October 7, 2021

An evidence-based approach to tackling homelessness health inequalities

Professor Gillian Leng

By Professor Gillian Leng, chief executive of the National Institute for Health and Care Excellence, and Dr Lígia Teixeira, chief executive of the Centre for Homelessness Impact

The COVID-19 pandemic highlighted how social inequality has implications for public health: rates of infection were much higher in communities where overcrowded households were more common. We know that the most extreme form of housing inequality is homelessness and it is here that health inequalities have, for decades, been greatest. Mortality amongst people affected by homelessness was around ten times higher than that of the general population, before the pandemic. This is a stark figure.

Although the government took ground-breaking steps to provide accommodation and access to services to people affected by homelessness during the pandemic, there are still many challenges in providing longer term support to this population post-pandemic. 

This is a group of people experiencing multiple disadvantages and who often have multiple physical and mental health problems, substance use problems and various social care needs in addition to housing needs. At the sharp end of health inequalities, homelessness is associated with extremely high healthcare costs coupled with appalling outcomes – we must be able to do better than this. 

While there have been some examples of good work to make healthcare services easily accessible to these individuals, there is currently no national guidance on providing joined-up health and social care for people experiencing long term homelessness. 

To help address this need, the National Institute for Health and Care Excellence (NICE) is partnering with Public Health England (PHE) and its successor organisation the Office for Health Improvement and Disparities and the Centre for Homelessness Impact (CHI) to develop such a guideline. The new guideline was commissioned by the Department of Health and Social Care as part of the Rough Sleeping Strategy and is expected to be published in March 2022.   

Tackling health inequalities across society is a key priority of NICE’s new 5-year strategy, and this project is a great example of where we can work together to improve outcomes and equal access to care in a vulnerable population. The new guideline will help all people experiencing homelessness gain access to and engage with the health and social care services they need to support them. This includes people who are sofa-surfing, those in temporary accommodation and people who are street homeless. 

This new guideline will not only shine a light on a very important issue, but also offer practical advice to commissioners and service providers to ensure they provide care that reflects the specific needs of people who are homeless. The guideline will also be used to develop a NICE quality standard.

Good research questions and evidence is a key foundation to creating effective guideline recommendations. Rather than having to start from scratch, this ground-breaking partnership has made it possible to save both time and resources by allowing us to draw on CHI’s knowledge of the evidence base, and their evidence and gap map.  

Both NICE and CHI are part of the What Works Network, which uses evidence to improve the design and delivery of public services. This is the first time that NICE and CHI have worked together in this way. Our partnership represents an exciting opportunity to bring together topic expertise in an innovative approach to developing evidence-based guidelines. 

We know that for the guideline to be effective, it will be important to share insights at the earliest opportunity as well as promote implementation through CHI’s networks. We are confident that by working together we will ensure more people experiencing the most extreme types of homelessness will have improved access to quality, well-designed, integrated health and social care services.

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