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January 30, 2023

Person-centred health and social care for people experiencing homelessness

Dr Lígia Teixeira

People affected by homelessness too often experience poorer-quality care, both from our health services and from the social care system. Too often care can be inconsistent, inappropriate or poorly delivered, without being personalised to individuals’ needs. 

Accessing health and social care at all can frequently be needlessly difficult for people experiencing homelessness. Even registering with a GP or being discharged from hospital can be unnecessarily complicated for a patient without a fixed address.

The Covid-19 pandemic has exacerbated health inequalities so decisive action is more important than ever. 

People impacted by homelessness have worse physical and especially mental health than patients in the general population. One survey found that 41% of people experiencing homelessness had a long-term physical health problem, compared to 28 % of the general population, and 45% had been diagnosed with a mental health condition, compared to 25% of all patients. Moreover, homelessness itself is very bad for a person’s health and wellbeing. Living in temporary or crowded or unsafe accommodation, or on the streets, is inherently unhealthy, stressful and traumatic. The average age of death recorded among people sleeping on the streets in England and Wales in 2021 was 45 years for men and 43 years for women. People need a safe place to relax, exercise and sleep to stay healthy. And, while poor access to health and social care among patients experiencing homelessness continues, they remain ‘invisible’ or under-represented in official data and commissioners of care therefore find it harder to plan for their current and future care needs. And so the pattern repeats itself.

This is the situation that prompted the development by the National Institute for Health and Care Excellence (NICE) and the Centre for Homelessness Impact (CHI) of a joint guideline on integrated health and social care for people experiencing homelessness. Its publication in March 2022 was an important step towards improving the access to and quality of health and social care for people affected by homelessness.

Other steps must follow, however. A guideline only has impact if it is implemented effectively. We have therefore produced an implementation manual to accompany the guideline and support practitioners, service providers and commissioners to help put its recommendations into practice as they deliver and plan care.

This implementation manual highlights some of the guideline’s key recommendations, summarises the evidence base behind each and gives step-by-step suggestions and at-a-glance checklists on how to work with each. Where there are examples of good practice, where health and social care services are already delivering or designing care for people affected by homelessness in similar ways, some of these are summarised as case studies in order to bring the recommendations to life.

Successful implementation of many of its recommendations requires more than just proficient care. Homelessness is, regrettably, often associated with stigma and the experience of homelessness frequently impacts negatively on an individual’s self confidence. In addition, it is important to understand that many people impacted by homelessness will have had poor previous experiences with public services of many kinds. Offering this patient group an equal standard of health and social care to that expected for the general population therefore requires empathy and, sometimes, persistence.

We hope that this resource is helpful to health and social care professionals. We wish to thank everyone who works to implement recommendations in the guideline in the design and delivery of care. If implemented as intended, this should make a meaningful and positive impact on the lives of tens of thousands of people with experiences of homelessness by giving them the opportunity to heal, recover and thrive. In doing so, it would represent a significant stride towards creating greater equality in our society. 

Read the NICE guideline on integrated health and social care for people experiencing homelessness.

Download the implementation manual.

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