Health and Homelessness standards
Section 2: Background
The Development of the Standards
Since the Health and Homelessness Guidance was published by the Scottish Executive in September 2001, the resulting activity and implementation of Health and Homelessness Action Plans has been the subject of some considerable scrutiny. The Health and Homelessness Steering Group (membership can be found at Annex C) formally assessed the progress made by all NHS Boards through a programme of Progress and Assessment Visits which commenced in January 2003. Each visit was organised to include the Health and Homelessness Co-ordinator and at least one member of the Health and Homelessness Steering Group. Over 40 such visits took place between January 2003 and March 2005 in addition to many more informal meetings with NHS Boards.
As a result of this intense process it has been possible to ascertain the crucial elements which determine effectiveness in addressing the health and health care needs of homeless people in Scotland. These have been analysed to ascertain the approaches that work and also those that are perceived to have fundamental weaknesses.
The process for taking this learning and turning it into these Standards has involved representatives from NHSScotland, the Scottish Executive Health Department, the Health and Homelessness Steering Group, members of the Homelessness Monitoring Group, the voluntary sector and Local Authorities as well as relevant individuals from out-with Scotland. This group has had the opportunity to comment on the Standards as they have developed and provided constructive feedback which was taken into account within the Standard Statements and Performance Requirements as well as in the remainder of the publication.
Once the Standards were sufficiently developed NHS Lothian and NHS Grampian tested out the individual Standards through a desk-based exercise. Once again the feedback assisted in the refining of this piece of work.
As a result of this inclusive process it has been possible to ensure that the Standards are firmly rooted in the learning from the performance assessment processes and the insight and experience of those working with homeless people. Therefore, whilst the Health and Homelessness Standards are challenging, they are also achievable.
Background to the Individual Standards
Standard 1 has been developed through observing the different corporate approaches to health and homelessness planning. There has been considerable variation in Boards' responses to the requirements of the Health and Homelessness Guidance (Scottish Executive, 2001) with the most significant of these being corporate support. The reports of the Health and Homelessness Steering Group show very clearly that where at a senior level there is a focus on this policy area then activity flows smoothly and the individuals tasked with delivering Action Plans are supported within a strong strategic framework. To reflect this there is a change to the accountability arrangements for health and homelessness which previously required each Board to choose their own lead officer; the Standards move to a position where this lead must be an official at Director level or above.
Strategic links are also seen as vitally important and where such links have been established there is evidence of the complex and diverse needs of homeless people being mainstreamed through wider planning processes. This was flagged as an issue in the Health and Homelessness Guidance and the Standards build on this way of working.
In addressing corporate buy-in and strategic links resources can flow towards meeting these Standards. Resources will be subject to each Board's prioritisation processes and are also broader than simply funding; experience shows that effective implementation of Action Plans is most sustainable when the individuals tasked with leading the work are also appropriately supported and resourced to ensure capacity to deliver.
Standard 2 focuses on the partnership approach to health and homelessness. Tackling homelessness cuts across the statutory and voluntary sectors and no one knows more about what works than homeless people themselves. Experience has shown that where there is in place a multi-agency group steering the delivery of the Health and Homelessness Action Plan then activity is focused and outcome-driven. These working relationships will also support Local Authorities in meeting the aims and objectives of their Homelessness Strategies.
The challenges of cross-boundary working are also recognised, so for those Boards that share Local Authority boundaries there must be good joint working and congruence of aims. Emphasis is also placed on the importance of effectively engaging with homeless people, an issue which will be followed through in the assessment process.
Standard 3 covers the need for good information and evidence on health and homelessness. The Health and Homelessness Guidance (Scottish Executive, 2001) required all NHS Boards to carry out needs assessments and the Health and Homelessness Standards build on this base. The health needs of homeless people are affected by a range of changing factors; hence the importance of ensuring information is current, and this has particular relevance as the Homelessness etc (Scotland) Act 2003 is fully implemented.
The information base can be achieved in a number of ways, so NHS Boards can tailor their approach to local circumstances including using mainstream feedback systems. In so doing, frontline staff will be assisted in their effectiveness by having the necessary information on homelessness in the local area, as a common barrier to effectiveness is a lack of insight into the nature of homelessness.
Standard 4 covers the important area of access to health services. In common with those who lead more settled lives, homeless people need to know how, where and when to access health services. However, the ways in which services respond may need more flexibility than has perhaps always been the case. Standard 4 therefore identifies some of the common barriers and specifies actions NHS Boards will need to consider if these are to be addressed.
Through the delivery of Health and Homelessness Action Plans it has been evident when such actions are taken then services become more responsive, so there is a consequent benefit for the wider population. In particular this Standard covers the usefulness of Single Shared Assessments as an appropriate way of working.
Standard 5 addresses improving service responses. In some areas of predominantly urban Scotland, specialist services are providing excellent services for those who are homeless. However, specialist services must not be the only option for homeless people, so this Standard has move on and mainstream responses at its core. There is also no expectation that all NHS Boards will develop specialist services, hence the focus on the mainstream.
Appropriate patient planning is also emphasised to reduce the prevalence of people being discharged into homeless circumstances, the incidence of which remains unacceptably high. Staff training is critical to ensuring appropriate service responses, though the content and level of training and awareness raising should be determined by local circumstances. Such training should include all relevant staff, including reception and administrative personnel.
Standard 6 formalises the use of Health and Homelessness Action Plans as the main planning tool. This Standard reflects the best approaches to health and homelessness planning and stresses the importance of making good strategic links to other relevant plans and processes. Whilst the Action Plan is in many ways an administrative tool, it is important that it is delivered and monitored in order that key issues which affect the health of homeless people are not lost.