Lived experience of dual diagnosis

    David, shares his experience of homelessness as well as overcoming alcohol abuse and mental health struggles.

    I’ve had depression, anxiety and OCD intrusive thoughts since I was around 9 years old. It was pretty scary at that age, as I had no idea of what was going on. I remember feeling apart or different from everyone else, and had a feeling that something was just ‘not right’. On the outside I was quite a happy outgoing friendly kid, but on the inside I was very unhappy and lonely.

    I first discovered alcohol at around the same age 9-10. I vividly remember the effect of alcohol leaving me calm and relaxed, and feeling ‘normal’, whatever normal means? It was a very addictive feeling. The only problem was once the alcohol wore off, the mental health problems came back. I didn’t realise it then, but I had learnt to self-medicate.

    I did try to reach out to my family and GP in my late teens and early twenties, but they didn’t understand what was going on. That left me feeling ashamed, stigmatised and misunderstood for many years. I remember telling myself ‘I’ll just get on with it myself ‘and ‘drink my way through it’. I was alcohol dependent by the time I was around 23. I was now caught in a trap, I couldn’t stop drinking because I would get withdrawals, and was also afraid to stop due to being mentally unwell.

    I continued to drink daily for many years, and ended up park drinking and street drinking. I developed alcoholic hepatitis which was really painful and was told by Doctors I had a year to live. But I was more afraid of stopping drinking than dying. I have no idea why I stopped drinking, but looking back it was a combination of a lot of factors. The main one being able to talk to someone in MH services openly about my MH issues without feeling judged for the first time. This was a very freeing experience.

    Stopping drinking was really hard, as my MH problems worsened instantly without the alcohol. I can’t explain how hard it was to go through it, especially as I knew one drink would take it all away. But I didn’t drink and threw myself straight into recovery. I started taking medication for my MH problems, I engaged with local MH services, had therapy, attend fellowship meetings, went back into education and volunteered at various local services.

    It hasn’t been easy in recovery, I was made homeless early on and that was a pretty hard time. I have SHP to thank for helping to rehouse me. I now believe I’ve come full circle working for St Mungo’s, and feel privileged to be able to help those who going through the same issues I once had. I still have to look after my mental health, but I’m doing well. Recovery has been a life changing experience it’s been incredible, and I haven’t a drink or drug now for over 12 ½ years.

    A Mental Health Act that works for vulnerable people

    This week we submitted our views to the public consultation on reforming the Mental Health Act. Emma Cookson, our Senior Policy and Public Affairs Officer, outlines what we want the legislation to remember about people who are homeless experiencing mental ill health.

    How many people who are homeless do you think suffer from mental ill health?

    From October to December 2020 our data showed that 72% of people accessing St Mungo’s housing-related support services had a mental health support need.

    The Mental Health Foundation (2015) found that depression rates are more than 10 times higher in the homeless population, and Office for National Statistics data for 2019 shows suicide rates 14 times higher than among the general population.

    But all too frequently people tell us they can only access help when they reach crisis point. And then even once they receive help, they can often be disempowered and not treated with dignity and respect.

    The role of complex needs and multiple layers of disadvantage – like homelessness – in people’s mental health and access to mainstream services is also completely under-acknowledged. Research carried out by St Mungo’s in 2016, for example, revealed that 68% of areas where 10 or more people sleep rough on any one night do not commission any mental health services actively targeting people sleeping rough. There has been some positive progress with the £30m in NHS funding to enable specialist homeless mental health services to be set up in some parts of the country. However, there is still plenty more to do.

    It’s been two years since the Independent Review of the Mental Health Act, led by Professor Sir Simon Wessely, which recognised the need to give people more say in their own treatment; to require stronger, transparent justification for using compulsory powers; and to improve services.

    It also highlighted the huge race inequality in the use of the Act: black people, for instance, are more than eight times more likely to be subjected to Community Treatment Orders than white people.

    In response, the Government has now published its long-awaited White Paper on reforming the Mental Health Act and held a public consultation on it. This is a huge opportunity to reflect the needs of St Mungo’s clients and ensure that people who are homeless are not forgotten in the reforms.

    Here are the main points we put forward in our submission:

    • We need more focus on prevention, rather than only being able to access help once someone has reached crisis point. Many homeless people are not engaged with statutory mental health services (for reasons including a lack of trust in services and barriers in access). This lets problems escalate. Specialist homeless mental health services are an invaluable means of overcoming the inaccessibility of mainstream health services. But these teams have been subject to major funding cuts during the past decade.
    • Wherever possible, successful community-based interventions are much more preferable to the situation where people are held in a secure, medicalised setting with other people who are also very unwell, with huge restrictions on their choices and freedoms, and where treatment may be administered against their will. Sometimes detention is necessary – but we want it to be a last resort.
    • Housing needs are too often forgotten in both prevention and recovery from mental ill health. Homelessness is toxic to mental wellbeing. To stop a cycle of discharge, re-admittance and worsening mental health, we need more Supported Housing and Housing First which can play a big part in improving mental ill health.
    • People who are homeless face significant stigma, including from ‘professionals’ in positions of responsibility. We need to make sure that there are checks and balances in place to prevent this. We also need more awareness of complex needs amongst mental health professionals to understand the complexities of being homeless with mental health needs.
    • Many people who are homeless with mental ill health have complex trauma. It’s crucial that detention – and other responses to mental ill health — do not re-traumatise the individual, exacerbating mental ill health and creating more difficulties in addressing other, intertwined problems – such as homelessness, substance use, chronic physical, health problems and crime.
    • Even though there is National Institute for Health and Care Excellence (NICE) guidance in place to prevent it, people are frequently pushed into individual treatment pathways. Mental health, homelessness, and drugs and alcohol services are all designed and funded as if people fit into one box, rather than the reality that people’s problems are complex and interwoven. They cannot be addressed one-by-one but need to be approached holistically.

    It’s so important to have a Mental Health Act which works for vulnerable people – like our clients — who find it difficult to engage in mainstream services and who need person-centred care which takes into account their complex needs.

    Just changing the law won’t be a magic switch. Money is needed for chronically underfunded mental health services and we need attitudes towards mental ill health to shift, although there’s been some good progress. Overhauling the Mental Health Act 1983 is a good place to start.

    World Social Work Day: “I am because we are”

    Today (16 March 2021) is World Social Work Day, which recognises the hard work and dedication of social workers, as well as celebrating best practices in social work. This year, the theme of World Social Work Day is “Ubuntu”. Here, Toni-Lea John-Baptiste, a student social worker on placement with St Mungo’s, discusses the concept of Ubuntu and how it applies to the work we do with our clients.

    I have recently been working as a student social worker with the St. Mungo’s Wellbeing Team in Westminster. While working with the team, I have gained invaluable transferable skills that I will use in my future practice, and I have gained a deeper understanding of the importance of creativity in social work, as well as how social workers can use these skills to think outside of the box when working with service users.

    Due to the current climate of COVID-19, I have had to adapt to remote working. This situation enabled me to draw upon my creativity to engage service users and promote digital literacy in a time where we heavily rely on technology.  Upon reflection, I have realised how important creativity is as a social worker, to be able to adapt and work in any environment.

    The idea of Ubuntu is all about humanism. It is the belief that your sense of self is shaped by the relationships you have with other people ‘I am, only because we are’, and this was a key theme throughout my placement at St Mungo’s. As an example, we used this philosophy as the basis to create a postcard project which involved members of the Westminster community sending ‘messages of hope’ and discussing things that have helped them during this time, to residents within the different projects of the Westminster Wellbeing Pathway.

    At the heart of this project was a sense of community and helping one another, through encouragement, regardless of who the person is or if they even knew them. This was ubuntu in its purest form, as the project was all about helping one another as humans and extending love and hope to echo the philosophy that as a human ‘I am’ ONLY ‘because we are’. It was a truly beautiful project that I am grateful to have been a part of.

    My placement has encouraged my creativity as a student social worker, which has played a big part in me developing projects to engage clients. I found that when working remotely, using a person-centred approach to develop tailor-made projects for clients was the best way to engage and support them.  An example of this would be my work with a client, in which I used a strengths-based approach to create a project based on their artwork. This then led to working on an intensive 1-1 basis, to create a virtual art exhibit with this client, to not only showcase their artwork, but also potentially create a social enterprise opportunity.

    Throughout all of this, particularly because of COVID-19, I’ve realised that you can’t limit social work to a building or a particular place. It’s about treating people as humans, with respect and dignity.

    The Independent Review on Drugs is an opportunity for bold change

    Today, St Mungo’s put forward a written submission to the Independent Review on Drugs by Dame Carol Black. Here Emma Cookson, Senior Policy and Public Affairs Officer at St Mungo’s explains what this review means and the primary calls St Mungo’s is making towards it.

    This is the second part of the review which is examining drug prevention, treatment and recovery (the findings of the first part were published in February this year).This is a huge opportunity to reflect the needs of St Mungo’s clients, and the many other hundreds of thousands who are homeless and face multiple layers of disadvantage.

    Sadly, as we are all too aware, there is a significant relationship between homelessness and drug and alcohol problems, which becomes even more pronounced amongst people sleeping rough. Data from the Combined Homelessness and Information Network (CHAIN), a multi-agency database recording information about people sleeping rough in London, shows that 62% of people sleeping rough had a recorded drug or alcohol need in 2018-19.

    And it’s not just that people who are sleeping rough have a higher likelihood of drug use – they are also more likely to die from it. The Office for National Statistics (ONS) data shows that in 2018, 726 people died while rough sleeping, with a staggering 40% of all those deaths related to drug poisoning. And it’s getting worse. The St Mungo’s Knocked Back report earlier this year showed that the number of deaths caused by drug poisoning increased by 135% between 2013 and 2018 and by 55% in just one year in 2018. This is an alarming increase.

    For many of our clients, drug use, alcohol use, poor mental health and homelessness are interlocking and mutually reinforcing problems. CHAIN data shows that over half of all people with a recorded drug and alcohol problem have a co-occurring mental health problem. These problems create a vicious cycle from which it is hard to escape. If you just address one of these without tackling the other, you are unlikely to be successful. But this is all too often what the current system does.

    A St Mungo’s Manager set out the disjoint between systems:

    Someone goes into prison and whilst they’re in prison they’re detoxed. But then they’re released and told to go to housing department who say they’re not priority need. They’re then picked up by an outreach team and the only place available is a hostel where there are lots of drug users. This isn’t going to help them in their recovery.

    The vicious circle continues. 

    Health, homelessness, and drugs and alcohol services are all designed and funded as if people fit into one box, rather than the reality that people’s problems are complex and interwoven. They cannot be addressed one-by-one but need to be approached holistically.

    This is why in our written submission to the Black Review we’re calling for the following:

    • Integrated, person centred and holistic services.

    To best support people we need integrated support and housing pathways, with a treatment package arranged for them in a way which works for them in that particular point in their recovery journey. One of the best ways to do this is through increasing joint commissioning and explore longer contracts. This would help health, homelessness and drug and alcohol services to work better together and encourage them to treat clients holistically rather than providing insular support related only to one need, whilst clients are caught in the gaps in between services. Longer contracts provide the time to build practice and culture change.

    • Access to affordable and appropriate housing.

    Access to affordable and appropriate housing can act as both prevention and cure for drug misuse. Therefore we want the Government to improve access to truly affordable housing by increasing investment to build 90,000 homes for social rent every year for 15 years, and improving security for tenants in the private rented sector by, for instance, re-aligning Local Housing Allowance Rates to cover the 50th percentile of local rents. There also needs to be an expansion in Housing First services (backed by sufficient funding) and an increase in supported housing provision. This would help prevent individuals from becoming homeless, and rapidly relieve their homelessness if they are forced to sleep rough.

    • Further funding for drug support services.

    There needs to be more funding for services which are interlinked with drug misuse, such as homelessness support services, to support an integrated approach which looks at the whole system and situations which both cause and exacerbate drug misuse. Previous research from St Mungo’s has shown that £1 billion less is being spent on housing related support services per year (which help many people with complex needs, such as drug misuse, gain and retain accommodation) than a decade ago. We are therefore recommending that the Government invest an extra £1 billion a year in services that prevent homelessness and end rough sleeping. This money should be ring-fenced so it can’t be spent on anything else. This echoes our calls in our Home for Good campaign. 

    This review is timely. In the midst of this global pandemic, the health inequalities suffered by those who are homeless have become even starker. This is a chance to put forward bold solutions, which recognise the need to see drug prevention and recovery as interwoven with other systems and services. People aren’t boxes — they have messy, complex lives. We need a whole systems approach which recognises this, so that we can effectively help people.

    The power of peer mentoring

    In this challenging time, it is more important than ever to look after your own mental health, as well as look out for the people around you. Here, we are highlighting the incredible work of our volunteers. During lockdown they have adapted how they work to carry on supporting our vulnerable clients with their mental health.

    Physical or mental health problems can be both a cause and consequence of homelessness. At St Mungo’s we take a holistic approach to mental and physical health, addressing these issues alongside each other. We run mental health dedicated services in Bath and our Building Bridges to Wellbeing programme empowers people to use their experience of managing their mental health to help others.

    Building Bridges to Wellbeing has a peer mentoring service where volunteers use their own experience of living with mental health challenges to help and support clients to improve their wellbeing, confidence and mental health. These volunteers, known as Peer Mentors, work on a one-to-one basis with their clients. They support them to explore how to make small changes, look at their interests and options available, hopefully enabling them to link with their community by joining groups or courses, planning and supporting them to make small steps towards this goal. Mentors use their own experience of living with mental health challenges to build this relationship and share useful tools and resources.

    However, due to safety guidance and Government restrictions relating to Covid-19 pandemic, this was no longer possible. Our peer mentors have adapted quickly to the Government’s measures and put in place a new way to support clients remotely. Our clients are now being supported by regular wellbeing phone conversations with their peer mentor, some have even started using video link calls, to share resources and encourage positivity in regards to exploring things they can engage with. We are working with local partners, to distribute wellbeing packs that include activities, puzzles and techniques to help with any mental health difficulties arising during lockdown.

    What is it like being a part of the programme?

    Two of our mentors, Zoe and Dena share why they got involved with the Building Bridges to Wellbeing programme and what it means to them.

    Mentoring has given me back a purpose.

    Zoe wanted to get involved with peer mentoring following her own personal battle with mental illness after the breakdown of her marriage and working long hours at a job in social care. Through various drug treatments, Cognitive Behavioural Therapy and the support of her family and friends, she’s been feeling stronger and felt that she wanted to give something back.

    I absolutely love what I do and I like to think I’m making a difference to those during the various stages of their journeys.

    After weeks of training, Zoe was matched with first mentee and has since been a peer mentor for five different people, supporting them with their own stories. She feels lucky to be able to support those in need during this difficult time, especially through uncertainty and loneliness in isolation. She hopes that her mentoring will lead to permanent position in a mental health setting.

    In these current times, everyone is prone to be feeling unsettled, scared and, at times, lonely, and this particularly true for vulnerable and isolated people.

    Dena, a fellow peer mentor wanted to help because she believes that mentoring and helping others is one of the key wellness techniques.

    I think the real power of peer mentoring is empathy.

    Following access to excellent resources and training through St Mungo’s, Zoe works with our clients, having a weekly a non-judgemental chat and providing support and information on the different kinds of self-care methods available that could make a difference to the client’s mental health.

    People can gain such reassurance and peace from simply hearing “I understand” from someone that they know really does.

    Mental Health Awareness Week

    Hosted by the Mental Health Foundation, Mental Health Awareness Week takes place from 10-16 May 2021. The theme is Connect with Nature.

    Knocked Back: A tragic loss of human potential

    Our Knocked Back report revealed that at least 12,000 people who are homeless are missing out on potentially life-saving drug and alcohol treatment. Oliver Standing, Director of Collective Voice, reflects on the report’s findings.

    Collective Voice is the national alliance of drug and alcohol treatment charities, whose members collectively support 200,000 people every year. A substantial proportion of these people will not only be dealing with a substance misuse problem but with other areas of severe and multiple disadvantage, including homelessness.

    For this reason, we welcome the publication of St Mungo’s latest report, Knocked Back, highlighting the growing prevalence of drug and alcohol use by people sleeping rough, and its increasingly tragic consequences.

    It will be sadly unsurprising to many in our sector to read that drugs and alcohol caused the deaths of 380 people sleeping rough in 2018 (over half the total number of people who died). But we must remain shocked and appalled at this growing public health crisis, and stay resolute in our ambition to reach the huge numbers sleeping rough who desperately need treatment but at present are not getting it – 12,000 people according to the St Mungo’s report.

    Every year people in the substance misuse treatment sector anticipate with sickening dread the latest drug death statistics. And with every year in recent times bringing more bad news, the dread only increases. In 2018, we know that hundreds of people sleeping rough died as a result of drugs or alcohol. The total number of drug related deaths are even higher, at 4,359. That’s the largest amount since we started counting in 1993 and a 16% leap from 2017’s figures. Those statistics alone make for disturbing reading.

    But what’s really disturbing are the human stories behind the statistics. Our communities have lost fathers, mothers, brothers, sisters, sons and daughters, who will no longer fulfil the promise their parents saw in their bright eyes as children, will no longer laugh or love. These are not just numbers, but a tragic loss of human potential.

    It can sometimes seem hard to determine the real-world impact of public policy making. But surely the seemingly unstoppable increase of this particular type of death marks a clear and significant failure of the public policy and political leadership necessary to protect a very vulnerable group of people.

    When it comes to people who use drugs and sleep rough we can’t ignore stigma as a factor. When people are dying on our streets from conditions we know how to treat we must ask ourselves the question — what is different about this group of people that allows this to happen well into 21st century Britain?

    The most frustrating aspect of this? That the evidence on what works is so very clear. We have a world class compendium of evidence in our “Orange Book” and multiple NICE guidelines. We have a substance use workforce not short of ambition, compassion and expertise.

    It’s welcome to see St Mungo’s Knocked Back report make clear the link between homelessness and drug related deaths. It demonstrates how some substance use outreach services, so vital in reaching people sleeping rough, have been lost in the blizzard of local authority cuts.

    While in 2013, local government was handed the responsibility for commissioning life-saving substance misuse treatment services, but it was asked to do so with one hand tied behind its back. In the eight years to 2020 local government has lost 60 pence in every pound it received from national government.

    It’s welcome to see the report stress the importance of close partnership work across the domains of severe and multiple disadvantage. People’s challenges simply do not resolve into the neat concepts such as ‘substance use’ or ‘mental ill health’ we use to think about the delivery of public services.

    On the frontline, practitioners have of course always known that partnership working across those boundaries is essential. The same can be said for service-managers, commissioners and Chief Executives. National programmes such as Fulfilling Lives and MEAM are making robust coordinated attempts to bring together these services at the local level. These are all to be welcomed.

    In the sector, we have the compassion, ambition and expertise to meet the needs of a great proportion of the people we support — we just lack the resource.

    The government’s new addictions strategy and monitoring unit should both be unveiled this year and will provide important opportunities to drive much needed change.

    I implore the government to set out an ambitious plan for preventing further deaths through the delivery of adequately funded evidence-based services — and I know that effective partnership between the substance use and homeless sectors will be essential in supporting the delivery of such a plan.

    Read our Knocked Back research.

    Find out more about Collective Voice.

    What must be done to prevent homeless deaths

    Photo of origami flowers made to commemorate those who died while sleeping rough

    Following the news of an increase in deaths among people who are sleeping rough or in emergency accommodation, Rory Weal, Senior Policy and Public Affairs Officer for St Mungo’s, discusses what must be done to combat this rising trend.

    Today we heard the news that 726 people died while sleeping rough or in emergency accommodation last year. This is a 22% increase compared to 2017, the highest year to year increase since the Office for National Statistics (ONS) started publishing these figures six years ago.

    These figures should shock and shame all of us. The figure of 726 means that someone dies while homeless every 12 hours – that’s the equivalent of two people a day.

    Moreover, these deaths are overwhelmingly premature and entirely preventable – the mean age of death was 45 for men, and 43 for women. To have so many people die in this way, in such discomfort and distress, failed by so many is nothing short of a national tragedy.

    But this is not the sort of tragedy where we simply pause, pay our respects, then move on, bemoaning the wretched luck of a particularly unfortunate group of people. It is the product of collective choices and decisions, and should be regarded as a national emergency, one which needs urgent action.

    The context to these figures is that rough sleeping has risen by 165% since 2010, the result of years of funding cuts which have devastated crucial services and the unavailability of genuinely affordable housing. More people are sleeping rough, which exposes them to a greater range of harms – a premature death being the greatest.

    To stop people dying on the streets we have to stop them living on the streets. We need to build homes, to make the welfare system truly work for the most vulnerable and to fund homelessness services to help people find a way off the streets, and out of danger, for good.

    And we must also tackle the direct causes of death – the figures show the majority of deaths are so-called ‘deaths of despair’, the result of drugs, alcohol or suicide. Drug related deaths in particular have soared in recent years, and account almost entirely for the increase we’ve seen last year.

    Just as housing and homelessness services have become harder to access, so too have drug and alcohol services, leaving many people languishing with serious drug and alcohol problems and going without the support they desperately need. We still have a situation where most of these deaths will never result in a Safeguarding Adults Review, the legal review process for deaths which have occurred due to  abuse or neglect. As a result vital lessons are going unlearned. We now need a new national system to review each and every death.

    As we consider what we need to do to tackle this emergency, we must remember each and every life that has been prematurely lost in recent years.

    At St Mungo’s, to commemorate those people who died while homeless, our clients, alongside staff and supporters, have together hand made hundreds of origami flowers, in tribute to lives needlessly lost.

    The most fitting tribute of all, however, would be meaningful government action to prevent future tragedies.

    No one should die on the streets or while homeless. This can, and must, change. You can help by taking action today.

    Help create change by backing our campaign to make the Prime Minister aware of this national emergency.

    Should we talk about death?

    Palliative Care

    Our Palliative Care Coordinator Andy Knee poses this important question and highlights the innovative ways our Palliative Care Service is supporting clients who are at risk of death or in need of bereavement support.

    Should we talk about death? In St Mungo’s Palliative Care team, we think the simple answer to this question is yes.

    Death is something that affects us all, that does not discriminate against gender, race, sexuality, culture, or religion. Many of us are fortunate to talk about death and our wishes with loved ones. But what if you don’t have a home? And what if you don’t have family or loved ones to have these conversations with?

    This is a sad reality for lots of people who experience homelessness. A reality where many of their deaths will be preventable, undignified and untimely, with no planning for their wishes, and sadly many will be forgotten.

    In 2017 there were an estimated 597 deaths of homeless people in England and Wales, which represents a 24% increase since 2013. The NHS has recently reported a rise in homeless patients returning to the streets with many observing a surge in serious illnesses in the past decade such as respiratory conditions, liver disease, and cancer. Without someone to be their voice and their advocate, many individuals will be trapped in a harmful cycle of being admitted to hospital and discharged to the streets. This is something we can change.

    Dying Matters Week 2019

    ‘Are we ready?’ is the poignant theme of this year’s Dying Matters Week, which helps to raise awareness around this issue. At the end of 2018 we responded to the increase in homeless deaths and continue to pave the way in making change for people experiencing homelessness. We know the importance of providing end of life care and support to our clients, and we are using creative and innovative new ways to provide this service.

    Our Palliative Care Service

    To mark Dying Matters Week, we’re shining a light on our Palliative Care Service. This service is the only one of its kind in the homelessness sector and has benefited from dedicated funders over the last five years.

    The purpose of the Palliative Care Service is to coordinate a flexible and responsive care pathway to support clients who have a terminal prognosis or acute and potentially fatal health conditions, and to provide them with options that protect their quality of life. The service works to ensure that our clients can access healthcare and that we provide appropriate support to help them approach the end of their life with dignity and respect.

    We meet with local health services, lead change with research, and continue to develop tools and support structures for St Mungo’s. We’re also here to support staff across St Mungo’s to feel empowered and discuss death as openly as possible.

    Our aim is to ensure that everyone experiences a ‘good death’. We are also working to destigmatise this term, which holds so much power and importance.

    New Befriending Service

    This year the service has expanded to include our Palliative Care Volunteer Coordinator, and in June 2019, St Mungo’s will launch a new Befriending Service.

    The Befriending Service will serve to support clients that are at risk of death, or clients who need bereavement support for a recent or historical loss. In addition, the Befriending Service will support colleagues and teams around loss and bereavement, reinforcing our message: “you are not alone”.

    In response to the theme of Dying Matters Week – “Are we ready?” – St Mungo’s can proudly say “We are, and will continue to be.”

    Find our more about our Palliative Care Service.

    Tackling homelessness in Lisbon

    In summer 2018 Ed Addison, Case Coordinator for St Mungo’s project Street Impact London, took part in a two week long cultural exchange programme in the USA. Since then he has also been to Portugal to see how they approach street homelessness. Ed explains more about what he learned from Crescer, an organisation which has homeless and substance use outreach services in Lisbon.

    In my work in London, I see on a daily basis how the cycle of homelessness and drug use can be very hard for people to break out of. Using drugs can make people very sick and hard for them to address some basic needs, including housing. I wanted to see if I could learn a different way to support people who are using drugs and facing homelessness, and was fortunate to be able to spend three days with Crescer, which has staff offering substance misuse and homeless outreach services in Portugal’s capital, Lisbon.

    Minimising harm

    Throughout the 1990s Portugal had high rates of HIV and opiate related death, affecting all levels of society. Many people in Portugal knew a close friend or family member who was affected.

    In 2001 the government decriminalised the use of drugs and gave organisations like Crescer a platform to use a harm minimisation approach to address the issue. This kind of approach recognises that sometimes people will not be ready to make changes such as stopping their drinking or drug use completely, and helps people to minimise the risks to themselves and others.

    On my first day at Crescer I went out with the ‘E Uma Rua’ service in the east of the city. The team was made up of three psychologists, a nurse, a social worker and a psychiatrist. I watched as they talked to people on the streets, offering harm reduction advice, distributing kits meaning people could use drugs more safely and collecting used needles in a needle disposal bin. I was moved to see how the outreach workers offered support to individuals where they were, regardless of their situation. Those they spoke to seemed to hold them in high esteem and were willing to talk about their issues.

    Crescer work in cooperation with other services including a methadone van. Once people are registered, they are able to access a mobile service to receive their methadone prescriptions from a van. This serves the city seven days a week distributing methadone to 1,200 people at four locations throughout the day and is thought to be behind a reduction seen in drug related antisocial behaviour.

    The harm reduction approach means in Portugal, whilst there hasn’t necessarily been a decrease in the number of drug users, there has been a massive drop in cases of HIV, other blood born viruses and opiate related death.

    Housing First

    Crescer also offers a Housing First service – ‘E Uma Casa’ – which provides people who have slept rough for long periods, and also have mental and physical health needs, with a home. Their approach is multi-disciplinary, meaning lots of different agencies work together to provide support. The team currently supports 36 people and is made up of psychologists, a social worker, a nurse, a psychiatrist and a peer advocate.

    The team establishes a relationship with a person living on the street over a number of months and offers them a house. Once they have a home, the team put support plans in place, conducting home visits and offering psychological support, to help manage their drug use, mental health needs and encourage development of independent living skills.

    The team also works to empower the local community to offer support to those housed in the project. For example, I saw people from a local convenience store looking after a person with mental health needs and dispensing their daily medication.

    The challenge of ending rough sleeping

    I would like to say a big thank you to Crescer for hosting me for three days and giving me a fantastic insight in to the amazing work they are doing in Lisbon.

    In London I cycle up to 100 miles a week as part of my job, finding and working with people who are sleeping rough. That equates to a lot of thinking time!

    I’ve been inspired by some of the innovations I saw, particularly those which take specialists to the streets to meet people where they are. In Portugal, working together in an interdisciplinary way is reducing harm, and linking people who are using drugs on the street with other services that could help them leave homelessness behind such as sorting out benefit claims and mental health support.

    What I have seen in Portugal convinced me that treating the issue of drug use as a matter of public health is effective. I believe it is time for the UK to follow suit and recognise the severe health crisis that is occurring on our streets, in our communities and in our prisons, often due to drug dependency and other complex interrelated factors such as trauma, and mental health issues.

    We are starting to see more funding for multi-disciplinary approaches to supporting people who are homeless. I believe introducing innovative ideas could improve health outcomes for people who are sleeping rough and using drugs, helping to reduce drug related antisocial behaviour, the number of people needing ambulance services and the number of drug related deaths.

    Find out more about our service models, including Housing First and Social Impact Bonds.

    Why it’s time for the NHS to step up and play its part in ending rough sleeping

    Rory Weal, Senior Policy and Public Affairs Officer, explains why St Mungo’s, together with more than 20 homelessness and health organisations, have joined forces to urge NHS England to spend more on specialist health interventions for people experiencing homelessness.

    Rough sleeping has more than doubled since 2010. Spiralling housing costs, increasing insecurity for private renters and cuts to services that prevent homelessness have all played their part. But rough sleeping is not just a housing problem, it’s a health problem too.

    One person dies every day while sleeping rough

    We face a situation where on average one person dies every day while sleeping rough or in emergency accommodation and many more have to cope every day with serious health conditions. Of the people seen sleeping rough in London in 2017-18, 50% had mental health problems, 43% were alcohol users and 40% were drug users. An estimated 46% had physical health conditions.

    Complex needs like these are mutually reinforcing. Without targeted interventions and support, many people end up stuck in a cycle of homelessness, poor heath, and – sadly too often – premature death.

    People can get stuck in a vicious cycle

    The issue of homeless health has gained increased attention in recent months. Over the summer the Government’s Rough Sleeping Strategy contained expectations for the NHS to be spending £30 million on health services for people who sleep rough. The Chief Executive of the NHS, Simon Stevens, also made similar promises that the needs of people sleeping rough would be addressed in the upcoming Long Term Plan for the NHS.

    This attention is welcome and long overdue. Health problems, particularly mental health problems, are often the reason why people are stuck sleeping rough. Poor mental health is an obstacle to engaging with services that can help move people off the street, while at the same time being homeless prevents people getting the mental health support they desperately need. This increases their exposure to the dangers of life on the street, and as a consequence, also increases their risk of early death.

    Urgent and emergency care costs are high

    The human costs of neglecting to address these issues are severe, but so are the financial costs. Estimates suggest the costs of treating homelessness for hospital inpatient and A&E admissions alone run to £2,100 per person per year, compared to £525 among the general population. In 2010 the total cost of urgent or emergency care for people sleeping rough was estimated to be £85 million per year, but this represents only a small fraction of the total costs to health services. The current figure is likely to be significantly higher.

    Without a conscious, proactive effort by the NHS and wider social services these barriers, and the resulting poor and costly health outcomes, will continue to persist, in turn costing core and acute services more in the process.

    The Long Term Plan is an opportunity for change

    The Long Term Plan is being developed by the NHS to cover the next decade of service delivery, and will be published later this year. It presents a vital opportunity to reduce the appalling health inequalities which exist for some of the most vulnerable and unwell people in our society.

    The £30 million promised by the Government’s Rough Sleeping Strategy is an insignificant amount in the context of the wider costs associated with homelessness. That’s why St Mungo’s, together with 20 other organisations across the homelessness and health sectors, want to see at least this amount pledged every year to develop specialist services for people who sleep rough, delivered in partnership with local authorities.

    Specialist interventions – such as dedicated mental health teams working with people on the street, or tailored services to increase access to general practice – can prevent admissions to acute service like A&E further down the line. When delivered in partnership with local agencies and homelessness services, these initiatives can be an essential in helping people off the streets too.

    We hope the contents of the Long Term Plan will build on the real momentum we have seen on the issue of homeless health in recent months.

    St Mungo’s, together with more than 20 homelessness and health organisations – including Homeless Link and The Queen’s Nursing Institute – wrote earlier this week to the Chief Executive of NHS England, calling for more action to address the appalling health outcomes faced by people sleeping rough. You can read our joint policy briefing, developed with Homeless Link, here.

    We campaign for an end to homelessness, making sure the voices of our clients are heard by decision-makers at every level. To join us and speak out for people experiencing homelessness, become a campaigner today.

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