Discharging homeless patients 'needs overhaul'

The way the NHS discharges homeless patients needs to be improved, according to a new report published today. The report, compiled by the group Homeless Link and the charity St Mungo’s, has featured prominently in today’s news.

The report, which was commissioned by the government, calls on NHS hospitals to do more to help homeless patients. It says that homeless patients are thought to cost at least five times as much as other patients because they often have multiple health problems and repeat admissions. To explore the issue, researchers examined the experiences of both homeless people and staff involved in the hospital admission and discharge process in England. While the report highlights cases where new approaches have improved the care of homeless people and saved money, it also contains examples where services are falling short. For example, many homeless people describe being discharged from hospital with nowhere to go.

The main message from the report is that hospitals, councils and local voluntary organisations should set up clear plans and work together so that nobody who is homeless or at risk of homelessness is discharged from hospital without their housing and any further support they need being taken into account.

What does the report look at?

The report addresses the need to improve hospital admission and discharge for people who are homeless. It was commissioned by the Department of Health, and was produced by Homeless Link and the charity St Mungo's. Homeless Link is the national umbrella organisation for groups and individuals working directly with homeless people in England, and St Mungo's provides accommodation and support for homeless people. St Mungo’s is mainly based in London and the south of England.

Previous research and surveys have highlighted the stark differences between the health of homeless people and that of the rest of the nation. It’s estimated that, as a result, homeless people have life expectancies around 30 years below average.

The researchers assessed the experiences of 57 homeless people and 38 staff from organisations involved in different stages of the hospital admission and discharge process in England. They also collected further feedback at two meetings with experts. The report highlights examples of effective admission and discharge procedures for people who are homeless, and the challenges faced when implementing these procedures. Based on these findings, it proposes a new set of standards that could be applied to admission and discharge procedures.

What problems were reported?

The researchers found that, while admitted to hospital, only a third of the homeless people interviewed reported receiving any support relating to their homelessness, and many were discharged back onto the streets. The report says that often housing and underlying health problems were not addressed when the homeless person was discharged.

Homeless people also reported prejudice from staff, such as the use of terms like “tramp”. Some reported being turned away by staff who felt a homeless person was simply after somewhere to sleep. The perceived prejudice was felt to contribute to poor care and support at admission and discharge. Many homeless people also reported being readmitted shortly after being discharged.

The report says that in 2010 the Department of Health estimated that homeless individuals use four-times as many acute health services and eight-times as many inpatient health services as members of the general population, costing around £85.6 million annually. Homeless people were also estimated to have an average length of stay in hospital three-times as long as the general population.

What were the examples of effective practice?

Some respondents felt there had been an improvement in the way homeless people have been discharged in the past few years, as shown by reductions in the number of homeless people seeking help from their local authority immediately after leaving hospital. However, few areas had data available to confirm this observation.

An important driver for these improvements was considered to be the development of formal protocols for hospital admission and discharge of homeless patients. The arrangements outlined in these protocols include:

a specialist post or service dealing with hospital admission and discharge of homeless patients
a clear process within hospitals for admission and discharge of homeless patients
good links between hospital staff, the local authority and community-based agencies to promote involvement of appropriate agencies in the discharge process

The report presents two case studies where good admission and discharge planning was also financially beneficial: the London Pathway and the Hospital Discharge Project at Arrowe Park Hospital in the Wirral.

The London Pathway provides a targeted service for homeless people admitted to University College Hospital (UCH) in London. It includes a GP-led ward round supported by a specialist homeless health nurse practitioner for all homeless patients. This round visits every homeless patient admitted to the hospital to co-ordinate all aspects of care and make appropriate plans with the patient for discharge, taking into account their homelessness. The pathway was tested as part of a pilot scheme and, after implementation, the results suggested:

The average length of stay for a homeless patient was reduced by 3.2 days (from 12.7 days to 9.5 days).
Over a typical year with about 250 homeless admissions at UCH this would equate to a potential reduction of 800 bed days.
The project was estimated to bring a saving of £100,000 net after taking into account the costs of the service. This equated to a £1,600 saving per patient on average due to lower length of stay.

What factors contribute to effective practice?

The report concludes that the factors contributing to effective hospital admission and discharge include:

homeless patients being treated well and not being discriminated against
co-ordination of services
patients being offered support relating to housing
patients being fit for discharge
early identification of homelessness by staff to trigger appropriate interventions
multi-agency involvement to co-ordinate support both before and after discharge
shared responsibility between all relevant partners
accountability – tracking and monitoring what happens to homeless people when they are discharged
the discharge process extending beyond the hospital and addressing wider needs that may prevent recovery
improving standards and expectation for staff – including support and training for staff

What needs to change?

The report makes recommendations at both national and local levels.

Local-level recommendations

Hospitals, local authority housing teams and voluntary sector organisations should work together to agree a clear process from admission through to discharge, to ensure homeless patients are discharged with somewhere to go and with support in place for their ongoing care.
NHS trusts should promote a concept of ‘fit for discharge’, taking into account whether the patient has somewhere suitable to go, with plans in place for ongoing care as required.
NHS trusts, working with local partners, should promote a cultural change in the way homeless people are viewed and treated, through strong leadership and training for staff.
Hospitals and local authorities should carry out routine monitoring and reporting of the outcomes experienced by homeless people after discharge.
NHS trusts, local authorities and providers should explore the development of ‘intermediate care’ between hostels and hospitals, for example through joint funding between health and local government.
All sectors should take a greater responsibility for maintaining links, sharing expertise and offering advice to others involved in discharge.

National-level recommendations

The Department of Health should set a clear agenda for the NHS Commissioning Board to improve accountability within health services so that no patient is discharged to the streets. This should be monitored through NHS indicators, including emergency readmissions within 30 days and unplanned A&E use within seven days. Ambitious improvement levels for homeless people should be set using these indicators, says the report.
The NHS Commissioning Board should introduce new standards to improve the recording of hospital attendance by homeless patients, including more accurate indicators of someone’s housing status.
The proposed indicators should be used to improve homeless people’s experience when using hospital and A&E services.
The Care Quality Commission should review whether these targets and standards are being achieved as part of its inspection of hospitals.
The Inclusion Health Board should ensure the NHS Commissioning Board reviews progress of discharge of homeless people on an annual basis, as part of its commitment to reduce health inequalities.

Are homeless people entitled to NHS services?

Yes, homeless people have a right to be treated for free by the NHS, as set out in the NHS Constitution. The constitution sets out the guiding principles of the NHS and states that:

The NHS provides a comprehensive service, available to all. It has a duty to each and every individual that it serves and must respect their human rights.
Access to NHS services is based on clinical need, not an individual’s ability to pay (although some services, such as prescriptions, may not be free).
The NHS has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.

This is not to say that obtaining NHS treatment in practice is always easy, faultless or straightforward. Clearly, if the experiences featured in today’s report are representative of homeless people’s attempts to access health services, further improvements need to be made before these principles are fulfilled.