IMPROVING THE HEALTH OF THE POOREST, FASTEST : INCLUDING SINGLE HOMELESS PEOPLE IN YOUR JSNA October 2014 Following the Health and Social Care Act 2012, Joint Strategic Needs Assessments (JSNAs) should underpin each local area s strategy for meeting the health and wellbeing needs of their population. This short briefing outlines why including and addressing the needs of single homeless people should be a core part of every JSNA so that Health and Wellbeing Boards, and local commissioners, can achieve their goals of improving the health of people in the area, and reducing health inequalities. It gives Health and Wellbeing Boards some practical examples of how this can be done in partnership with local agencies and service users. Background Many Health and Wellbeing Boards already include data on homeless people in their area as part of their JSNA. However, this varies between areas. Even where homelessness is included, the data used is not always comprehensive, and is often based on only those who are accepted as statutory homeless. While this is important, it does not provide an adequate picture of the health needs of one of the most excluded populations single homeless people. Single homeless or non statutory homeless people are those who are not owed a duty by local authorities for housing. 1 They either fall outside the definition of priority need or are found ineligible for support. 1 Non-statutory homelessness is where households or individuals are not found to be eligible, do not fall within the definition of priority need, are deemed to be intentionally homeless or have not gone through the legal application for housing.
Single homeless people may not be offered housing support by the local authority but they often have high levels of health needs and complex problems. They include people living in hostels, on the streets, in squats, and others in impermanent accommodation at high risk of homelessness and street homelessness. Research carried out by St Mungo s Broadway and Homeless Link 2 in 2014 found that consideration of the health needs of single homeless people in JSNAs is inconsistent. Only 28% included substantial information on the needs of single homeless people; a further 8% made only passing reference to their needs. We call on health and wellbeing boards to include the health needs of single homeless people in their JSNA, as part of their responsibility to improve the health of the whole population. Statutory guidance on JSNAs makes clear that the core aim is to develop local evidence-based priorities for commissioning, which will improve the public s health and reduce inequalities. 3 JSNAs should provide evidence and needs analysis to help determine how local authorities, the local NHS and other agencies meet the health needs identified. JSNAs should aim to: Provide big picture intelligence and analysis of the health and wellbeing status of local communities Identify what is working, as well as areas of unmet need Use local community views and evidence to shape the future investment and disinvestments of services. Understanding health inequalities will lie at the heart of achieving these aims. As such, JSNAs must include a particular focus on the needs and views of vulnerable people, those with complex medical and social care needs and those experiencing exclusion. The Department of Health has provided guidance on achieving this across the inclusion health groups, including homeless people. 4 Why include data on homeless people's needs? We know that homeless people suffer from poorer health than the general population and experience some of the most persistent inequalities in access and health outcomes. Single homeless people have significantly worse levels of ill health and early death than the general population: 73% of single homeless people have one or more physical health condition. For four in 10, this is a long term problem 80% of single homeless people have one or more mental health condition 2 Alcott, L Albanese, F and Hutchinson, S (2014) Needs to Know: Including single homelessness in Joint Strategic Needs Assessments Homeless Link and St Mungo s Broadway http://www.mungosbroadway.org.uk/homelessness/publications/ latest_publications_and_research 3 Department of Health (2013) Statutory Guidance on Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategies https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/223842/statutory-guidanceon-joint-strategic-needs-assessments-and-joint-health-and-wellbeing-strategies-march-2013.pdf 4 Inclusion Health (2013) Commissioning Inclusive Services: Practical steps towards inclusive JSNA s, JHWS s and commissioning for Gypsies, Travellers and Roma, homeless people, sex workers and vulnerable migrants https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/287787/jsna_and_jhws_guide_-_final.pdf
Four in 10 single homeless people with poor mental health self medicate with drugs or alcohol Some of the causes of poor health are more prevalent in the single homeless population, for example, 77% of single homeless people smoke compared to 21% of the general population. 5 As a result of their complex needs, single homeless people are costly to the NHS. They disproportionately use acute local services, at a cost four times more than the general population, while inpatient costs are on average eight times higher than the comparison population. 6 This population also has high prevalence of communicable diseases such as TB and hepatitis, particularly among those living in hostels or on the streets. There are particular challenges in screening and treating this group for such illnesses. What can be achieved? The impact of homelessness on health means it is vital we include homeless people in health and wellbeing strategies. There has already been a national commitment from the Ministerial Working Group on Homelessness to improve the way Health and Wellbeing Boards include the needs of homeless people in JSNAs. 7 Inclusion of single homelessness in the JSNA will bring a number of benefits to local authorities. It will help: Identify and address health inequalities The Statutory Guidance on JSNAs published by the Department of Health states that their purpose is to improve the health and wellbeing of the local community and reduce inequalities for all ages. 8 This guidance also notes that a lack of evidence about the needs of seldom heard and vulnerable groups may indicate that these may have unmet needs or face deprivation. People who are single homeless are one such group. The data collected on homelessness can be used to inform the Joint Health and Wellbeing Strategy (JHWS) and clinical commissioning group planning. 5 Homeless Link (2014) The unhealthy state of homelessness: health audit results 2014 http://www.homeless.org.uk/sites/default/files/site-attachments/the%20unhealthy%20state%20of%20 homelessness%20final.pdf 6 McCormick, B (2010) Healthcare for single homeless people Office of the Chief Analyst, Department of Health http://www.qni.org.uk/docs/healthcare%20for%20single%20homeless%20people%20nhs.pdf 7 HM Government (2011) Vision to End Rough Sleeping: No Second Night Out 8 Department of Health (2013) Statutory Guidance on Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategies https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/223842/statutory-guidance-on- Joint-Strategic-Needs-Assessments-and-Joint-Health-and-Wellbeing-Strategies-March-2013.pdf
Local authorities to meet their duty to engage the community JSNAs should actively engage with communities, patients, service users, carers, and providers, with a particular focus on the views of vulnerable groups. There are many ways some detailed below in which JSNAs can directly draw on the views and needs of both homeless people and voluntary and community sector organisations who support them. Achieve wider outcomes Access to suitable housing is an important wider determinant of health. At the same time, good health is also a crucial step in enabling people to move on from homelessness. What data can be included? There is no blueprint of information that a JSNA should include on homelessness. However, a wide range of relevant data can be gathered from both existing sources and from working in partnership with voluntary and community providers, who are well placed to provide this evidence. Sources of data that can contribute to the JSNA include: Housing related support client data 9 Internal client monitoring data, which is collected by a homelessness agencies about client need, demographics, outcomes Case studies of homeless people s experiences of health and social care Data from a Homeless Health Needs Audit 10 An area s Housing Needs Assessment, which should include information on unmet housing need including estimates in the number of homeless households, overcrowded households, concealed households and those living in temporary accommodation An area s Housing Stock Condition survey, which will help identify the number of dwellings in poor condition and households at risk of homelessness due to disrepair. While some relevant data is already available, local authorities should be proactive in identifying gaps in the knowledge base to avoid less visible population groups being systematically overlooked. Without focusing on groups known to face exclusion and poor health, patterns of inequality may not be identified. 9 This can include Supporting People data, which is based on information collected about people who enter housing related support services. Prior to April 2011, data collection was mandatory but it has since become the responsibility of individual administering authorities. Consequently, data is not available for all areas since this date. For more information on housing related support data see https://supportingpeople.st-andrews.ac.uk/ and http://www.sitra.org/ policy-good-practice/housing-related-support-data/ 10 The Homeless Health Needs Audit offers a practical way to collect data from homeless people across a local authority area: http://www.homeless.org.uk/our-work/resources/health-needs-audit-toolkit
The following suggestions offer a way to ensure the needs of the most vulnerable are picked up: It is important to look at statutory homelessness and non statutory homelessness as two distinct groups. Data on those statutorily homeless (i.e. to whom the local authority has a duty to house) is more readily available. Many people living on the street, in hostels and in other forms of temporary accommodation will fall into the category of non-statutory homeless. Particular steps to include information on this group should be taken. Some existing data sources can be disaggregated by housing status to identify the specific needs and inequalities experienced by homeless people (e.g. Hospital Episode Statistics can be coded by NFA, which can identify patterns of disproportionate service usage patterns among this group). Equally, mortality rates can be examined by social group or status to identify patterns of premature mortality. It is important JSNAs identify the assets as well as needs of a community. To inform responsive commissioning plans, JSNAs should pick up where services are already effectively meeting needs to promote the need for continued investment. Eliciting service user views should be an essential part of this process. Many measurements will favour groups already engaged with services or health systems. JSNAs should also identify those excluded from or not engaging with treatment in order to identify potential service gaps. For example, this could include unregistered patients, or patients turned down for treatment due to the criteria for some health and social care services. If complex and additional health needs are identified, the JSNA should examine the extent to which these are met and make provision for improving the response in the Joint Health and Wellbeing Strategy.
How can local areas ensure best information is captured? Some of the data sources highlighted above will no longer be required for central collection. Some of the information is, however, invaluable to mapping the needs of a local area s single homeless population. Thought should be given locally as to how useful information from a number of data sources can be maintained. In particular: Housing related support services information Housing Needs Survey In addition to this, a regular cycle of health needs audits, as set out above, can provide invaluable information and need not come at a high cost, particularly with local engagement of services. Luton Health and Wellbeing Board Luton s JSNA not only includes substantial detail about the health needs of single homeless people, it proactively addresses the issues that they face. It emphasises the importance of improving access to both primary and secondary health services and acknowledges some of the barriers to care. For example, it identifies a lack of mental health provision for people with substance use problems and sets out the intention to address this. In addition to the information provided in the JSNA itself, Luton has also carried out a Homeless Health Needs Assessment. This set out the following aims: 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. Luton s Homeless Health Needs Assessment initiated a review of health services in the area with the view of their effectiveness in dealing with the needs of homeless clients. Luton s Annual Public Health Report gives examples of changes made as a result of this review. One example is of an agreement between Luton clinical commissioning group and three Luton GP practices to provide enhanced services to homeless and hard to reach groups. These include a twice weekly outreach service at The Day Centre run by NOAH Enterprise, a welfare centre and street outreach team. http://www.luton.gov.uk/community_and_living/luton%20observatory%20census%20statistics%20 and%20mapping/pages/joint%20strategic%20needs%20assessment%20-%20jsna.aspx
Health and Wellbeing Boards should provide clear channels through which voluntary sector organisations can contribute views and data as part of this process. This can include: Involving organisations that represent those facing multiple disadvantage in Health and Wellbeing Boards for example, through a sub group Via existing homelessness/provider forums, which provide a useful mechanism to gather views and data from a variety of homelessness providers Contacting local homelessness agencies to facilitate consultation with their service users (use www.homelessuk.org to identify your local agencies) Hosting an open and visible channel (for example, a webforum hosted by the local Healthwatch) into which community groups and users can contribute their own data or views. The levels of need mapped by the JSNA process should provide clear priorities for action when developing commissioning plans. Progress made against meeting these priorities should be made available and reported on in the JSNA document. JSNAs will inform the development of Joint Health and Wellbeing Strategies, prepared by Health and Wellbeing Boards, as well as commissioning decisions made by clinical commissioning groups. To help commissioners use the evidence to set priorities, it will be helpful to include specific reference to how they will address any health inequalities identified in the JSNA. It is also important to ensure these commissioning plans are integrated with wider strategies and outcome frameworks, which will impact on improving health and wellbeing, such as housing, as well as the related NHS and Public Health Outcomes Frameworks. Case Study: Homeless Health Needs Audit Patterns from the local authority, clinical commissioning groups and local homelessness services in Birmingham conducted a Homeless Health Needs Audit to gather data about the service utilisation, health and wellbeing needs, and views of homeless people across the city. In total, 150 clients took part. This data was shared with the Public Health team who were conducting a deep dive into mental health needs within Birmingham. The health audit had flagged up high needs across a spectrum of different mental health problems for example 41% experienced depression and 42% of those with a mental health need selfmedicated with drugs or alcohol. The data provided a strong, local evidence base, giving the partners the ideal basis for starting discussions with Public Health teams: The data from the audit has been very useful as evidence to give commissioners and to feed into the local JSNA as previously there was a gap between our perceptions on the ground and the findings of national research studies; we now feel our views have got much more weight behind them. [CEO of local provider]
Contact us for further information Homeless Link is the national membership charity for organisations working directly with homeless people in England. We work to make services for homeless people better and campaign for policy change that will help end homelessness. www.homeless.org.uk Through this work, we aim to end homelessness in England. St Mungo s Broadway provides a bed and support to more than 2,500 people a night who are either homeless or at risk, and works to prevent homelessness, helping about 25,000 people a year. We support men and women through more than 250 projects including emergency, hostel and supportive housing projects, advice services and specialist physical health, mental health, skills and work services. www.mungosbroadway.org.uk Homeless Link, Gateway House, Milverton Street, London SE11 4AP +44 (0) 20 7840 4430 info@homelesslink.org.uk www.homeless.org.uk Chief Executive: Rick Henderson Chair: Ann Skinner Charity Registration No. 1089173 Company Registration No. 4313826 To receive future briefings or other St Mungo s Broadway information, visit www.mungosbroadway.org.uk and sign up to our e-newsletter. Dissemination of our good practice is funded by charitable voluntary income. We are grateful to our donors whose support enables us to share this information briefing. St Mungo s Broadway, Griffin House, 161 Hammersmith Road, London W6 8BS Tel: 020 8762 5500 Fax: 020 8762 5501 www.mungosbroadway.org.uk Charity exempt from registration I&P Society No. 20598R Housing Association No. LH0279 Thank you to everyone who has contributed to this report.