Reducing the inequalities of health outcomes – What can the NHS achieve for the homeless?

Over the last few weeks I have tried to provide some very concrete examples to show how the NHS can play a role in reducing the inequalities of health outcomes in our society. Whilst we cannot solve the problems on our own, in terms of inequalities of health and life expectancy there are a great many straightforward things we can and need to do. And since we are the NHS we need to make them national.

Last week, in his first interview about how the NHS might rework its relationships with the public (who are, after all, giving us more of their money) one of Simon Stevens five main issues was tackling inequality. He specifically mentioned having the NHS take a bigger role in tackling the relationship between ill health and homelessness as a major example of inequality in our society.

To restate the main point here.

Earlier this month the country celebrated 70 years of the NHS and most commentators thrilled to the basic principle of “Equal access for all, free at the point of need.” This is a vital attribute of the NHS and indeed the life of the country, but in too many areas it’s a principle that isn’t being followed.

Any new compact between the public and the NHS needs not just to reaffirm this principle but to more fully put it into practice.

So today I want to look specifically at the homeless and how the NHS needs to change its practices if it wants to deliver “Equal access for all free at the point of need” for them.

(Note that there is no clause in this principle that says “Equal access for all free at the point of need provided you have a home”. It’s meant to be a principle about humanity and should apply to everyone).

A few years ago we lost Aidan Halligan, one of the brightest stars in the NHS firmament. He’d been Deputy Medical Officer for England at the Department of Health where I was very lucky to get to know him. When he left there he turned his ferocious energy and morality towards a range of very different issues; the importance to the NHS of learning from others about leadership; the use of simulation in training and the provision of services for homeless people.

He had a strong moral drive, but was also aware of the need for economic argument,

“No humanitarian, no moral, no spiritual argument would ever be strong enough to influence the powers that be unless we wedded it to a robust and rigorous economic framework. We found the health economics of homeless health were overwhelmingly crying out for a response that was structured and accountable. So we built a homeless health team that has grown to where we are today.”

Pathway Annual Report

Keeping this in mind he had played a leading role in setting up a homelessness charity called Pathway in 2009. This was established after an audit of homeless admissions data demonstrated, following Aidan’s ideas about commercial needs above, the enormous cost to the NHS of hospital care for the homeless.

Once you think about it, the reason for this state of affairs is obvious. In England, and in the NHS, we are proud of our primary care system. A fundamental principle of which is predicated on a patient registering with a GP. To do that you need an address.

So we don’t have a universal NHS ‘free at the point of need’ because one of the basic parts of the NHS, primary care, discriminates against people who need primary care – but don’t have an address.

Those of us with homes know what having one provides. It helps us physically and mentally to keep well. Cooking, sleeping, eating, sheltering from the weather, leisure, all take place within these personal spaces. Every day, having a home benefits our health a lot.

If you don’t have a home you don’t have these daily additional health benefits, and it is fairly certain you will need more healthcare.

And this is how inequality works. Those that need healthcare more (because they don’t have a home) will have less access to it (because they don’t have a home).

The NHS health care they do have access to is And E, and this where they go.

So let’s think what our policy has done here. We have a group of people with high healthcare needs and we are funnelling those diverse needs into the very busiest part of the NHS as the ONLY place they can go. If they are accepted to an emergency bed they will remain there until they are medically fit and can be discharged to go home.

Ah but since they have no home they stay in hospital for a lot longer.

Sometimes 70 years of policy can create outcomes that are very odd indeed and make no sense in either healthcare or economic terms.

Pathway now has 10 teams in hospitals across the UK where in hospital GPs and nurses hold multidisciplinary meetings to address the housing financial and social health issues of patients. An audit of Pathway patients was carried out between November 2014 and November 2015 and found that there was a 38-78% reduction in A and E presentation and admission of bed days following Pathway care.

There are other organisations working with the NHS that have similar aims.

The NHS has learned how to provide this service. But we do so in a patchy way depending on the enthusiasm of local providers or commissioners. If the National Health Service is really going to deal with inequality of health on a NATIONAL scale, healthcare for the homeless needs to become a national service.

Renewing the compact between the public and the NHS provides us with an opportunity to construct a service not just based on the principle of Equal access for all free at the point of need but with the opportunity to put what is a good principle into a practice. Principles are great, but making it happen for real people all across the country is much more important.

(I’m off on holiday for August so this is my last post for now. Enjoy the break and I’ll see you in September).

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