Sectioning on the street - futility or utility?

Psychiatric Bulletin, 1998

Clinical Medicine, 2023

Background People experiencing homelessness frequently die young, from preventable and treatable conditions. They experience significant barriers to healthcare and are often critically ill when admitted to hospital. A hospital admission is an opportunity to intervene and prevent premature mortality by providing compassionate care and facilitating access to safe onward accommodation and support. Methods To quantify needs, a cross-sectional audit of inpatients experiencing homelessness across 15 acute hospital teams in London, was undertaken in February 2022. Integrated discharge and hospital homelessness teams were interviewed about each patient identified as homeless or vulnerably housed. Data was collected about patients' health, housing, support needs, and reasons for delayed discharges. Results Detailed information was gathered on 86 patients. There was a high level of clinical complexity and multimorbidity. For a safe discharge 60% of individuals were deemed to need accommodation providing high or medium level support and at the time of the audit, half were delayed discharges. Conclusion There is an urgent need for a range of intermediate/step down and longer-term accommodation and support to enable safe appropriate discharge from hospital and start to address the huge inequity in health outcomes of this population. This paper includes recommendations for clinicians and commissioners.

2016

Charity number: 1138741 Literature review Homelessness is strongly associated with multi-morbidity, premature mortality and frequent use of urgent secondary care. There is strong international evidence for Medical Respite services showing benefit to patients and the health economy. Positive outcomes have been demonstrated in pioneering pilot projects in the UK including the Homeless Intermediate Care project based in Lambeth. Local context Published statistics suggest a homeless population across Lambeth, Southwark, Lewisham, Croydon and Westminster (the main boroughs that the 5 hospitals serve) of at least 16,491 people. This figure represents rough sleepers, clients living in homeless hostels, clients living in second stage supported accommodation, and Part VII statutory homeless declarations at the local authority, but does not include 'hidden homeless' people. Emis Web (clinical computer record) data analysis for 421 Pathway patients across KHP who had a comprehensive health assessment completed between April and August 2015 confirms tri-morbidity. 78.4% of patients had a physical health problem, 49.9% had a mental health problem, and 60.3% had a substance misuse problem. Blood Borne Virus (BBV) prevalence was high with HIV at 5%, Hepatitis C at 8.8%; and 1.7% had a history of TB. 826 patients referred to the Pathway team at GSTT occupied an estimated 5981 bed days during Oct 2014-Sept 2015, with an average length of stay of 7.2 days. Re-attendance and readmission rates were high (21% and 19% respectively). At King's, the number of bed days occupied by 306 homeless patients for the same period was 4109, with an average length of stay of 13.4 days. SLaM data is still being collected, but prior research shows that the average length of stay ranges from 110.1 to 173.6 days for homeless clients who needed re-homing. 132 patients were referred at SLaM in the first 11 months. Key findings Across the 3 Trusts an estimated total of 4410.2 bed days could have been saved in year if medical respite options were available. Analysis of homeless patients across KHP who might benefit from Medical Respite revealed a variety of needs that have been separated into 5 groups, requiring different types of service provision. An estimate of the total number of bed days required to meet the needs of the KHP Pathway team has been made (by extrapolating the sample findings to fit the whole population). Sampling methods and the assumptions are explained in the main document. Within these groupings it has been assumed that clients with primary physical health and primary mental health diagnoses can be managed together. As most existing services allow direct admission from the community to avoid hospital admission (step-up), we also include additional capacity for this purpose where this is relevant, and set a target of 80% bed occupancy to support throughput and rapid admission (as suggested by many stakeholders). Additional figures, considering the needs of the population with a Lambeth and Southwark connection only, are offered at the end. A Patients requiring hotel-type low level support-30% of the 76 cases. These are relatively independent patients with physical or mental health difficulties (sometimes with mobility issues) who are statutorily homeless, but would not normally be expected to become rough sleepers. They have often been evicted (as unable to cope due to their health problems), or have been sofa surfing with friends or family who can no longer cope. They don't usually have addictions. They can often be demonstrated to be in priority need, but are short term bed blockers while their housing case is argued with the local authority. 6.5 bed spaces per year. Options for delivery of Homeless 'Medical Respite' Services (SUMMARY) Recommendations/ opportunities At the time of writing the London Homeless Health programme is developing pan-London priorities for homeless health care. This paper identifies local opportunities for change, and also opportunities to improve care by regional initiatives. London wide commissioning Provision for rough sleepers with significant care needs who need registered care home provision (group C) is a regional challenge, and is beyond the remit of this paper. However this was a consistent stakeholder concern, and probably justifies a separate project. A Locally Agreed Tariff for Medical Respite Care would facilitate health care funding for most of the other groups, and overcome current problems regarding the need for dual housing benefit when hostel beds are in Local Authority control. This tariff would be paid by the patients' CCG, which in almost every case is already paying for the higher cost of repeated acute medical admissions, and could be tailored to reflect the different levels of care identified. Developing such a tariff would be a very useful contribution from London wide commissioners, and could lead to medical respite unit(s) that could meet pan London needs. Local commissioning in Lambeth and Southwark A number of possible options are outlined in the paper. It is important to note that full feasibility / operational details have not been worked out for all these options, and some relevant stakeholders have not yet been contacted. Interested parties will most likely wish to view all the options described to form their own opinions, however the projects felt to be most realistic for development by the authors are profiled here. Stakeholder suggestions for strengthening discharge arrangements and improving existing community support warrant further consideration. Discharge 'Hotel' with low level support. Piloting this might be eminently achievable using hospital or charitable funds. Such a project could be delivered in partnership with acute Trusts, working alongside any other projects in development aimed at bed-blocking in the wider hospital population. Specialist hostel based support already exists for Lambeth residents at Graham House, supported by the Health Inclusion Team (HIT), but there is no rapid access to the beds, because they are in a Local Authority hostel which has very high bed occupancy. Additionally the hostel is due to move soon. Southwark has the recently renovated the Great Guilford Street hostel, and it now has 8 beds on the ground floor alongside two high specification medical rooms. This could be used as a medical unit within a hostel, and was designed as such. The beds are currently used as standard beds, because additional health input has not been commissioned. Extending existing HIT team medical support to this unit, and allowing access by both Lambeth and Southwark residents with a funding package that doesn't require housing benefit (so patients retain their original hostel bed), would make this possible. The HIT team obviously has existing expertise in this area, and would be ideally placed to staff, guide and lead this process if funding were made available. This might be achieved as a charitable pilot, whilst a Locally Agreed Tariff was developed. Rapid access dry provision. Reorganisation of the Equinox community alcohol detoxification unit in Brooke Drive (or similar), might allow for direct admission from hospital to provide support to maintain abstinence, and move patients on towards recovery. This appears 'just' to need a change of protocols to allow the admission of carefully selected patients who have not previously fully engaged with addictions, and lack a clear discharge destination, but who have a definite desire and will to stay dry. A pilot project could be small, with patients receiving additional clinical and move-on support from extended Pathway / HIT teams. The Pathway and HIT teams could advise on the additional capacity required. A larger unit could be developed in the future if successful, again based on a Locally Agreed Tariff.

Journal of Mental Health, 2006

Background: Mental health is a growing concern for organizations offering temporary accommodation to young homeless people. Aim: To establish the characteristics of homeless young people referred to a mental health service provided by the non-statutory sector, to determine the appropriateness of referral. Method: The service was provided by five mental health practitioners to 18 Foyers in five regions. Data was collected on 150 consecutively referred young people aged 16 -25 years on their psychosocial history, mental health problems and risk factors. Results: Young people reported multiple needs such as use of illicit drugs, experience of physical or sexual abuse, and self-harm. They presented with lengthy and recurrent mental health problems from childhood, with intermittent and usually fragmented contact with services. Young people presented with a range of mental complaints, predominantly depressive, anxiety and post-traumatic stress symptoms, as well as different risk factors. Conclusions: The young homeless people referred to the mental health service reported a range of complex mental health needs, the majority of which could not be met by statutory specialist services. Young people's lower to medium level mental health needs could be met by services operating on the interface with specialist services, if these are jointly planned and co-coordinated.

The difficulty in achieving good quality community mental health care for homeless people has received increasing attention during the last few years. Less consideration has been given to the provision of inpatient care. By comparing data collected before and after its inception, we examined the impact of a specialist community mental health team for homeless people on 'no fixed abode' admissions in Birmingham.

Journal of Psychiatric and Mental Health Nursing, 2008

Journal of Mental Health, 1992

In the last decade there has been growing concern about the numbers of mentally ill homeless people on the streets in Britain. It is widely believed that this is a direct consequence of the closure of hospital asylums. In this report we examine the existing evidence for such a link drawing on material collected in recent British studies. Several tentative conclusions can be drawn from the available information: (I) rates of severe mental illness amongst the long-term homeless are considerably in excess of what might be expected given general population rates of these disorders; (2) schizophrenia accounts for the majority of these illnesses; (3) levels of disability (both social and symptomatic) are broadly similar to those found in long-stay populations; (4) the majority have never experienced long periods of hospitalization and are not those people who have been discharged as part of the planned closure of a large mental hospital; (5) recent studies demonstrating an apparent failure to deliver effective ongoing care to this population precisely echo studies conducted four decades ago. It is likely that the present crisis of visibility is the consequence of long-standing failures to provide assertive community care coupled with the less widely publicised reduction in direct access hostels which since the mid-1950s have served as unacknowledged asylums for large numbers of mentally ill people.

The European Journal of Public Health, 1997

Housing has long been identified as a prerequisite for good health. In Britain not all members of the population have access to housing. The homeless population may be divided into those who are officially accepted as homeless and the unofficial homeless population. The official homeless population is dominated by families with children whilst the unofficial homeless population includes a range of circumstances from those living in squats to those literally living on the streets. In Britain the number of official homeless tripled between 1978 and 1992 and is currently 143,500 households (approximately 330,500 people). It is estimated that there are a further 6,000 people living on the streets and 50,000 in hostels giving a total estimated homeless population of 386,050. Demographic data indicate that there are important differences in the composition of the official and unofficial homeless populations. The official homeless group consists almost exclusively of young families, usually headed by a lone female. The unofficial homeless group is predominantly male and older. The official homeless population report higher prevalences of chronic health problems and general psychiatric problems than the general population whilst the unofficial group are characterized by elevated rates of psychiatric disturbance and alcohol consumption. These data indicate that homeless people are not a homogeneous social group but present a variety of different health needs which require the provision of appropriate services.

British Journal of Healthcare Management

Pathway teams provide individual care coordination for homeless people in hospital (Dorney-Smith et al, 2016), and use the opportunity of hospital admission to help patients into appropriate housing, support and care in the community. However, despite this expert support, not all discharges are timely or to ideal destinations. Medical respite is an American term for clinically-supported intermediate care for homeless people in the community. This includes peripatetic nursing and bed-based solutions, and can range from low-level supported housing to comprehensive clinical care. Such services provide a safe, recovery focused environment into which homeless patients may be discharged. Some already exist in the UK, and four are profiled later in this article. This article summarises the results of a local needs assessment for potential medical respite services that was undertaken to support the King's Health Partners (KHP) Pathway Homeless Team (that works across Guy's and St Thomas' (GSTT), King's and the South London and Maudsley (SLaM) Foundation Trusts). The work was funded by the Guy's and St Thomas' Charity, and included a literature review and review of current homeless medical respite service provision in the UK. The article outlines potential learning from the project, and offers recommendations for the future. Literature review Respite provision Mainstream intermediate care services are provided in the UK to help stop patients entering