Making health equity a reality through research, education, policy and practice
Specialist or Integrated? Looking after the health needs of homeless people
Two researchers from Scotland and Norway joined forces to examine approaches to meeting the health needs of homeless people, using their own countries as comparative samples and looking at the evidence from Europe-wide research. Their findings were published in the Journal of Social Policy in 2012.
Their paper examines approaches to meeting the healthcare needs of homeless people within the concepts of universal and specialist provision. They define the challenge for states providing for the healthcare needs of people who experience homelessness as recognising “the need for a process approach, which supports an effective transition from the use of specialist services for this group towards full integration into mainstream health care”. They also remark that internationally, research has identified homelessness as a multi-dimensional problem needing a range of interventions over and above the provision of accommodation.
The authors quote from Alcock et al in 2001, who argued for a universalist approach to welfare, delivering services that have a preventive dimension and are available to the whole population. In their paper on Norway and Scotland, the authors use the terms ‘universal’ and ‘mainstream’ broadly to describe services available to all, and ‘selective’ and ‘specialist’ to refer to services “provided in response to the exclusion of some groups from services which should be available to all, but where in practice they are not”.
The homelessness strategies of Norway and Scotland, countries with well developed national level responses to homelessness, although deriving from different welfare systems, were analysed and compared. Although the ideal of universal health care is shared by these countries, differences in service provision and different challenges are discernable in meeting the ideal. The authors specifically aimed to conceptualise strategies to meet the health needs of homeless people in these countries and to draw out implications for the wider debate on how to meet these needs.
In the context of increasing awareness of inequality, poverty and homelessness in Norway at the beginning of the 2000s, a comprehensive strategy to address homelessness was established, with the overarching aims of reducing demands for eviction by 50% and reducing actual evictions by 30%; and the additional aim of restricting lengths of stay in temporary accommodation. A clear goal within the strategy was that no specific health service be developed for homeless people, rather, their needs should be met by the range of welfare services already in place with responsibility for meeting the needs of all. The exception was some limited care service provision for those with substance dependency. The Norwegian strategy takes a ‘soft’ approach and does not dictate centralised directives, nor provide guidelines, but leaves municipalities (local authorities) free to organise services to meet local needs. However, output goals are defined.
A further aspect of the strategy was a state grant aimed at preventing homelessness from occurring. The grant was to go directly to work with clients and be used for services delivered in the user’s home. Health services were less involved than social services in the use of this grant, with few municipalities choosing to use it to strengthen health care services.
Knowledge dissemination and professional competence development are also covered in the strategy although competence development was not specifically addressed at the health sector.
Homelessness is now addressed in other political and expert documents from national health authorities and in 2006 a municipal level clinical guideline on mental health care was published, which included a chapter on how to help those with mental health disorders to achieve a stable housing situation.
Scotland contrasts with Norway in that the local authorities (municipalities) do not have a direct role in the provision of health services, which responsibility remains the domain of the National Health Service (NHS) Boards. However, since 2004 and the establishment of Community Health Partnerships (CHPs) matching local authority boundaries, the CHPs were charged with reducing local health inequalities, acknowledging the health needs of particular groups including the homeless. CHP effectiveness was questioned in Audit Scotland 2011, which recommended a further review of the health service and local authority partnerships.
Since 1977 Scottish local authorities have had legal duties to assist ‘priority need’ homeless (families with children, retired people and those with severe health problems or impairments). Homeless single people were for the most part considered ‘non-priority’. The Homelessness Task Force, set up by the Scottish coalition following devolution, issued its final report in 2002, which became the national policy framework. This was followed by legislative change, again contrasting with the soft approach in Norway. The Housing (Scotland) Act 2001 required local authorities to assess and address homelessness levels in their areas and to provide temporary accommodation to all homeless households pending decisions on their housing applications. The 2003 update of the Act did away with the distinction between priority and non-priority needs and local authorities were tasked with the duty of providing settled accommodation for all homeless people, except those who were intentionally homeless, by 2012. By 2011 statistics indicated that local authorities were 88% of the way towards achieving this target.
But what of the health care aspects? The 2002 report of the Task Force acknowledged the need for health and other services to contribute to effective solutions to the needs of the homeless, as their needs were not necessarily being met by the NHS mainstream services, although these were theoretically available to all. From 2001 NHS boards were required to produce health and homelessness action plans for service improvement based on local need and in 2005 the Scottish Executive introduced Health and Homelessness standards for NHS boards for delivery through CHPs. So housing needs were addressed through legislation, and homeless health needs were addressed through policy guidance. In 2010/11 a health or health related issue was reported as the reason for being in priority need of housing for more than one fifth of 14,000 homeless in need of some kind of support.
Similar to Norway, the Task Force review recommended training for all relevant workers, e.g. drug and alcohol workers should be trained in homeless issues. The effect was a cross-departmental, multi-ministry knowledge gain, but the fact that local authorities are the lead agencies in tackling homelessness in Scotland means that the Scottish framework is more housing-led than its Norwegian counterpart.
Europe-wide research focusing on the healthcare needs of homeless people shows that prolonged periods of homelessness are likely to have more negative impacts on an individual’s health than shorter stays in temporary accommodation.
Homelessness itself can cause ill health and makes dealing with chronic illness more problematic. Poor living conditions can make treatment adherence difficult, however, there is a lack of rigorous international research on the effictiveness of housing interventions to improve health outcomes. Specialist services have resulted from the recognition of homeless people’s exclusion from health services in many countries. Homeless people encounter many difficulties in accessing and using mainstream services and it is argued that special services may overcome these difficulties. Nevertheless, mainstream service provision has the advantage of offering the full range of ordinary services in a non-segregated environment. So although specialist services may be needed for homeless people in crisis, transitional services should provide a bridge between segregated and integrated services so that the homeless can move back into mainstream services when their crisis is resolved. Also lessons for mainstream services could be learned from the flexibility of some specialist services.
In Scotland, where specialist services are provided for the homeless population, those moving out of homelessness face the challenge of trying to re-integrate into mainstream services, whereas in Norway, where separate services have not been developed, the challenge is to identify those who may have fallen through the safety net and whose health care needs may not have been met.
The authors call for more research around the mainstream versus specialist debate. They caution that homelessness is not best interpreted as something that happens to a specific and easily identifiabe group of people, but rather to an inseperable part of society, like other vulnerable or disadvantaged groups. Therefore, universal provision (mainstream) should be the preferred way of meeting their health needs. They pose the question as to whether mainstream versus specialist provision is an ongoing dilemma or a means to the same end. They suggest that Scotland may offer a model for evaluation of transitional services from specialist to integrated, while Norway may remain a benchmark for universal, inclusive provision.
Source: Isobel Anderson and Siri Ytrehus. Re-conceptualising Approaches to Meeting the Health Needs of Homeless People. Jnl Soc Pol (2012), 41, 3,551-568 (summary by Deirdre Handy)