Aldridge, R

English

UCL Discovery

Commentwww.thelancet.com/public-health   Vol 5   January 2020 e2Homelessness: a barometer of social justiceThe number of people experiencing homelessness in the UK has dramatically increased since 2010. In the autumn of 2018, 4677 people in England were estimated to be sleeping rough, a worrying increase from 1768 in 2010.1 Although these numbers almost certainly underestimate the total number of people affected, the trends in these data are important and unsurprising, given that one in five bed spaces for single homeless people have been lost during the same period, a reduction from 43 655 in 2010 to 34 900 in 2018.2 Rough sleeping is at the extreme and visible end of homelessness, and estimates of the total number of people affected by the UK’s housing crisis highlight an even larger problem. Data from 2019 suggest that around 250 000 households and 400 000 people are currently homeless or at risk of homelessness.3Homelessness can have fatal consequences. The UK Office for National Statistics (ONS) estimated that 726 people experiencing homelessness died in England and Wales in 2018.4 These figures represent a 22% year-to-year increase and are the highest since these estimates began in 2013. The ONS data suggest that most deaths among people who were homeless were caused by drug-related poisoning, suicide, and alcohol-specific deaths. Like estimates of the number of people who are sleeping rough, these data are likely to underestimate deaths, but the trend is important and provides a rare insight into the precarious health of this population.Our recent study of deaths among people experiencing homelessness showed a different pattern of deaths to that of the ONS data.5 We examined the causes of death among people previously admitted to hospital and seen by specialist integrated homeless health and care schemes. Similar to the ONS data, we found high numbers of deaths caused by drug-related poisoning, suicide, and alcohol. However, our study highlighted the importance of chronic and potentially preventable diseases, such as coronary heart disease, respiratory disease, and cancer. Crucially, after adjusting for age and sex, nearly one in three of the deaths among people who were homeless in our study were due to causes that are amenable to timely health care.5Collectively, this evidence demonstrates a public health emergency that we already know how to tackle—but have failed to do so. Most people experiencing homelessness had been admitted to hospital in acute health crisis.5 Their health needs represent a system failure to intervene early and prevent serious harms. Evidence from England, corroborated internationally, highlights multiple missed opportunities for timely intervention. First, the unsafe discharging of patients who are homeless must be stopped. Safeguarding Adults Reviews into the deaths of people who are homeless have highlighted poor hospital discharge practices, including people being discharged back onto the street.6 Health-care professionals have a duty of care and should apply the same standards of quality and safety to all patients; for example, discharge should be delayed when it is not safe.7 Discharging a patient without them having somewhere safe to stay is a safeguarding issue.Second, specialist integrated homeless health schemes are more effective and cost-effective than standard care.8 Despite large increases in homelessness and deaths among people who are homeless, many of these specialist schemes closed because of an absence of sustainable funding. The case for reinvesting in and scaling up these services nationally is clear.Third, intermediate care facilities in the community can prevent serious illness and unplanned hospital admissions, saving lives and money.8 These services play a vital role in freeing up acute beds, while ensuring that people still get the help and support they need to manage long-term conditions and plan for their future. These services need to be widely accessible to both community and hospital health-care providers as part of specialist integrated homeless health schemes, and all of these services should be designed collaboratively to ensure they are accessible to, and meet the needs of, people experiencing homelessness.9Fourth, we need to move away from emergency hostels and unaffordable or unsustainable private lettings to adopt a full housing-first approach to homelessness. People who become homeless should have rapid access to permanent housing with ongoing health and social care support that recognises the complex needs of individuals who have experienced long periods of severe adversity.10 This approach to housing should be accompanied by a large increase in social housing to reduce the number of people at risk of homelessness. Finally, we must tackle Published Online December 2, 2019 https://doi.org/10.1016/ S2468-2667(19)30240-3Commente3 www.thelancet.com/public-health   Vol 5   January 2020the political determinants of homelessness, including child poverty, poor education and employment oppor-tunities, criminalisation, invisibility, and stigma. Everyone has a right to dignity and respect. Home-lessness is a barometer of social justice that reflects a serious problem in our society, the remedy to which is within our grasp.Rob AldridgeInstitute of Health Informatics, University College London, London NW1 2DA, UK r.aldridge@ucl.ac.ukI declare no competing interests.Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.1 UK Ministry of Housing, Communities & Local Government. Rough sleeping statistics: autumn 2018, England (revised). Feb 25, 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/781567/Rough_Sleeping_Statistics_2018_release.pdf (accessed Nov 20, 2019).2 Homeless Link. Annual review of single homelessness support in England. https://www.homeless.org.uk/facts/our-research/annual-review-of-single-homelessness-support-in-england (accessed Nov 20, 2019).3 National Housing Federation. How many people need a social rented home? September, 2019. http://s3-eu-west-1.amazonaws.com/img.housing.org.uk/NHF_Briefing_How_many_people_need_a_social_rented_home_FINAL.pdf (accessed Nov 20, 2019).4 Office for National Statistics. Deaths of homeless people in England and Wales: 2018. Oct 1, 2019. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsofhomelesspeopleinenglandandwales/2018 (accessed Nov 21, 2019).5 Aldridge RW, Menezes D, Lewer D, et al. Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England. Wellcome Open Res 2019; 4: 49.6 Martineau S, Cornes M, Manthorpe J, Ornelas B, Fuller J. Safeguarding, homelessness and rough sleeping: an analysis of Safeguarding Adults Reviews. Sept 3, 2019. https://kclpure.kcl.ac.uk/portal/files/116649790/SARs_and_Homelessness_HSCWRU_Report_2019.pdf (accessed Nov 20, 2019).7 Cornes M, Aldridge R, Tinelli M, et al. Transforming out-of-hospital care for people who are homeless: support tool complementing the high impact change model for transfers between hospital and home. Nov 18, 2019. https://kclpure.kcl.ac.uk/portal/files/119151993/HHD_SUPPORT_TOOL_Nov_2019.pdf (accessed Nov 20, 2019).8 King’s College London. Effectiveness and cost-effectiveness of ‘usual care’ versus ‘specialist integrated care’: a comparative study of hospital discharge arrangements for homeless people in England. https://www.kcl.ac.uk/scwru/res/hrp/hrp-studies/hospitaldischarge (accessed Nov 21, 2019).9 Nobody Left Outside. NLO checklist guidance document. October, 2019. https://nobodyleftoutside.eu/nlo-checklist-guidance-document (accessed Nov 22, 2019).10 Baxter AJ, Tweed EJ, Katikireddi SV, Thomson H. Effects of Housing First approaches on health and well-being of adults who are homeless or at risk of homelessness: systematic review and meta-analysis of randomised controlled trials. J Epidemiol Community Health 2019; 73: 379–87.

Homelessness: a barometer of social justice

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Homelessness: a barometer of social justice

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