A review of the health needs and healthcare costs of rough

sleepers in the London boroughs of Hammersmith and

Fulham,

Kensington and Chelsea, and Westminster

Rough sleepers needs assessment

The review includes three work streams:

Literature review - to set the scene, understand the health needs, and identify interventions to support rough sleepers

Qualitative research - interviews to understand the barriers to healthcare (undertaken by Broadway)

Analysis of hospital data to understand the healthcare utilisation

Setting the scene (literature review)•Health needs – most common are alcohol or drug dependence,

mental illness, and dual diagnosis. Homelessness is associated with tri-morbidity

•Service use – greater use of A&E and hospital services than general population. Rough sleepers face a range of barriers to accessing services

•Costs - homeless people consume about 4 times more acute hospital services than the general population, costing £85m. Very little cost effectiveness research – although some economic evidence for intermediate care

•Effectiveness of interventions - overall lack of good quality research, although some evidence for case management for mental health and substance misuse, and that housing should be provided as part of integrated model.

•Models of service delivery - models of care range from mainstream practices providing homeless services to fully coordinated primary and secondary care. Discharge planning should be a component of an integrated model to prevent inappropriate discharge back on to the streets and reduce emergency readmissions

Reducing barriers to accessing healthcare(qualitative research)

As identified in the qualitative study, there are examples of practice which could enhance access to health services and improve health outcomes:

health services removing barriers to access and enhancing patient experiences

using homelessness support services to enhance access to health services

taking services to where homeless people are

services coming together to improve joint working

Examples to support access to health services(qualitative research)Enabling access

Specialist homeless GPs GPs registering people without the need for proof of identity Local accommodation projects which have a health focus Accompaniment to appointments, eg Groundswell peer health

advocates Open referral system to secondary healthcare, eg UCL

Pathway team

Bringing services to the patient Day centres where health services are brought in Outreach e.g. outreach team that are accompanied by a mental

health social worker and in nurses from GP practices going out with the homeless outreach teams

Hostel in-reach One stop shops, eg a supported accommodation projects

offering regular ‘health MOT’ sessions Working across service and organisational boundaries

Find and treat tuberculosis services Dual diagnosis outreach worker

Discharge from hospital (qualitative research)Concerns include:Early discharge before patient feels health needs have been

fully met.Discharge to the street either because homelessness is not

identified or hospital staff do not make the necessary referrals following the disclosure of homelessness.

Poor communication between service providers upon discharge.Discharge without clothing or transport.

Suggested improvements:The provision of respite accommodation with adequate

healthcare.A system of care coordination for every homeless person to

ensure that all their health and social care needs have been fully addressed

Analysis of hospital data3450 individuals confirmed to be rough sleepers was

identified from the CHAIN (Combined Homelessness and Information Network) system and matched with NHS general practice registered data.

Those rough sleepers from CHAIN were identified between January 2010 and December 2011.

933 patients had NHS numbers within Health services data.

For those rough sleepers:High proportion of 30-59 age population compared with INWL

general population

Common countries of birth: UK (49%), Poland (12%), Ireland (4%), Lithuania (4%), Romania (3%), Portugal (2%), Rest from 76 other countries

More than half of rough sleepers had contacts with a hospital

Out of 933 patients that registered with a GP practice in INWL

GP practice 555 patients had

contacts with acute NHS hospital.

Nearly 40% of rough sleepers

attended all three types of hospital services (A&E, outpatients and

inpatients)

Hospital Activity ratios for rough sleepers,compared with INWL general population

Rough sleepers have significantly

high hospital activities

compared with general

population

Total cost of services for rough sleeping population, split by hospital service per year

Excess hospital cost of rough sleeping per year = (real cost of rough sleeping per year –Estimated cost for 933 patients from Inner North West

London with same age and gender

Rough sleepers have high rates of did not attends (DNA) to hospitals

One Westminster based GP said:

‘We need to be as concerned with the people who do not attend the service as the people who do, cause often the ones who are not attending us have the greater need.’

10% of rough sleepers contribute to 50% of health care cost

Other findings (data analysis)Increase in trends in hospital activity: 2 fold

increase in rate of hospital activity from 2010 Jan- 2011 Dec to 2012 Jan- 2012 June period.

Outpatient activity: Rough sleepers have high number of attendance due to mental illnesses, trauma & orthopaedics and alcohol related attendance

Inpatient activity: Rough sleepers have significantly high emergency rates while low rates elective admissions compared with general population.

Inpatient activity: Main diagnosis for admissions for rough sleepers are mental illnesses, injuries, poisoning, alcohol related problems and musculoskeletal problems.

Number of rough sleepers in Westminster by ward location of GP practice

Ward location of GP practice Number of rough sleepersSt James's 312West End 59Warwick 40Westbourne 36Harrow Road 26Vincent Square 25Church Street 18Little Venice 13Maida Vale 11Queen's Park 9Marylebone High Street 8Churchill 7Hyde Park 6Knightsbridge and Belgravia 5Tachbrook 5Abbey Road <5Bayswater <5Lancaster Gate <5Bryanston and Dorset Square <5Regent's Park <5

Final Summary Hospital utilisation and hospital cost for rough sleepers are significantly

higher than the tri-borough general population

Rough sleepers have a high proportion of co-morbidities and a high frequency of attendances/ admissions. A small sub group of rough sleepers have a particularly high level of need - 10% of the rough sleepers accessing hospital services consume approximately 50% of the total cost of hospital services

Commonest diseases for these rough sleepers are Mental illnesses,

Alcohol related diseases, Trauma & Orthopaedics. Rough sleepers have high rates of DNA (did not attends)

Access to healthcare is problematic and rough sleepers face many barriers e.g. GP registration

Integrated model of service delivery needs to ensure access to a package of care which links health, social care, housing, and voluntary sector provided ser vices. Discharge planning following a hospital admission requires joint working and an agreed process.

Next Steps

Central London CCG programme of work:

- Targeted health promotion with ‘Groundswell’: peer advocacy to support the highest users of secondary care- Nurse outreach service- Community hepatitis C treatment service

Commissioning cycle