In order for us to work towards an evidence-based end to homelessness, tackling the causes, minimising and eventually eliminating the effects, it is vital that we look at all routes into homelessness.
We know that individuals who are discharged from institutions such as hospitals, mental health facilities, prison, social care or the armed forces face higher risks of homelessness for several reasons; maybe because they were experiencing homelessness before entering these settings, or because previous accommodation arrangements no longer exist or are now unsuitable.
In England and Scotland, prisoners were released early during COVID-19 to reduce the impact of the virus on the prison system. However, this could have increased the pressures on adult social care services that were already under strain as they respond to the crisis, meaning that some people may ‘fall through the cracks’ and it could lead to homelessness and other nefarious outcomes both for these people and society at large.
In this context, understanding the impact of effective discharge planning, as well as how to implement it, becomes of paramount importance.
We conducted a systematic review which summarises all the available evidence on discharge interventions that can be used to inform policy. Following on from the review, I spoke to three individuals who had been discharged from various settings, about their experiences.
John had been in and out of prison for over 30 years and each time the discharge was the same; a small amount of money and nowhere to stay.
“In 2016 I was released with £42. I didn’t even get the sleeping bag they were supposed to give us because the prison had run out. You’d have thought there would be support around housing because obviously if you go to prison for a long time you lose your home, you lose everything. You have to wait a month before you can claim benefits, you have no options. I was given no help whatsoever and told to report to a probation officer.”
Our recent systematic review on accommodation highlighted that accommodation interventions which include high-levels of support are more successful in terms of both housing stability and health outcomes.
Luckily, he managed to arrange a stay in a treatment centre which helped him overcome his addiction problems.
“If I hadn’t arranged to go into treatment I would have without a doubt gone back to what I knew. When you get kicked out with nothing, all you think about is going back to using [drugs].”
“You feel resentful and completely let down. I didn’t waste my time in jail, I did a lot of learning, I was a peer supporter for 3 years and I got a lot of qualifications, but I was still just kicked out the gate.”
“I had childhood trauma that I needed to deal with, that’s what led me to using [drugs], so I had to first work on myself and I only managed to start doing that in 2016. Housing would have helped, but everyone who goes to jail has some form of trauma. You have to find out what's going on underneath the addiction, because no one chooses that lifestyle. Accommodation would be great, but you also need support to deal with the trauma and addiction.”
John’s story backs up the findings of the systematic review, which emphasises the importance of trauma informed approaches, planning around discharge, and coordination between different services.
At 17, Casey Armstrong was discharged from the care system into a supported living placement. After a few months, the host decided Casey couldn’t stay, which meant she was left with very little notice to find somewhere else. She ended up sofa surfing before moving into a private flat.
“Social services paid for my first months rent and the deposit on a private flat, because it would have taken months to get a council property. When you've been in care and don’t have contact with your family you don't have that to go back to if something does go wrong. Whatever risk you take there's nothing to fall back on, it’s not a good way to live your life.”
“Like now, if i drop out of college social services will stop paying me so I won’t be able to afford my rent, universal credit wouldn’t cover it. I feel like I should have been able to stay in care longer to make sure I was safe.”
“With the supported living placement, I didn’t have a choice or even get to meet her before I moved, or ask questions. There was lots of pressure to accept it because if I didn’t, they would offer it to someone else and there weren't other placements available at the time.”
To prevent experiences like Casey’s, discharge plans should be created in consultation with the person being discharged, with services communicating with the individual more effectively. If services had consulted with Casey, maybe her experience of homelessness could have been avoided.
David* is currently staying in temporary accommodation having experienced homelessness on and off since 1958. He has severe stage 4 Chronic obstructive pulmonary disease (COPD) and has been discharged from hospital straight back to the streets more times than he can remember.
“Your discharge summary goes in the bag along with your other belongings. Not once was the discharge summary read out to me, it was taken for granted that I understood all of the medical terms. One discharge summary literally said "discharged back to streets."'
“After 11 visits to the same hospital, while staying at a hostel that was giving me severe breathing problems (my room was above a residents smokers shelter), the discharge summary said ‘unsatisfactory ‘accommodation’. ”
“I had surgery in another hospital and four days later they were thinking about discharging me. (I was living in the same hostel still) I told them it would be an unsafe discharge, but no, it was deemed safe for me to go back. Then two weeks after the discharge you guessed it, I was right back again, this time I had a major flare up of COPD.”
The systematic review on discharge suggests that discharge protocols should also consider performance indicators which are in line with the prevention of homelessness. For instance, hospitals pay fines by discharging patients too late which could be changed so that they pay fines if they discharge into homelessness.
These types of measures could help prevent cases like David’s and highlight the role that different services play in preventing homelessness and addressing multiple types of disadvantage.The coordination of multiple public services is one of the crucial characteristics in effective discharge policies. He would have benefited from follow up support for his health, but also for his accommodation to be conducive to his recovery. Existing health challenges meant that individuals may be at further risk of poor outcomes if discharged into homelessness or accommodation that is not suitable to their needs.
There is a significant need to identify and implement effective policies and interventions around discharge from institutions as they could break or even prevent a costly cycle of future interactions with these institutions.
The systematic review suggests that many of the principles of Trauma-Informed Care are applicable to discharge projects including flexible, compassionate, person-centred, non-judgemental approaches.
To ensure a discharge is successful key features should include: creating a clear plan alongside the person, planning before discharge, and joint working between agencies with clear lines of accountability to ensure that no one falls through the cracks.
The results from the systematic review are encouraging, as they show that discharge programmes can be effective in reducing homelessness and hospitalisations and may be effective in reducing reoffending. However, there is a need for a deeper look into other outcomes such as health, wellbeing and employment and more research is also needed to understand how discharge from different institutions is affected by different interventions, especially in the UK.
If you would like to discuss the findings of the review, you can contact the team on firstname.lastname@example.org
*Some names have been changed to protect anonymity
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