Health and Homelessness standards
Section 3: Health and Homelessness:
The Key Issues
Homelessness in Scotland
Homelessness affects people throughout Scotland including in both rural and urban areas. In 2003-04, 54,829 households made homelessness applications to Scottish Local Authorities, of whom 38,659 were found to be homeless (Scottish Executive, 2004). The scale of homelessness has grown significantly since the beginning of the 1990s; in the years 1992-93 the number of homeless applicants was 42,822 of whom 30,100 were found to be homeless.
The Scottish Household Survey (NFO System Three and MORI 2002) found that across Scotland 3% of adults reported having experienced homelessness in the past which gives some indication of the level of hidden homelessness.
There have been many different attempts to define homelessness in research and there is also a definition contained in legislation in the Housing (Scotland) Act 1987 (HMSO, 1987). However, for the purposes of these Standards the definition adopted by the Scottish Executive's Homelessness Task Force should be used. This can be found in Annex B.
The Homelessness Task Force was set up by the Scottish Executive in 1999 "to review the nature and causes of homelessness in Scotland; to examine current practice in dealing with cases of homelessness; and to make recommendations on how homelessness in Scotland can best be prevented, and, where it does occur, tackled effectively". (Scottish Executive, 2002).
The purpose of the Task Force was to find ways to achieve a step reduction in the incidence of homelessness in Scotland. The Task Force recognised that tackling homelessness effectively meant not only addressing housing policy issues; in many cases homelessness is the result of wider needs not being met.
An important principle underlying the conclusions of the Task Force was that a "one size fits all" approach would not work. The Task Force concluded: ". . . all the varying needs of people affected by homelessness must be addressed individually, effectively and flexibly. If they are not, purely housing solutions are unlikely to be sustainable". (Scottish Executive, 2002). The Health and Homelessness Standards form a key element in achieving this holistic approach.
As well as those who literally have no roof, the Task Force's definition includes people living in emergency or temporary accommodation, people living in hospital or other institutions because they have nowhere else to stay, those in accommodation which is overcrowded and a danger to health, people who risk violence by living in their accommodation and households who have to share accommodation on a long term basis in unreasonable circumstances, or in other substandard or unsuitable accommodation.
It also therefore includes people who are at risk of becoming homeless, and hidden homeless households, such as those "sofa surfing" - moving from one house to another every few days.
Who is homeless in Scotland?
Homelessness affects a wide diversity of households with a range of needs. It can affect those who have suffered a disaster (such as a fire or flood), people with debt problems, people with unresolved health or addiction problems, those who have experienced abuse, family breakdown and a whole range of other circumstances. Very often a homeless person may be affected simultaneously by a number of different but inter-related issues.
Homelessness affects families with children, childless couples, same sex couples, single people (both men and women), single parents, all ethnic groups including gypsy travellers and refugees, and all age groups. Statistics from 2003-04 (Scottish Executive, 2004) show that just under 25% of those found to be homeless were single people aged under 25, around 23% were households with children, and just under 40% were single people between the ages of 25 and retirement age.
All of these groups will have specific needs both in terms of their homelessness and in their access to health services. The policies and practices NHS Boards adopt in developing their equality and diversity approach will need to take account of the heterogeneous nature of homelessness.
The immediate causes of homelessness vary greatly. Across Scotland as a whole, the two most significant reasons for homelessness are friends or relatives no longer being able to accommodate the household, 35%, and family or relationship breakdown (which may or may not involve violence or abuse) 22% (Scottish Executive, 2004). However, there are many other reasons. These may include debt, leaving institutions such as hospitals and prisons without appropriate accommodation and support being in place, leaving the care of a Local Authority, mental or physical health problems and many others. Often there will be a combination of issues which have to be addressed, as clearly illustrated in needs assessment research by NHS Argyll and Clyde (NHS Argyll and Clyde, 2002).
It is important, therefore, to recognise that reasons for homelessness will vary across Scotland and each Board area will need to understand the profile of the local homeless population in order to appropriately address their health needs.
Because of the diversity of the homeless population, responses to the health and the related requirements of homeless people need to be tailored to the individual household. Some people may benefit from specialist services, whilst most will simply require equitable access to mainstream services. Finding a sustainable solution to a household's homelessness is likely to involve different agencies working together to resolve all of the key issues.
The health needs of homeless people
The health needs of homeless people have been recognised within Scottish health policy as part of the broad goal of reducing health inequalities.
The White Paper, Our National Health: a plan for action, a plan for change (Scottish Executive, 2000), highlighted the need to improve the health of homeless people. This commitment was built upon in Improving Health in Scotland: the Challenge (Scottish Executive, 2003) and in the White Paper Partnership for Care (Scottish Executive, 2003).
Poor health is not only a consequence of homelessness but can also help to precipitate it. More generally there is a greater risk of premature death and morbidity amongst the homeless population than amongst the population at large.
There are a wide range of health problems which are more prevalent amongst homeless people than the wider population. These include chronic conditions as well as anxiety, stress, self-harm, other mental health problems and infectious diseases. A significant minority of homeless people are dependent on drugs or alcohol often alongside mental health problems and other multiple needs. A study of homeless people in Aberdeen (Love, 2002) found that only 22% of homeless people in Aberdeen considered their health to be "good" compared to an average of 77% of the general population.
A study by the Office of National Statistics of homeless people in Glasgow (Kershaw, Singleton and Meltzer, 2000) found that:
73% had experienced one or more neurotic symptom in the past week and 44% were assessed as having a neurotic disorder.
Over half experienced levels of hazardous drinking.
65% had a longstanding illness.
29% had attempted suicide.
18% had self-harmed.
The final two figures were substantially higher amongst young people.
It is important to recognise that health problems are not confined to those sleeping rough. People living in temporary accommodation, with friends or in hostels have little stability, often have to share kitchens and bathrooms and have little privacy or security. They may also experience problems relating to damp or overcrowded conditions. Research also shows that homeless families in rural areas may spend longer in temporary accommodation than those in urban areas (Fitzpatrick, Pleace and Jones, 2005). Some of the health problems arising from such circumstances include an increased risk of dermatological problems, musculoskeletal problems, poor obstetric outcomes and a range of mental health problems.
The effect on children in homeless families living in temporary accommodation can be serious. There are many detrimental effects on the physical and emotional development of children living in unsettled or overcrowded accommodation with little room to play or do homework. Studies have shown children in these circumstances to be prone to behavioural disturbance, have higher levels of illness and infection, have poor sleep patterns and are more prone to accidental injury (Quilgars and Pleace, 2003).
Homeless young people may also neglect their health needs unless they become debilitating (Quilgars and Pleace, 2003). They may also be reluctant to approach health services because they expect a hostile response.
Health visitor contact can be extremely important and may be the most frequent point of contact, especially for homeless families. However, there can be a perception amongst some homeless people that the health visitor can be judgemental of their circumstances (Fitzpatrick et al, 2005).
It can be more difficult for homeless people to sustain continuity of care, to meet appointments made a long time in advance, or to participate in health improvement and health promotion activities, such as healthy eating and physical activity. Maintaining contact with key workers such as the family GP, social workers, dentists and lawyers can be difficult if the household is accommodated temporarily some distance away from such support networks.
Research suggests that flexibility in health services for homeless people results in high levels of satisfaction (Quilgars and Pleace, 2003). It further indicates that joint working, especially between housing, care and support providers, is extremely important. However it is important that access to health services should not be conditional upon a household also making contact with other services or participating in other resettlement activities.
The Scottish Executive's response
The Scottish Executive's Homelessness Task Force recommended a holistic and joined up approach to tackling homelessness in Scotland. Part of the Executive's response has been a new legislative framework, which will give every homeless person a right to a home after 2012. (Housing (Scotland) Act 2001 and Homelessness etc. (Scotland) Act 2003, HMSO).
This will mean that a broader range of homeless people will be housed by Local Authorities and, if accommodation is to be sustained, health, social and emotional needs will also have to be addressed. A fundamental principle is that no-one should have to sleep rough. This means that there should be a safety net even for people with the most complex needs, which is likely to necessitate joint working across a range of agencies.
Linked to this framework was the Health and Homelessness Guidance (Scottish Executive, 2001) which required each Health Board to develop a Health and Homelessness Action Plan in co-operation with relevant partners. Every Local Authority is also required to have in place and implement a Homelessness Strategy, incorporating the Health and Homelessness Action Plan.
The initial Action Plans included a profile of the local homeless population and assessments of their health and health care needs. Plans were also required to demonstrate an understanding of the network of health care services that support homeless people in the area, combined with an assessment of the accessibility of services alongside an assessment of which services are, and are not, used by homeless people.
The Action Plans included implementation plans for improving services to meet the needs of homeless people, and they formed part of the NHS Board's Local Health Plan. Much has been learned from the initial Action Plans and the Standards have built upon the lessons learned.
Underpinning the framework of legislation and guidance is a new culture with an emphasis on trying to prevent homelessness where this is possible, and if homelessness does occur, to tackle the whole of a household's problems so that solutions become sustainable in the long term.
The emphasis in this new culture is to move away from a "gate-keeping" role in relation to services, towards one of seeking to meet individuals' needs. It involves proactive involvement from whichever agency the homeless person first approaches to help ensure that all the needs are assessed and addressed as effectively as possible. This includes both hard issues such as ensuring effective information sharing protocols are in place, and softer issues such as ensuring that attitudes towards homeless people encourage the use of services.
The Health and Homelessness Standards are therefore an important tool to assist NHS Boards to work in partnership to ensure that all of their activities take into account the health needs of homeless people, and to ensure that there is a commitment to helping prevent homelessness and contributing to sustainable solutions.