How the Health and Care Bill can help the homeless and socially excluded

The Health and Care Bill currently going through Parliament will make better integration of health and care services a fundamental objective for the system. Who would argue with this? We can all think of examples where more co-ordination and joint working across the boundaries between departments, organisation and jurisdictions should make services better, and more efficient.

However, for many of our patients, better integration is not just a matter of improved care quality or patient satisfaction, but of life and death. People experiencing homelessness die around 30 years earlier than the general population. The average age of death is 46 and 43 respectively for men and women experiencing homelessness. Whatever is precisely meant by “integration”, health and care services working more closely together must be central to our joint efforts to tackle Britain’s widening health inequalities. Provision of decent services to the most excluded should serve as a benchmark for health and care; if we get access and outcomes right for the most marginalised in our society, we will likely get it right for everyone.

The extreme health inequalities faced by people who are homeless are sobering; a recent study found 50-year-olds in homeless hostel accommodation in London had levels of frailty routinely found among 89-year-olds. The homeless hostel residents had an average of seven long-term conditions, far higher than people in their 90s. Tragically, most deaths in this group are from preventable or treatable conditions.

Over 50 years ago Tudor-Hart observed that people who need care most were least likely to receive it. The barriers to care faced by people experiencing homelessness are often overwhelming. Alongside the direct stresses of poverty and chronic insecurity, people often feel shame, they are fearful of being asked to prove their address or provide photo ID, of repeating their story again and again to fragmented services; being on the street or moving between emergency temporary accommodation means follow up gets lost, and of top of this there is a lack of awareness among many healthcare professionals of the specific needs of people in this group.

Time and time again we see people fall through gaps in care, leading to attendance at the only place they feel they can go: the emergency department. People experiencing homelessness attend A&E six times as often as people with a home, are admitted to hospital four times as often, and stay three times as long.

On the positive side, over the last 10 years our shared knowledge of what works in providing health and care for people who face acute social exclusion has grown substantially: specialist services set up to address the tri-morbidities of physical and mental illness and addiction; active care coordination across health, housing, social care, and other services; using active, non-judgemental patient engagement techniques, prioritising relationship forming, and ensuring peer involvement in service design and outreach all help.

Such services have been commissioned on a wider scale as more commissioning bodies have recognised the deeply damaging impact that homelessness and chronic social exclusion have on health outcomes. But while coverage has improved, it still remains a postcode lottery. King’s College London found that 56.5 per cent of homelessness projects in England do not have specialist primary healthcare services in their area.

This is why we are working with a wide range of organisations, including Crisis, St Mungo’s, Doctors of the World, Basis Yorkshire, Refugee Council, Changing Lives, Groundswell, Praxis, MEAM, Single Homeless Project, and Friends, Families and Travellers, to promote a set of targeted amendments to the Health and Care Bill within the wider health inequalities duties being proposed. Taken together our amendments would require Integrated Care Partnerships specifically to focus on the urgent need to improve health outcomes for “inclusion health groups”, such as people experiencing homelessness, who experience the poorest health outcomes as a result of profound social exclusion.

The new structures and duties proposed in the Bill, to integrate services around patient’s needs and across organisational boundaries present the opportunity for a step-change in our collective responses to the most excluded. Our amendments would ensure Integrated Care Partnerships cannot simply look away from our population’s needs and help us all get care right for some of the people in our society who would benefit from it the most.