New NICE guidelines: recognising that homelessness is a health problem too

Last week, the National Institute for Health and Care Excellence (NICE) published new guidelines on ‘Integrated health and social care for people experiencing homelessness’. In this blog Emma Cookson, our Senior Policy and Public Affairs Officer, explains why these guidelines are so important.

Homelessness is not just a housing problem, it is also a health problem. Poor health is both a cause and a consequence of homelessness.

All too frequently we see the devastating result of this, with the average of death for people sleeping rough or living in emergency accommodation just 46 for men and 41 for women. Lives cut horrifyingly young, often from preventable causes which would have been amenable to timely and effective healthcare.

That’s why the publishing of NICE’s new guidelines on ‘Integrated health and social care for people experiencing homelessness’ matter.

First, they show an explicit recognition of the intertwined nature of homelessness and poor health, stating that “homelessness and access to appropriate housing is a public health issue”. This is something which lots of individuals and organisations have been stressing for years  — but we need it to become commonly accepted everywhere. These guidelines push that message out to a new audience of mainstream health practitioners, who play a crucial role in supporting people experiencing homelessness and rough sleeping.

Then second, through these guidelines setting out principles and examples of what ‘good’ looks like, they now mean that people experiencing homelessness and rough sleeping, as well as those supporting them, have something tangible to point to as to how their care should work. It also means that practitioners can no longer say they don’t know what to do, or it isn’t clear.

That’s why St Mungo’s fed into the development of these guidelines, with people from across the organisation bringing all their various expertise together to send in detailed comments on first the scope of the guidelines, and then the first draft of them last October. We also consulted with the people who know best — those who have lived experience of homelessness and rough sleeping and can therefore say what really works.

We were pleased to see that the final guidelines really listened to our submissions, and reflected some of the omissions or concerns we had flagged. The final product is hugely welcome. It sets out clearly and thoroughly the key points we would want to see and provides a helpful template for what health and care services should be providing people experiencing homelessness and rough sleeping.

Some of the main points:

  • People who are experiencing homelessness and rough sleeping often require more targeted approaches to ensure that health and social care is available and accessible. Practical barriers like needing to walk across the other side of town, or having lost of clashing appointments with the tangled web of support services available, can make it difficult for people to access structured and rigid appointments. Equally, other factors such as deep-rooted trauma and a resultant lack of trust, or previous distressing experiences of interacting with health services, can make it difficult for people to engage. The recommendation in the guidelines for flexible opening and appointment times and providing ‘one stop shops’ for multiple services is therefore welcome, as well as expressly saying “do not penalise people experiencing homelessness for missing appointments, for example, by discharging people from the service”. This has historically been a huge problem for our clients, as highlighted in the Knocked Back report, and the need for flexible appointments was one of the recommendations in the Kerslake Commission report.
  • Care should be empathetic, trauma-informed and person-centred. Experience of psychological trauma and adverse childhood events (ACEs) are common in people experiencing homelessness. The guidelines set out practical pointers such as “longer contact times in developing and sustaining trusting relationships”, and “strengths-based approaches to care” (more on that here, but it’s reflected in St Mungo’s Recovery Based Approach which focuses on empowerment), as well as avoiding “unnecessary and potentially distressing repetition of their history if it is already on record”. Person-centred, trauma-informed and psychologically-informed: these should form the base principles for all services – be they housing, health, or welfare.
  • “Commissioners of health, social care and housing services should work together to plan and fund integrated multidisciplinary health and social care services for people experiencing homelessness, and involve commissioners from other sectors, such as criminal justice and domestic abuse, as needed.” This was a central theme of the Kerslake Commission, which stressed that ending rough sleeping requires an integrated, system-wide approach and highlighted joint commissioning as the primary way to do this: bringing all parts of the system around the table to discuss the desired outcome, and collaborating and sharing responsibility for achieving it. People’s problems are not siloed: they experience them in an overlapping and often mutually enforcing way. Services must reflect this.
  • “Take health and social care services to people experiencing homelessness by providing multidisciplinary outreach care in non-traditional settings, such as on the street, hostels or day centres.” As with flexible appointment times, taking services to where people are rather than waiting for them to approach traditional place-based services, makes a significant difference in enabling engagement and establishing trusting relationships. Multidisciplinary teams was highlighted in the Kerslake Commission, which flagged the need to embed specialist workers – such as drug and alcohol and mental health workers – in generic outreach teams.
  • Recognise the value of co-designing and co-delivering services with people with lived experience of homelessness. This is fundamental — not just because it’s the right thing to do — people should be involved in the decisions that affect their lives — but also because it leads to better outcomes through better insights. As these guidelines set out, peers should be integral to all stages of support, from designing how services work, to being peer advocates and helping others navigate services.

These guidelines are a big step forward, and have the chance to be a really helpful tool for improving the health of people experiencing homelessness — both in making mainstream practitioners more aware of what they should be doing to help, but also in giving individuals the ability to point to something and say ‘this is what standard I should be receiving’.

There is some real momentum building in this area, with the Levelling Up White Paper mentioning inclusion health (albeit briefly) and tackling the core drivers of health disparities; the NHS’ new Core20PLUS5 initiative to reduce health inequalities; the publication in December of the Government’s 10 year Drugs Strategy which recognised the role that housing has to play; and the Health and Social Care Bill which is just finishing up in the House of Lords and, although unfortunately the amendments on inclusion health were not brought in (which we supported alongside Crisis), this did lead to a significant amount of attention in parliament and more constructive conversations for the future. There is also the promised upcoming White Paper on Health Disparities which we’re looking to next.

We must all keep working together towards the vision set out in the Kerslake Commission, where all parts of the system — including health — are joined up, and have the individual, whom it is designed to support, at the centre.

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