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.

    Why the budget 2018 is a missed opportunity for ending rough sleeping

    Following the announcement of the autumn 2018 budget, Rory Weal, Senior Policy and Public Affairs Officer, analyses what the Government’s plans mean for those sleeping rough or at risk of homelessness.

    Amongst talk of an ‘end of austerity’ budget, the Chancellor yesterday delivered one that was really a missed opportunity from the perspective of homelessness.

    It had been a positive summer, with the Government listening to the homelessness sector and deciding to keep funding for supported housing in the welfare system, as well as publishing a rough sleeping strategy which contained a variety of interventions to stop the scandalous rise in the number of people sleeping rough across the country.

    However, the Budget failed to build on these developments, and did not contain measures which will deliver on the Government’s commitment to halve rough sleeping by 2022, and end it all together by 2027.

    There were bits of positive news to be found which – if delivered with homelessness in mind – could contribute to helping people off the streets.

    A new mental health crisis service

    On mental health, there was the news that a new mental health crisis service will be developed, as part of the NHS Long Term Plan. Given the scale of the mental health crisis on the streets and the difficulty many have accessing support, this is particularly welcome.

    The service will include comprehensive mental health support in every major A&E, more mental health specialist ambulances, and more crisis cafes. We want to see this service work with people sleeping rough who have mental health problems, providing support on the street if necessary.

    More money for the NHS

    However, we know that prevention is always better than cure. We want to see fewer people getting to crisis point and helped much earlier before conditions worsen.

    People sleeping rough have much higher rates not only of mental illness, but of physical health problems too, and shockingly high levels of mortality. So the cash injection for the NHS – £20bn over the next five years – is desperately needed and clearly welcome. But we know that without a clear plan, these kinds of funding injections often don’t make their way through to helping the most vulnerable. That is why we want the upcoming NHS Long Term Plan to earmark some of these funds for specialist services for people sleeping rough, to ensure their needs are not forgotten.

    Funding to address problems in Universal Credit roll-out

    Universal Credit roll-out has had a particularly damaging impact on people sleeping rough, which is why the £1bn announced in the budget to address problems with roll-out is welcome. These problems include large deductions being taken from Universal Credit awards to repay Advance Payments and other debts such as rent arrears. We are also seeing increases in arrears for service charge in supported housing, as Universal Credit no longer allows claimants living in supported housing to request direct payments to their landlord for the likes of gas and electricity.

    The complexity of the new system means that many struggle to navigate it and make a claim without support. The cumulative effect of this is to make it even harder for people to move on from homelessness.

    We want this new funding used to address these serious problems. However, in order to stop vulnerable claimants being pushed further into destitution, we still want to see a pause in the roll-out to give time for the process to be fixed.

    But not enough to end rough sleeping…

    Despite these positive notes, the overall feeling is that this was a missed opportunity. With no funding measures on rough sleeping specifically, and no plans to tackle the key drivers of homelessness, there is still much more to do to get close to the Government ambition to ending rough sleeping by 2027.

    We need to see further commitments to increase social housing, strengthen private renting and funding for homelessness services for people to find, and keep, a home for good. We will be working to build support for these changes in the months ahead. With the numbers sleeping rough continuing to rise, we cannot afford to delay.

    Our Home for Good campaign is calling on the government to put an end to rough sleeping by ensuring that everyone gets the long-term housing and support they need to rebuild their lives. Sign Kevin’s open letter to the Secretary of State for Housing, Communities and Local Government.

    “The dignity and respect she deserved”

    Image: Map of London

    St Mungo’s project worker, Shayeena, explains how the Street Impact project enabled her to provide innovative, holistic support for our client June when she really needed it

    Working at St Mungo’s you sometimes receive some difficult phone calls. But last week I got a call that really made me smile.

    I received a voicemail from a man who had recently been bereaved. He said he was a relative of June, and was sorting out her affairs. While he was doing this he came across her old phone, and by looking at the messages she had saved, he came to understand more about June’s story, and the part St Mungo’s had played in helping her rebuild her life after experiencing homelessness. He had called to thank me for all our support for her.

    I met and supported June. She told me she had come to the UK from Ghana in 2002, fleeing domestic violence, on a three-month tourist visa. She overstayed her visa and worked informally, before borrowing a friend’s document to get official work in a supermarket.

    However, in 2010 she was diagnosed with a serious illness and her accommodation and social networks started to break down. She ended up rough sleeping in central London and eventually was picked up and placed into a detention centre.

    At this time St Mungo’s had just established our Street Impact project, which was designed to develop innovative ways to tackle rough sleeping in London. It was the first such project to be funded by a Social Impact Bond (SIB). This meant the running costs were funded by social investors, who were reimbursed by the Greater London Authority on a ‘payments-by-results’ basis.

    This meant we only received payment if it achieved certain agreed outcomes, including reducing rough sleeping and helping people into tenancies, while working with a group of 415 rough sleepers.

    Payment by results meant we were free to innovate in the ways we supported people, and take a much more holistic model in helping them rebuild their lives. June was among those 415 people.

    When we contacted the detention centre about June they told us she had been released but gave us no other information. We eventually tracked her down in north London. We sent her a letter with our phone number and she called us straight away.

    At that point June was 69, depressed, withdrawn, clearly isolated and in need of assistance. While in detention, she had been diagnosed with terminal cancer but was still living on £35 vouchers per week and sharing a room with a lady suffering from post-traumatic stress who would wail throughout the night, meaning that June was getting very little sleep.

    The Home Office eventually granted June exceptional Leave to Remain on medical grounds. Alongside her solicitor, I was able to support June through this stressful experience, and then help June to get a home in a sheltered housing scheme. This was an incredibly complicated process, involving her council’s homelessness team, supported housing team and social services.

    Because of the innovative way we were able to work within Street Impact, however, I could support June with everything from taxi fares to hospital visits, gathering evidence for an appeal and securing donations of furniture. Eventually we were able to establish a support network for June that included medical staff, social workers, the local hospice, a minister from her local church and a St Mungo’s palliative care volunteer.

    We also helped her to stay in contact with her family in Ghana, which had become harder for her as her speech deteriorated. She was 70 by then, not used to computers, and found it hard to speak on the phone. With her consent, I started emailing her family and asked her daughter to send photos of her young granddaughter (who June had never seen) and printed these all out for her and framed a couple so she could keep them in her living room. She was so happy to have these… I remember her laughing with joy and looking at the prints over and over again. In her final years she was treated with dignity and respect that she deserved.

    Much of this would have been impossible under a more conventional outreach model. Despite everything she had been through, I think June managed to trust me and my colleagues and this allowed us to help her.

    Find out more about Street Impact.

     

    “There are no words”

    Tracey Jacob, St Mungo’s Housing Management and Lettings Coordinator, based in Westminster, shares her experience of working with people who are homeless and near the end of life.

    When a person has been diagnosed with a terminal illness, there are no words that can describe the emotions or feelings.

    When a client has no family, or has not been in contact with them, or wishes for them not to be informed of their illness. When a client makes a decision that he does not want to go to hospital or a hospice but wants to stay at home. This is when you realise they may see you as their family.

    Over the years, I have known and supported people who have been diagnosed with a terminal illness.

    There are guidelines, other colleagues, to help support and direct us as staff in that situation. But it’s those words – “I want my keyworker” – which cannot be substituted.

    With one of my clients, I had to start a conversation with him about being resuscitated. I didn’t know how.

    I called his GP who arrived the same evening to ask the questions and do the paperwork.

    I had to fight back the tears as I did not want the client to see me crying.

    The GP had a one to one with me after the meeting as well, to debrief me and make sure I was OK. These are the situations that don’t get seen, or talked about.

    On another occasion, I had to go through my client’s clothes to take some to the funeral parlour, wiping away the tears as I have never dressed a person who had passed away.

    My thoughts were, I want the client to look lovely, hoping that I chose a good outfit. I was given a cup of tea and they explained that I was not expected to do this, they would do it. These are the things that don’t get seen, or talked about.

    I have worked for St Mungo’s for many years. Any death is difficult. I have learnt that it’s ok to say “I need help and support” and to step back, take a few minutes to regroup your thoughts.

    For me, I take away that the person was not alone and I did the best I could do.

    It was Dying Matters last week . Please see our other blog by St Mungo’s Palliative Care Coordinator, Niamh Brophy, on the work being done to prevent people who are homeless dying on the streets.

    Hope from terrible tragedies

    Niamh Brophy is St Mungo’s Palliative Care Coordinator. We are the only homeless organisation to have such a person, supporting both clients and staff with ‘end of life’ experiences.

    For most of us, I hope Dying Matters Week is an opportunity to talk to our loved ones about death and the things that feel important to us: where we’d like to be cared for (for most of us it would be at ‘home’), and how we’d like to be remembered by our loved ones.

    But what if you don’t have a home? And what if you don’t have a family or support network to have these conversations with?

    This is the reality for the rising numbers of people experiencing homelessness. For many, their death will go ignored, not given the dignity or respect they are due, and with little planning given to their end of life wishes or preferences.

    This year’s Dying Matters Week (14-20 May) comes at a particularly poignant time. Recently, news that the number of deaths of people sleeping rough has more than doubled in the past five years shocked the public.

    These are individuals dying in car parks, on street corners and park benches, with no one around to support them as their lives draw to a close. This is desperately sad, and something most of us would think completely unacceptable in our society today.

    But from these terrible tragedies has sprung some hope. Campaigns have been launched to address and prevent these deaths from happening in future such as the #makethemcount campaign.

    Ed Davey MP has also proposed a new Homelessness End of Life Care Bill that aims to ensure people do not die homeless and alone on the streets, but have access to care and accommodation for the end of their life.

    At St Mungo’s we contributed to both of these initiatives. But more work is needed to ensure people get access to the care they need. That’s why we’re calling on the Government to ensure a review is carried out every time someone dies on the street, as part of their new rough sleeping strategy. This would ensure deaths no longer go ignored, and that lessons can be learnt to ensure such tragedies are not repeated.

    St Mungo’s were also involved in research published last year that explored the unique challenges in providing end of life care to people in hostels. What emerged was a picture of great complexity, but also plenty of opportunity to improve the experience of residents and staff when faced with such difficult situations.

    It’s now a decade since St Mungo’s first acknowledged the importance of providing end of life care to people who are homeless by establishing a Palliative Care role.

    In response to the increase in need of our residents, and the growing numbers of people dying on the streets, we will be expanding the service in 2018 and recruiting another member of staff to ensure all residents can be supported and cared for in the way that feels right for them.

    We continue to work every day to ensure our residents can access healthcare and be supported to approach the end of their life with dignity and respect. This Dying Matters week, we would encourage everyone to start a conversation on how we as a society can prevent the unnecessary deaths of people sleeping rough, as well as how we treat homeless individuals with dignity as they approach the end of their life.

    People who are homeless and facing the end of their life

    As Dying Matters Week comes to a close, Niamh Brophy, St Mungo’s Palliative Care service – the only one of its kind in the homelessness sector in the UK – explains more about how the service helps people the end of their lives.

    Last week I met John. He is 65 and has been intermittently homeless since his marriage broke down in 2009. The trauma of losing his family meant John lost control of his life. He ended up on the streets before coming to live in one of our hostels.

    When John was diagnosed with cancer a few weeks ago it came as a shock not only to him, but to the staff and residents of the place that had been his home for the past eight years.

    I also met Stephen, his support worker, who helps him in many ways, and who is doing his best to help John do what he wants to do with the rest of the time he has.

    The link between homelessness and health is widely recognised. Our wider understanding of the experiences of homeless people dying on the streets, in hostels or in hospital remains patchy.

    People experiencing homelessness have a much higher likelihood of having a long term health condition. Illnesses can often go undetected and untreated over time if people are reluctant to engage, because of other priorities they may have around being homeless. Care can then often become crisis led, particularly if further compounded with alcohol or drug use and worsening mental health.

    A consequence of this ‘non-engagement’ is demonstrated most shockingly in the statistic for the average age of death for someone who’s been homeless: 47 for men, 43 for women.

    St Mungo’s Palliative Care service

    It should not come as a surprise to hear that most homeless people do not gain access to palliative care until very late in their illness, if at all. Often their choices for care are limited, and their death is more likely to be perceived as sudden, untimely and undignified.

    In 2007, St Mungo’s started working to address these issues and improve care services for residents with advanced ill health.

    Our service aims to give our residents with serious health concerns the opportunity to choose their treatment, the chance to reconnect with loved ones, and the possibility to die in a dignified, comfortable way in a place of their choosing.

    We do this in five different ways:

    • Support residents to make informed choices about future needs and wishes and ensure access to supportive services, including specialist palliative care;
    • Support residents and staff in dealing with the psychological and emotional aspects of approaching the end of life;
    • Provide appropriate training to frontline staff in dealing with end of life issues, including bereavement support and spotting when clients may be at risk of dying;
    • Provide bereavement support to frontline staff and residents through a volunteer-led bereavement befriending service;
    • Work in partnership to raise awareness of the end of life care needs of people who are homeless.

    Since the service started a decade ago, we have:

    • Provided more than 190 residents with end of life care support including bereavement support. This created opportunities for residents to stay longer at home, feel supported emotionally, as well as allowing them the opportunity to make their wishes and preferences known.
    • Delivered training about homelessness and end of life care to more than 300 staff, including training sessions tailored to the specific needs of our individual projects. This has enabled staff to feel more confident in identifying those who may benefit from support.
    • Developed an online resource pack aimed at supporting staff working with people who are homeless.
    • Forged greater links and partnership working with services such as a multidisciplinary working group set up to identify earlier on those residents whose health may be deteriorating. This involves the local alcohol service, GP, hostel and hospice staff and is chaired by the Palliative Care Coordinator.
    • Partnered on collaborative research and training development with UCL, Marie Curie and Pathway that explores the challenges of palliative care for homeless people and how best to overcome them.

    In the UK, according to the Economist Intelligence Unit, we provide the best end of life care in the world. Providing end of life care for people, like John, who are homeless brings unique challenges. (Here’s a link to more information)

    We must work to ensure best practice is extended to all members of our society, particularly those vulnerably housed who all too often fall through the cracks.

    How you can help

    If you’re interested in the work we do to help our clients and want to do more, here’s how you can get involved:

    Ref: Economic Intelligence Unit. The quality of death: Ranking end-of-life care across the world. 2010

Go back