Health and Homelessness Policy: crossing the hurdles

Isobel Anderson

Origin of links with oral health research team

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Two comparative research studies

1.Reconceptualising approaches to meeting the health needs of homeless people.

Isobel Anderson and Siri Ytrehus, Journal of Social Policy 2012.

2.Meeting the needs of homeless people: interprofessional work in Norway and Scotland.

Isobel Anderson, Evelyn Dyb and Siri Ytrehus, 2012, Norwegian Institute for Urban and Regional Research.

Funded by Norwegian Housing Bank

1: Reconceptualising approaches to meeting the health needs of homeless people

Aim – look at health and homelessness policies, drawing on international context

Objectives Analyse and compare housing, homelessness and health care systems in the two countriesSet within context of wider international research literature on health and homelessness

Method – ‘Back to basics’ Literature review – in-country and internationalPolicy analysis/review – in countryExchange visits & conference presentations – develop comparisons and conceptual framework

Reconceptualising approaches to meeting the health needs of homeless peopleIsobel Anderson and Siri Ytrehus

Research for Norwegian Housing BankPublished in Journal of Social Policy 2012

Health and homelessness: international research evidence

Substantial research literature, numerous reviews– Health characteristics of homeless people– Access to services to meet health care needs

‘Lack of rigorous evaluation of the effectiveness of housing interventions in improving health outcomes in vulnerable groups such as homeless people’ (Pleace and Quilgars, 2004).

Universal or selective provision?

Universal

Full range of services in non-segregated environment

SpecialistOvercome ‘managerial

disincentives’?Preferences of

homeless people?Overcome lack of joint

working in main service?

Bridge to mainstream?

Health Care Systems and Homelessness Strategies

Norway Scotland

Universalistic Welfare Liberal Welfare (universal legacy?)

Decentralised health care system – state grants and municipal taxes (434 municipalities)

Centralised health care system (devolved) – central taxation - (14 boards, 32 municipalities)

High home ownership, very limited social rented housing,

Med-high home ownership, relatively high social rented housing

Single comprehensive homelessness strategy (inter-ministry)

Comprehensive legal framework for homelessness, (‘corporate’ but housing led)

No new or separate health services for homeless people (or indeed any group)

Some long standing and recently funded specialist separate health services for homeless people

Health care in homelessness initiatives

Norway Scotland

Goals for output (local autonomy on implementation)

National Health and Homelessness Standards for Health Boards – with performance requirements (2005)

Homelessness strategy – no specific guidance on health

Joint health and homelessness action plans – NHS boards and municipalities

Guidance on mental health care includes housing

Top-down approach to multi-agency working

Competence enhancing education programmes (homelessness)

Professional education and some new training for health workers re homelessness

Homelessness grant rarely used to strengthen health care delivery

Some NHS boards have funded specialist health services for homeless people

FEANTSA (2006) Right tohealth, access for homeless people

All EU nations reported some specialist provision to reach homeless people not in regular contact with general healthcare system

Meeting all health needs through emergency or specialist services – not quality health care

Specialist structures ‘legitimise’ exclusion? Mainstream ideal/specialist – temporary/bridge

So - Is Norway unique?Process of optimising mainstream service

access?

Impact of strategic responses to homelessness?

Norway – universal approach – less attention to distinct health and homelessness issues– Might some homeless people be receiving less

good access to health care?

Scotland – liberal – recognises exclusion but lacks effective evaluation of integrative strategies– Creates more exclusion and therefore

necessitates more complex interventions.

Important to take account of changes over time (especially in literature reviews)

EU: consensus on some need for specialist provision, but goal remains settled accommodation and mainstream health care

Both countries – need for evaluation of changing practice Integration rather than conflicting strategies?

– Scotland – moving from exclusion to integration; model for

Conclusions (study 1)

Norway Scotland

Still achieving integration?Variable practice/outcomes?

Moving from exclusion to integration

Standard bearer for universalism

Model for transitional services?

2) Meeting the needs of homeless people: inter-professional working in Norway & Scotland

Pilot project aims and methods:– identify factors that influence integration of

housing into inter-professional welfare work (Norway)

– Scotland – established housing profession– Literature review– Interviews with health and social work

professional in both countries– Develop a larger scale study (?)

What is inter-professional work?

Ambiguous? Distinct from inter-organisational work? Inter/multi- disciplinary work? Roles of housing, health, social work

professionals?– Meeting needs of homeless people– Individually and jointly?

Findings fromliterature review

Emerging conceptual analysis of collaborative working

Self-evident good? – Become the ‘norm’ but rarely rigorously evaluated

More challenging at operational level than policy/strategic level?

Much more literature on health and social care, compared to housing

Care Management approach very significant Emergent role of housing support Vulnerable groups still face exclusion

Participant Interviewees and discussants

Norway (9)– Mental Health/Alcoholism Team leader (4);

Nursing and Care Area Managers (2); Social Services Manager (2); Housing Service Environment Worker (1)

Scotland (11 – 6 individual interviews and group discussion with 5)– Community Psychiatric Nurse (1); Occupational

Therapists (3); Nursing Addictions Team Leader (1); H&H liaison (1); Care Manager (2); Case Workers (2); Social Work Addictions Worker (1).

Findings from interviews

Norway Scotland

Need for co-operation, little work time allocated. Social housing not mainstream to health and welfare work.

Joint working across health, housing and social care very much the norm.Variable understanding of ‘housing profession’ by health and social care professionals.

Varied opinions of where housing fitted in inter-professional working. Issues around training, understanding how best to resolve service users needs.

Understanding of housing needs and contributions from other professions more consistent.

Lack of strategies, guidelines for inter-professional work.

Process of increasingly embedding inter-professional working in everyday working life – but still scope for improvement.

Further work needed

Norway – possible further work on better integrating housing issues into welfare service provision

Scotland– Effectiveness of health and homelessness

standards?– ‘Reintegration’ into mainstream health care

(parallel to housing resettlement)? Fits with conclusions of oral health and homelessness

reseach.