This report presents the findings of a major study in England of the delivery of primary health care to single people who were homeless. It included people sleeping on the streets or in other public places, squatting, staying in temporary accommodation such as hostels or bed-and-breakfast hotels, or staying temporarily with friends or relatives (sofa surfing). It did not include families or couples with dependent children who were homeless. The study, Health Evaluation About Reaching The Homeless (HEARTH), examined four models of primary health care provision at 10 Case Study Sites (CSSs), and included a mapping exercise across England of specialist primary health care services for single people who are homeless. To our knowledge, it is the first UK study to compare and evaluate different models of primary health care provision for this patient group.
Background
Since 2010, homelessness has increased substantially across England. Contributory factors include high housing costs and a shortage of affordable housing; the ending of assured shorthold tenancies in the private rented sector; welfare benefit changes and sanctions, including the capping and freezing of Local Housing Allowance; and cuts to social support budgets.1 A 2018 report suggested that approximately 200,000 single people experience homelessness each year.2 Many stay in hostels, bed-and-breakfast hostels or with friends or relatives, and move from place to place. Others ‘sleep rough’ on the streets, in vehicles or parks, or in other public places. The number of rough sleepers in London increased from 3673 in 2009/10 to 11,018 in 2020/21.3,4 Of the 2020/21 number, 7531 were described as ‘new’ rough sleepers.
Physical health, mental health and substance misuse problems are common among people who are homeless.5–7 Their health needs are greater than those of the general population, and many have multiple long-term conditions and die earlier.8–10 People sleeping rough are exposed to damp and the elements, are at risk of exposure and hypothermia, and are susceptible to infestation. Chronic respiratory disorders and circulatory and gastrointestinal problems are common. Physical health problems are aggravated by alcohol use, drug use and malnutrition, and injuries from accidents and assaults are common. Homelessness is also associated with demoralisation and depression. Health problems among people who are homeless are exacerbated by their unsettled lifestyle and sometimes disorganised behaviour, which can reduce their engagement with treatment programmes. Many also face barriers to accessing health care, including inflexible services, negative attitudes from some staff, and the challenges of treating complex and multiple needs.11 They make unusually high demands on emergency health services, such as accident and emergency (A&E) departments.12 A 2010 Department of Health (DH: known as Department of Health and Social Care (DHSC) since 2018) study estimated that this group consumes around four times more acute hospital services than the general population, costing at least £85M each year, and hospital stays are, on average, three times longer than those of the general population.13
Since the 1980s, specialist primary health care services for homeless people have been established in several UK towns and cities. Their development took various forms, including dedicated ‘walk-in’ health centres and mobile health teams visiting hostels and day centres.14 The National Health Service (Primary Care) Act 199715 provided the statutory framework for the development of Personal Medical Services (PMS). Through flexible contractual arrangements, health professionals were encouraged to deliver primary health care to underserved groups, including people who were homeless. According to Wright,16 this was ‘the most significant favourable piece of legislation for homeless people since the start of the NHS’. There have, however, been very few evaluations of these services, and their success in engaging people who are homeless in health care is unknown.
The 2010 DH study13 grouped specialist primary care provision for people who are homeless into four models: (1) mainstream general practices providing special services for people who are homeless, (2) outreach teams of specialist homelessness nurses, (3) full primary care specialist homelessness teams and (4) a fully co-ordinated primary and secondary care service. The analysis was unable, however, to demonstrate whether or not the provision was fully meeting the needs of people who were homeless. The study reported lack of systematic data on the use of health services and on costs, and lack of research evidence of the potential to improve primary care and health outcomes, and reduce secondary costs.
There are long-standing debates about whether primary health care for people who are homeless should be provided by mainstream or specialist services. Several researchers and clinicians believe that some targeted provision is necessary to reach people on the streets, but the aim should be integration into mainstream general practice services.16–18 A survey of 86 people who were homeless found that 84% preferred specialist primary health care services.19 A 1999 survey in England of managers of services for people who were homeless found that the majority favoured integration into mainstream primary health care services for their clients, believing that separate services were divisive.20
Study proposal and aims
In 2013, the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme issued a call for studies on the effectiveness and cost-effectiveness of innovative and integrated health and care services for homeless people. In response to this call and to address the knowledge gap identified in the DH study,13 this research proposal was submitted and funded.
The overall aim of the HEARTH study was to evaluate the effectiveness and costs of different models of primary health care provision for people who are homeless, with special reference to their integration with other services, and how this affected a range of health, social and economic outcomes. The objectives were as follows.
To identify (1) the prevalence of specialist primary health care services for single people who are homeless and their geographical distribution, (2) types of models found in different NHS regions and key characteristics of these services and (3) areas with a homeless population but no specialist health care service.
To examine the characteristics and integration of different models of primary health care services for people who are homeless with dental, mental health, secondary health, substance misuse, homelessness sector, housing and social care services.
To examine the effectiveness of different models in (1) engaging people who are homeless in health screening; (2) responding to the physical health, mental health and social care needs of people who are homeless; and (3) providing continuity of care for health problems including long-term and complex conditions.
To evaluate the impact of different models over time on service users’ health and well-being, and their use of other health and social care services including dental, emergency and secondary care.
To investigate the resource implications and costs of delivering services for the various models.
To compare the various models across a range of outcomes, reflecting service user and NHS perspectives, using a cost–consequences framework.
To provide evidence to NHS commissioners and service providers regarding cost-effective organisation and delivery of primary health care to people who are homeless.
It was proposed that four Health Service Models would be evaluated, including a ‘usual care’ model for comparison.
Health centres specifically for homeless people, comparable to the DH’s full primary care specialist homelessness team, but located at a fixed site.
Mobile Teams that run sessions in homeless services such as hostels, comparable to the DH’s outreach team of specialist homelessness nurses.
Mainstream general practices that also provide specialist services for people who are homeless.
Mainstream general practices that provide ‘usual care’ services to the general population, which by default include people who are homeless. This type of provision was not included in the DH models, but is commonly used by people who are homeless if there are no local specialist services.
The research questions that the study would address were as follows.
Which models or service elements are more effective in engaging people who are homeless in health screening and health care?
Which models are more effective in providing continuity of care for long-term or complex health conditions?
What are the associations between integration of the models with other services and health outcomes for people who are homeless?
How satisfied are service users, primary health care staff and other agencies with the services?
Layout of this report
Chapter 2 presents literature reviews undertaken during the study, and Chapter 3 describes the study design and methodology. Chapter 4 summarises the findings of the mapping exercise. Chapters 5 and 6 set the scene, by describing the CSSs and the case study participants. Chapters 7–13 focus on primary and secondary outcomes. Chapter 14 examines ways in which contextual factors and mechanisms of health care delivery are likely to have had an influence on outcomes. Finally, the conclusions and implications for NHS commissioners and primary health care managers and practitioners are discussed in Chapter 15.
