling or cause problems in the waiting room. In addition, some felt unsafe when engaging with males who appear or known to be to be rough sleepers. However, staff working with homeless people at night shelters confirmed that users were peaceful and cooperative. There are overtones of prejudice against homeless people from some health care services receptionist and health care professionals. These perceived attitudes towards people sleeping rough, with drug and alcohol problems have a potential to discourage use of primary care services. Recommendations The report proposes the following recommendations for consideration and implementation, (see section 7.0) Coordinate the health service for marginalised groups in Luton Improve access to primary care health services for Luton s homeless population and those threatened with homelessness Improve access to secondary/universal health services for Luton s homeless population and those threatened with homelessness Improve access to mental health services for homeless people with drug and alcohol problems Conclusion Improving access to primary, universal, and mental health services underpins the success in addressing the health needs of the homeless population. To attain this coordination, communication, and partnership working with agencies supporting homeless people is crucial. Some of the key structures identified are Homeless Steering Group, Mental health Forum and The Rough Sleepers partnership. 4

7 Contents Page 1.0 Introduction Meaning of homelessness Aim and Objectives of this HNA Specific Objectives Health and homelessness in Luton Defining the target population Statutory Homeless Non-Statutory Homeless People sleeping rough Sofa surfing Methodology Health Survey Questionnaire Questionnaire design and pilot Sample Data entry and analysis Focus groups Stakeholder Interviews Findings Links to strategic objectives Government's new rough sleeping strategy Strategic Health Authority pledge nine The Luton Housing Strategy The Luton Health and Well-being strategic plan The Joint strategic needs assessment Services for homeless people Severe winter weather shelter Local health and homelessness Initiatives New Opportunities and Horizons (NOAH) Overview of Health Services in Luton Local Enhanced Service (LES) provision Bedfordshire Community Dental Health Service Mental Health Universal Services Hospital Admission and discharge Hospital Accident and Emergency (A & E) Primary Care Services 26 5

8 Page 4.4 GPs and Nursing services Dr Rieger and partners Local healthcare Solutions Ltd Health for Homeless, Asylum Seekers & Travellers (HHAT) team Mental Health Mental Health Services in Luton Luton Crisis Resolution / Home Treatment Team (CRHT) Adults Facing Chronic Exclusion (ACE) Programme Drug and Alcohol services Luton Drug & Alcohol Specialist service (LDASS) Stakeholder, Community Contribution/Engagement Stakeholders Engagement Health Care and Homeless/Housing Professional Health and social services General and Health Issues Improvements and unmet needs Homelessness prevention Health Issues Homelessness steering group Rough Sleepers Partnership Workshop Health Survey Questionnaires Demography Types of Accommodation Medical Conditions/Issues Medical Support Accesses to Primary care Secondary and Acute Care Smoking, Drugs and Alcohol Services Health Promotion Focus Groups Health and Wellbeing Homelessness and health Lifestyle factors and health Attitudes to mainstream health services Luton Accommodation Move on Project (LAMP) Homelessness and health Lifestyle factors and health Attitudes to mainstream health services Luton Community Housing (LCH) 46 6

9 Page Health and Wellbeing Homelessness and health Lifestyle factors and health Attitudes to mainstream health services Summary of the focus groups Conclusion, Recommendations & Action Plan Conclusion Recommendations Coordinate the health service for marginalised groups in Luton Improve access to primary care Improve access to secondary/universal health services Improve access to mental health services Action Plan References 53 Appendix 1 Definition of Homelessness from the Housing Act Appendix 2 Health Survey questionnaire 57 Appendix 3 Stakeholders structured interview questions 61 Appendix 4 Focus group thematic topics 63 Tables 1. Homelessness for Health Purposes Overview of primary and secondary medical services for homeless people in Luton Overview of mental health services for homeless people in Luton Outreach services for homeless people in Luton Estimate number of people aged and mental health Health promotion information request 42 Charts & Graphs 1. Household in Temporary Accommodation in Bedfordshire Health Survey questionnaire Respondents by age group Health Survey questionnaire Respondents by ethnicity Health Survey questionnaire Respondents by Gender Health Survey questionnaire Respondents by Type of Accommodation Health Survey questionnaire Respondents self reported medical/health issues 39 7

10 Page 7. Health Survey questionnaire Respondents GP & Dentist registration Health Survey questionnaire Respondents use of GP & Dentist in the last 12 Months Use of Accident and Emergency department in comparison to GP & Dental service use Department in the last 12 months Numbers of respondents with smoking/non-smoking, drug & alcohol issues 41 8

11 1.0 Introduction This Health Needs Assessment (HNA) is contributing towards the objectives of NHS Luton s 5-year strategic plan. It is also in line with the Strategic Health Authority (SHA) pledge 9, which seeks among other things to ensure that health care is available to marginalised groups as it is to the rest of the Luton population. NHS Luton recognises that improving access to health services for homeless people is fundamental in addressing the Health Inequalities in Luton. Single homeless people without children and are not deemed vulnerable are not entitled for assistance under the homelessness legislation. Most single homeless people live in short term accommodation such as hostels, and bed and breakfast hotels, but a substantial minority live on the streets. People who live for some or all of the time on the street are usually referred to as people who are sleeping rough (Crisis, 2008). As at 30 November 2010, Luton had 562 homeless households in temporary accommodation awaiting settlement, of these 459 are households with children and 103 are those with no children. The total number of children living in temporary accommodation is 808 (DCLG, 2010). In Luton, Pakistani and African households are overrepresented amongst homeless applicants, while White British households remain significantly underrepresented. Luton Borough Council last conducted a rough sleeper s count on 4 November 2005 this count determined that there were three (3) people classified as rough sleepers within the borough (LBC, ). However, Luton Borough Council estimate that there are 17 people sleeping rough based on the 2009/2010 people who used the severe winter weather shelter. Of which, (80%) of these were Eastern or Central European migrants (LBC, 2010). In addition, The Luton Drug and Alcohol Partnership estimated that there are 47 sofa surfers. Data on people living in hostels, night shelter and short-stay hostels is limited and information on certain groups such as single homeless people from ethnic minorities and homeless asylum seekers and refugees is limited. 9

12 1.1 Meaning of homelessness Homeless Legislation and Government rough sleeping initiatives across the United Kingdom have fundamentally shaped the definition of homelessness. A person is homeless if he or she has no accommodation available for occupation in the United Kingdom or elsewhere, which he/she is entitled to occupy (Housing Act 1996, Section 175). It also means having no rights over an accommodation facility, living in an unreasonable accommodation, or where there is a risk of domestic violence, or living in unconventional accommodation (Appendix 1). 1.2 Aim and Objectives of this HNA The purpose of this Health Needs Assessment is to gather and analyse relevant information about homeless people in Luton. This would facilitate access to suitable and appropriate health and social care service. Secondly, the HNA aims to identify actions that may improve the health of homeless people and reduces health inequalities. 1.3 Specific Objectives Understand the homeless population and those threatened with homelessness in order to inform planning and commissioning of health and social care services in Luton. Improving the levels of awareness and understanding of the culture and needs of Luton s homeless population among health care and other staff supporting homeless people 1.4 Health and homelessness in Luton The link between poor health and homelessness is well-established (Pleace and Quilgars, 1996; homeless Task Force, 2001). Homeless people in England and Scotland have proved that homeless people have very poor health status compared to the rest of the population (Anderson, et al, 1993). However, some people s mental health problems may predate or even lead to homelessness. Therefore, homelessness can be a cause mental ill health and/or exacerbated with homelessness experiences (HVA and GMSC, 1988). Homeless children are reported as showing behavioural disturbance, depression, disturbed sleep, bed-wetting, toilet training problems, and violent mood swings Pleace, and Quilgars, (1996). There are also concerns about general mental and physical development. Parents within homeless families are often subject to stress, isolation, boredom, and loneliness (Pleace, and Quilgars, 1996). 10

13 An established link exists between homelessness, unemployment, and health. On average 80% of homeless households in temporary accommodation in Luton, depend on some level of housing benefit to make payment for their accommodation (LBC ). The government s homelessness strategy sustainable communities : settled homes; changing lives (CLG: 2005), highlights that people who are homeless or living in temporary or insecure accommodation are more likely to suffer from poor physical, mental and emotional health than the rest of the population. ST Mungo a London homeless charity surveyed 1491 homeless people, discovered that 2 in 3 homeless people have physical health problems, and over 1 in 3 who needed treatment indicated that they were unable to accesses it. The average life expectancy is 42 down from 47 less than a decade ago (Crisis, 2008). There is evidence of a high level of alcohol use among people who are sleeping rough, often existing in combination with a mental health problem (Crisis, 2008). In broad terms, the severity of health problems among this group of people is likely to be higher than that of other single homeless people and they are more likely to have multiple health problems (Crisis, 2008). 1.5 Defining the target population For this HNA, the focus is on homeless for health purposes as in Table 1. Table 1 Homelessness For Health Purposes Statutory homelessness Temporary accommodation Households accepted by Local Authorities Non-statutory homelessness Insecure Accommodation Squatters Sofa surfers Temporary guests Facing eviction Unacceptable housing Overcrowding accommodation Sub-standard accommodation Personal safety or well being at risk Involuntary long Term Long term sharing against Rough Sleepers Sharing Houseless Roofless will Hostels/Shelters/Foyers Bed and Break Fast Rough sleepers NB: Homeless people under immigration control such as asylum seekers and refugees needs are provided under the immigration system. A separate study is available on request from NHS-Luton. 11

14 1.6 Statutory Homeless The local housing authority (Luton Borough Council) arranges temporary accommodation (TA) in pursuant to the requirements of the homelessness legislation. This can include local authority housing stock or housing association homes let on a temporary basis, a house or flat leased from a private landlord, B&B accommodation, hostels, and refuges. This occurs where a main homelessness duty is owed; people may remain in temporary accommodation for a considerable period before a settled home becomes available. People can become homeless for many reasons. Luton is one of the largest towns in Eastern England, with a population of 187,000 residents, although local estimates have placed this figure at 202,500 (LBC: ). As at 31 March 2010, Luton had 565 homeless households in temporary accommodation, awaiting an offer or settled accommodation. It is evident that even as a stock retaining authority the demand for affordable housing outstrips supply within Luton. Luton has the largest number of homeless households in temporary accommodation within the region (see chart 1). Chart # 1 Household in Temporary Accommodation in Bedfordshire at year-end 2004/-2008/09 Source: Bedfordshire Housing Monitor, 2009 accessed at Number of households Number of Households in Temporary Accommodation in Bedfordhshire at year end 2004/ /09 Bedford Central Bedfordshire Luton 2004/ / /07 Year 2007/ / Non-Statutory Homeless By contrast, the non-statutory homeless were, and are, those to whom local authority has no obligation to support, either because they are deemed intentionally homeless, or are not in a priority need categories. These include the single homeless, many of whom happen to be young people of both sexes and, in the larger cities and of different ethnic groups, as well as some older white men (Smith, 2003). 12

15 1.8 People sleeping rough The government led rough sleeping counts in Luton have significantly underestimated levels of rough sleeping in the town. Using the Local Government criteria for counting rough sleepers, in November 2005, LBC identified 3 people that met the criteria of rough sleepers. However, based on the people who recently used the severe winter weather shelter, LBC believes that there are at least 17 rough sleepers in Luton. Many 80% of these are Eastern or Central European migrants; a minimum estimate for the number of A8 rough sleepers is 12. An A8 national is someone from one of the following countries Latvia, Lithuania, Estonia, Hungary, Slovakia Czech Republic, Poland, and Slovenia. 1.9 Sofa surfing Based on the evidence gathered by Luton and Drug Alcohol Partnership (LADP) the number of current clients sofa surfing is estimated to be 47, that is 23 females and 24 males (LDAP, 2009). 'Sofa surfing' is a form of homelessness that affects many homeless young people. Sofa surfers could have often just left home, for whatever reason, and are staying with friends. They may find themselves sleeping on a sofa in a shared living room for one or two nights before moving on to stay with another friend. They will usually have nowhere to put their belonging and will only be able to sleep when the rest of the housemates are not using their sleeping room. A recent report by homeless charity Crisis recorded that 72 per cent of homeless people had 'sofa surfed' at one time or another (Crisis, 2009). The recently completed Black and Minority Ethnic (BME) Housing strategy action plan on homeless decisions amongst ethnic groups. It indicates that both Pakistani and African households are overrepresented amongst homeless applicants, while White British households remain significantly underrepresented. There is an inequality in terms of access to temporary accommodation between ethnic groups. This perhaps explains why there is over representation of white people within the rough sleepers community. One reason could be, non-white community households have children, which makes them meet the criteria compared to the white single homeless men. 13

16 2.0 Methodology This Health Needs Assessment reviewed national and local evidence on Homelessness and Health; these included guidelines, policies, strategies, and needs assessments reports (see section 3.1). In addition, using guided interviews we engaged the health care professionals and agencies supporting homeless people. In order to capture the views of the homeless people on health and homelessness, we utilised focus groups and health questionnaire surveys. This methodology was adapted in order to achieve the following objectives: To gain an awareness of frontline housing and health care service staffs perceptions of health and homelessness; To determine their knowledge of current health services; To discuss their experiences of facilitating access to health services for homeless people; To explore their perceptions of gaps in health service provision and their suggestions for improving health services for homeless people. 2.1 Health Survey Questionnaire The literature review and discussions with other professionals working with homeless people influenced the content, design and testing of the user survey. In view of the relatively small number of potential respondents and uncertainty about the personal circumstances of homeless persons involved, the questionnaire surveys had to be administered by the staff trusted by homeless people. For details of the outcome of the survey, questionnaire and focus groups (see section 5.3 and 5.4 respectively). 2.3 Questionnaire design and pilot The data collection tool was adapted from a questionnaire developed during another Health Needs Assessment carried out by NHS Luton. The questionnaire was piloted with the drug and alcohol team clients in October 2009 and other three homeless people. We incorporated the feedback into the final version (Appendix 2, Health Survey questionnaire). 14

17 2.3.1 Sample We allocated 12 weeks for data collection, in an attempt to capture the needs and views of a broad range of agencies and homeless respondents; a decision was made to seek a wide representative sample of homeless people. We briefed and distributed 120-health questionnaires survey to staff for homeless and health care agencies. Staff working with these agencies and in contact with homeless individuals administered and facilitated return of completed questionnaire. Due to time constrains, it was not possible to consult all Luton agencies working with homeless people or all health care service providers Data entry and analysis Data entry and analysis of the quantitative information from the questionnaire surveys was completed using Microsoft Excel 97 a computer software package. 2.4 Focus groups We organised three focus groups through three agencies providing support to homeless people. We carefully chose the agencies based on their clientele base and speediness to put together the groups. We ensured a representation from the three categories of homelessness that is people in temporary accommodation, young people, and rough sleepers. The focus groups were organised by the staff at NOAH, Luton Community Housing (LCH), and Luton Accommodation Move on Project (LAMP).Due to small group representation, NHS Luton acknowledges that views presented would not reflect the views of the entire homeless people in Luton. In addition, there are no claims being made that these views are generalised to all homeless people in Luton. 2.5 Stakeholder Interviews We designed a questionnaire, tested it, and compiled a list of key stakeholders, with the list regularly updated. We arranged appointments via telephone and prior the meetings. Each interview lasted an hour, in some situations, this was an opportunity to organise service users focus groups. We typed notes of the meetings immediately, before the next appointment. Any follow up or clarifications were via telephone and or . Appendix 3 shows a list of guiding questions explored during the stakeholders consultation process. The review of services provided was in two parts, consultation with the homeless steering group for 2 hours and we were part of the rough sleepers workshop, 15

18 organised by Luton borough council. The Rough sleepers partnership sought to strengthen partnership working and ensuring that people working with rough sleepers are aware of the potential outcome of this health needs assessment. As part of the service providers consultation, we reviewed existing National Health Service strategies, namely Mental Health Strategy, NHS Luton operation plan, the discharge and Admissions Policy and the GPs hard to reach service level agreement and review. In addition, we analysed the Luton Borough Council Housing strategy and review of the same. The next sections will present and analyse the findings of this HNA 16

19 3.0 Findings 3.1 Links to strategic objectives The national guidance on health and social care has been plentiful in recent years. The most important and significant being the two White Papers: Our Health, Our Care, Our Say (DOH, 2006), Choosing Health (DOH, 2004) and the Green Paper Independence, Well-being and Choice (DOH), 2005). The Choosing Health (2004) White Paper sets out the key principles for supporting the public to make healthier and more informed choices in regards to their health. 3.2 Government's new rough sleeping strategy The government's new rough sleeping strategy No One Left Out: a community ending rough sleeping was launched on 18 November Building on the success in reducing the numbers of people sleeping rough by two thirds over the last 10 years, the strategy sets out a new ambitious objective of ending rough sleeping in England by Diverting people from the streets to ensure no one needs to remain sleeping rough and to circumvent people becoming entrenched and exacerbating problems such as poor mental health, substance misuse and physical health is one of the key action of this strategy (CLG, 2009). Meeting the 2012 target is potentially not feasible given the complexity surrounding homelessness. The coincidence of this date with London Olympics is consistent with what has happened in other Olympic hosting cities; the displacement of homeless people for the benefit of the sports tourists. 3.3 Strategic Health Authority pledge nine The Strategic Health Authority pledge nine, ensures that homeless people access the health services in a manner as good as it is to the rest of the Luton population. It is against this background that this Health Needs Assessment (HNA) seeks to contribute towards the above strategic objectives. 3.4 The Luton Housing Strategy The Luton Housing Strategy Statement seeks among other things to reduce levels of homelessness through prevention, advice, and advocacy. Homelessness prevention strategies have been developed to offer advice, guidance, and practical support to families facing homelessness. 17

20 3.5 The Luton Health and Well-being strategic plan The Luton Health and Well-being strategic plan supports the delivery of the health and well-being priorities identified within the Luton Sustainable Community Strategy (SCS,). The plan also supports the delivery of NHS Luton s five-year strategic plan. 3.6 The Joint Strategic Needs Assessment (JSNA) The Luton JSNA highlights the health and well-being issues facing our population and points to the commissioning priorities that need to be considered to improve life expectancy and reduce health inequalities, of which homelessness is part. In addition, Luton Borough Council has a five-year homeless strategy ( ) and a Housing and Community Living strategy to tackle homelessness and housing issues Services for homeless people The Local Authority may not be able to provide a council home for every person who is homeless but it can facilitate other accommodation facilities (LBC: ). The Homeless Persons Team processes applications, in line with section 188 of the Housing Act 1996 (as amended by the Housing Act 2002). While the council is processing the homeless application it may also consider whether it has a duty to provide the applicant with emergency accommodation. The council may have to use emergency accommodation depending on availability, individual needs and circumstances. The most likely type of accommodation offered will be one of the following: (B&B) a form of emergency accommodation used if the council's allocated temporary accommodation is unavailable. Luton Borough Council currently has a target to limit to a maximum stay of 4 weeks in Bed & Breakfast accommodation to ensure that individuals are placed in settled accommodation as soon as possible. (LBC, ). Self Contained Accommodation (private sector leased), these are flats and houses not owned by the council or managed by them. Any problems or repairs should therefore be reported to the owner directly. Individuals will be responsible for their utility and council tax bills. Any damage caused to the property or its contents will be recharged to the occupant (LBC, )). If a person loses a temporary accommodation facility as a result of their own actions the council s legal duty to 18

21 provide accommodation will no longer be enforceable. Such people will be potentially roofless if they are unable to secure alternative accommodation Severe winter weather shelter In response to severe weather conditions, Luton Borough Council provides rough sleepers with a shelter and hot food in collaboration with, The Salvation Army, NOAH Enterprise and City Life Church Luton. The shelter opens to Rough Sleepers only from 10:00pm to 7:00am, with hot food being served from 10:00pm to 12:00am. The places are allocated on a first come first serve basis. The severe winter weather is mainly staffed by volunteers. In regards to general provision of homeless people night shelter facilities, Luton has one night shelter facilities. 3.8 Local health and homelessness Initiatives NHS Luton and Luton Borough Council (LBC) commission services to tackle homelessness and to deliver health care. Although LBC and NHS Luton work in partnership, this in some instances was not reflected in services for homeless people. For example at the previous cold weather shelter health care was provided by St John Ambulance under contractual arrangements with LBC. This aspect of the service could have been improved if NHS Luton and/nhs Luton Community Services had provided additional clinically skilled staff to assess and refer homeless people appropriately. Some of the services facilitating or providing health care to the homeless community are discussed below: New Opportunities and Horizons (NOAH) NOAH is a local charity offering hope and support to people struggling against homelessness and exclusion using a holistic approach. The centre is open 365 days a year and is used by over 1,000 people. An additional 60 people are supported at any one time through their outreach work. This HNA identified one day centre for homeless people in Luton. All the stakeholders consulted during this HNA, have shown evidence that they have a formal or informal link to NOAH, as a path way to health services for Luton homeless people. The next section will give an overview of current health care provision for homeless people in Luton. There is a need to ensure that these dwellings meet the quality standards of an acceptable home, energy efficient, dry and clean. Some users of these facilities have this to say regarding their temporary habitat environment. The fact that one is unable to pay (responsible) for his or her own bills like everyone else in addition to not having your own is unhealthy 19

22 3.9 Overview of Health Services in Luton NHS Luton has some dedicated primary health care services for marginalised and hard to reach groups. Further to using these services, homeless people in focus group discussions indicated that they also access generic primary care services (see section 5.4). Furthermore, knowledge about the health services dedicated to homeless people was limited among some agencies offering support to homeless people. However, the health questionnaire survey revealed that most (39) and (35) of people had not accessed their GP and/or a dentist in last 12 months (see chart 8). Table#2 Overview of primary & secondary medical services for Homeless people in Luton Level of Health Care Primary Care Secondary and Acute Care including A & E Hospital admission and discharge planning Core Service Main Stream service Main Stream service Main Stream service Main Stream service Main Stream service Main Stream service Generic Service Main Stream service Main Stream service Main Stream service Main Stream service Main Stream service Main Stream service Dedicated Homeless People services Post NHS Luton commissioned Services Summary of the service General Dr Rieger & Signed to a service level Practitioner Partners agreement to provide clinic at people accessing NOAH General Practitioner General Practitioner General Practitioner Dr Warriner & Partners Local Health Care Solutions Dr Janet Bietzk Health Luton Community Visitor Services Health Visitor- Health for Homeless & Travellers Team (HHAT) Main Stream service services Signed to a service level agreement to provide Health care to travellers Provide a range of primary care services with on the spot registration available. Non-Registered Patients can walk in for a GP appointment opportunity Assesses, vulnerability of the homeless person and suitability of property Out reach services at NOAH Enterprise, hostels, B &B weekly and or on requests Accident and Emergency This HNA could not find evidence of an admission or discharge policy/pathway for the homeless people from the Accident and Emergency (A&E) department, Nor any support services for opportunistic intervention for this group of people, in the event that they turn up at A & E There is a clear discharge policy for complex situations. The Luton and Dunstable hospital discharge policy could reflect more one the DOH and CLG guidelines on discharging and admitting homeless people (DOH,2006).. Health care services in Luton including the Luton and Dunstable Hospital did not have a specific policy for dealing with homeless people. However, there is a provision for dealing with people who might require a complex discharge procedure. Staffs at the L&D Discharge planning unit are aware of the homelessness issues and work closely with the LBC housing needs support team. Table 2 provides an overview of 20

23 primary and secondary services that homeless people in Luton may or are accessing. Table # 3 Overview of Mental Health services for Homeless people in Luton Level of Health Care Adult Mental Health South Essex Partnership NHS Trust (SEPT) Child and Adolescent Mental Health service (CAMH) Core Service Mainstream services Mainstream services Mainstream services Generic Service Mainstrea m services Mainstrea m services Mainstream services Dedicated Homeless Service Name Detail of the service NOAH ACE Pilot The ACE Enterprise Project Programme designed to test new approaches to tacking chronic social exclusion amongst the most marginalised people in society. LDASS Supports people Luton with complex or Drug & multiple diagnosis, Alcohol alcohol and drug Specialist dependent patients, Services dual diagnosis and those wanting treatment for the aforementioned Mental Health Mainstream services People may access services as everybody else through the GPs, Emergency services, family, or Courts of law. Tier 1 & 2 services are available in primary care settings while tier 3, 4 and specialist services are part of the secondary care. There is no Tier 3 or 4 services for CAMHs within secondary care. The independent sector agency/company provides specialist and tertiary services. Enhanced services are optional for GP practices and are essential or additional services delivered to a specified standard; or more specialised services not provided through essential or additional services (RCGP, 2009). 21

24 Table # 4 Outreach services for Homeless people in Luton Level of Health Care Mainstream services Mainstream services Mainstream services Core Service Mainstream services Mainstream services Mainstream services Generic Service Mainstrea m services Mainstrea m services Mainstrea m services Dedicated Homeless Service Name Role Detail of the service Luton Health Luton Community Community Visitor Services Health services Visitor- Health for Homeless & Travellers Team GP Practices Dental Mobile Unit Dr Rieger and Partners Dental Mobile Unit (HHAT) Provides outreach health care to clients at the NOAH centre Provides outreach dental care to clients at the NOAH centre Local Enhanced Service (LES) provision NHS Luton s strategic plan (NHS, 2009) places priority on transforming and strengthening primary medical care services and it is known that local enhanced services play a key role in achieving this. The main purpose of enhanced service is to expand the range of services provided in the primary care setting. There is a Local Enhanced Service (LES) agreement between NHS Luton and two GP practices; they both continue to provide health care to marginalised groups. These two practices each provide this service to a distinct population: Dr Rieger & Partners provide a primary care outreach clinic to the homeless population attending NOAH (see section 4.1.1) and Dr Warriner & Partners provide a primary care service to the traveller s site on St Thomas Road. A separate health needs assessment report for Gypsies and Travellers is available from NHS Luton upon request Bedfordshire Community Dental Health Service The Mobile Dental Service is an integral part of the Bedfordshire Community Health Services (BCHS). It provides oral health care to patient groups who are unable to access dental treatment in general dental practice environment or clinic based surgeries in Bedfordshire. This include people accessing the homeless centre, special needs primary and secondary schools, adult special need day centres, residential care homes, psychiatric secure unit and patients who may be seen on a domiciliary basis (DOH, 1997). 22

25 In Luton, the service provides full comprehensive dental care and oral health education for clients attending the NOAH using a fully equipped dental Mobile Unit. It operates closely in conjunction with the NOAH staff all day every Monday from 09:30am to 5PM. The service also arranges a dental treatment to be carried out under conscious sedation or general anaesthetic at the general district hospital. The dental service has special facilities to allow disability access or specialist practitioners with expertise in treating homeless people. In addition the dental service undertakes other responsibilities of dental health promotion, general unaesthetic; oral screening for children in state funded and of other client groups with special needs Mental Health Homeless people are expected to access mental health services as the rest of the population. It is anticipated that referrals to mental health services are via numerous sources including GPs. According to mental health service, homelessness should not be a barrier if a homeless person is appropriately, identified and signposted. However, agencies working with homeless people and some homeless people see things differently. Adult Facing Chronic Exclusion (ACE) Pilot project has become a catalyst for a constructive and effective partnership between NOAH and a number of agencies including the Primary Care Trust, Mental Health Partnership Trust, Drug & Alcohol Partnership, Local Authority, Community Police Division, Probation Services and other voluntary organisations (see section 4.4 for more details on mental health services in Luton). This HNA recommends piloting an outreach healthcare service in Night Shelters, Hostels and severe cold weather facilities. The outreach service would follow the model of the Bedfordshire Community Dental Health service. 23

26 4.0 Universal Services These are services commissioned by NHS Luton and are available to the general population. These services are not specific to a particular group or population. They include primary and secondary care services. Primary care is the term for the health services that play a central role in the local community: GPs, dentists; practice nurses, pharmacists, community therapists and midwives. In general, primary care is the entry point into the health care system and most (80%) people in England begin and end their health care journey with primary care (DH, 2009a). Secondary care refers to hospital and acute care services. 4.1 Hospital Admission and discharge In discharge from hospital: pathway, process and practice (DOH, 2003 ) the Department of Health stated that all acute hospitals should have formal admission and discharge policies ensuring that homeless people are identified on admission and that their pending discharge be notified to relevant primary health care services and to homelessness services. Inadequate discharge, arrangements may create a cyclical situation with homeless people repeatedly needing to return to A & E services because their situation makes it difficult to recuperate or causes further health problems (Victor et al, 1989 Scheuer et al 1991, Fergurson, 1997). More recently, Our health, our care, our say ( DOH 2006), clarified that enhanced integrated health and social care can help prevent the inappropriate use of specialist or acute health care and can help prevent or reduce homelessness. Commissioning a patient-led NHS Delivering the NHS Improvement Plan 4 emphasises the need to change systems to be more responsive to patients needs through better integration of services. Hospitalisation of a homeless person presents an opportunity to deal with underlying medical, social, and mental health problems, and to address their accommodation needs. More work needs to be done to support the hospital admissions and discharge multi disciplinary teams to ensure homeless people that present at the hospital have their health needs assessed and appropriately referred. 24

27 4.2 Hospital Accident and Emergency (A & E) Homeless people use of A&E services is a likely indicator of inadequate access to primary care. In Scotland and England, there are concerns that homeless people present to A&E with health problems that GPs could have handled (Powell, 1887, Collins, 1997) (See section 5.3.4). Based on the Health Survey Questionnaire, it is possible to identify the number of people who sustain their health care through the A&E service. (See section 7.1). During this HNA period, contact with Luton and Dunstable A& E department, gave an impression that there is little evidence of Homeless people using that service. The term for recording homeless is NFA No Fixed Abode many homeless people have a temporary address with varying levels of stability. Even those sleeping rough may have a fixed place where they sleep. There is a need to use a precise definition of housing status instead of using the term (NFA). This will be useful in sustaining a person s tenancy or secure appropriate accommodation. Staff operating severe winter weather shelter in Luton noted that some homeless people had to be taken to the A&E. In addition, other people refused the offer to go to the hospital in anticipation of transport problems to return to their usual place of residence. The hospital admission teams including A&E should revisit their registration of people s housing status, ascertain at the point of admission the risk of homelessness, and inform the discharge team. Recording of accommodation status at a point of hospital admission will help to identify people who are homeless, or at risk of becoming homeless. The issues facing NHS Luton in meeting the health needs of its population is captured in its three strategic priorities of improving public health by focusing on improved self care, disease prevention and targeted interventions to meet the needs of its most deprived and vulnerable groups (NHS Luton 2009/10). On discharge all patients have a letter automatically generated for their GP outlining what treatment has been given and if a diagnosis has been made as well as any follow up procedure necessary (L&D 2009).This arrangement risks excluding those homeless people especially the rough sleepers who may not have any historical link with a health service. This HNA strongly recommend a specific discharge and admission specific for the homeless people. 25

28 Homeless people in Luton, like the rest of the population also use A & E services. However most homeless people, compared to house based individuals they appropriately present themselves to the emergency services. While homeless people may present with more minor problems, significant numbers do present appropriately, because they have experienced trauma or are critically unwell (North et al, 1996). It is important to consider and institute discharge arrangements for homeless people who present at the A & E, even if they do not require admission or a bed. On discharge all patients have a letter automatically generated for their GP outlining what treatment has been given and if a diagnosis has been made as well as any follow up procedure necessary (L&D 2009). Potential problems may arise if that person is has no regular contact with his or her GP. 4.3 Primary Care Services Most people share the view that being homeless provides a challenge in attempting to secure permanent register with a GP. Inappropriate use of emergency services by lone homeless people is indicative of poor access to primary care (Powel, 1987). This HNA did not find evidence of GP outreach services to hostels or people in temporary accommodation. However, a named specialist Health Visitor supports homeless families with children only. 4.4 GPs and Nursing services NHS Luton has commissioned services for the convenience of marginalised groups and hard to reach communities (see section 3.2). Some focus groups participants in temporary accommodation confirmed that they use universal GP services. 1. NHS Luton should consider allowing an exception report by Dr Rieger and Partners of the homeless and hard to reach patients. This should be in relation to prescribing and secondary care costs against their indicative Practice Based Commissioning budget, as these patients are not registered with the practice and therefore there is no indicative budget allocation yet they do incur spend against these patients 2. This HNA recognised that the responsibility and commitment seem to be centred on the two Medical Practitioners, and the value of this work is perceived not to be shared by some staff members at the practice. 26