| Author(s): | Michela Tinellia; Michelle Cornesb; |
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| Institution(s): | a CPEC, London School of Economics and Political Science; b NIHR Policy Research Unit in Health and Social Care Workforce, King’s College London; |
| Production date: | February 2023 |
| Acknowledgements: | We are grateful to the ESSENCE project advisory group for their helpful comments on earlier versions of this case summary. |
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The overall level of core homelessness in England (number of homeless people on a typical night) has risen from 120,000 in 2010 to 153,000 in 2017, an increase of 28%.1 Compared to people who are not homeless, people who are homeless are likely to attend hospital Accident and Emergency departments (A&E) six times as often, be admitted three times as often and stay in hospital three times as long, have unscheduled care costs that are 8 times higher and experience poor care (70% discharged back onto the street).2
In 2013, the Department of Health (DH) funded 52 homeless hospital discharge projects across England at a cost of £10million. A study commissioned by the National Institute for Health Research from 2015-2019, compared the effectiveness and cost-effectiveness of these 52 new hospital discharge arrangements for homeless people in England.
In the last five years, thousands of homeless patients have been discharged from NHS hospitals directly back to the streets in England. In 2018, 8,758 people were discharged without a fixed abode, 2,010 more than in 2014 (figures obtained under freedom of information requests from 89 NHS trusts).3
There is good evidence about ‘what works’ to secure consistently safe, and timely transfers of care from a hospital. This is summarised in national guidance on the ‘High Impact Change Model for Managing Transfers of Care’.4 The underpinning principles of this model are that: (1) there should be less focus on assessment (for longer-term care and support) at the point of discharge and more on recovery – assessments should take place after this help has been offered; (2) there is a specifically commissioned set of services to help people recover post hospital discharge.
In 2013, the Department of Health’s £10 million ‘Homeless Hospital Discharge Fund’ enabled 52 local partnerships to develop and test a range of specialist discharge and intermediate care arrangements for patients who were homeless.5
Between 2015-2019, researchers at King’s College London and their partners undertook an evaluation of these homeless hospital discharge schemes. This comprised an economic evaluation and ‘data linkage’ in which information was identified on outcomes for 3,882 users of homeless hospital discharge schemes. The study also involved in-depth qualitative fieldwork in six hospitals. Four of the hospitals had homeless hospital discharge schemes, two did not, thus enabling comparisons between ‘specialist’ and ‘standard’ discharge arrangements.6
According to an early evaluation report by Homeless Link7, such schemes fall into two broad categories:
The research team also explored different homeless hospital discharge service delivery models/configurations such as:
As part of the evaluation, information6 was collected on 3,882 patients who had received support from a homeless hospital discharge scheme. Data were collected from across 17 different hospitals in England and information about this group was compared to a comparator group of patients who were housed and living in the most deprived areas in England.
Compared to the comparator group (matched housed patients), homeless hospital discharge patients had much higher levels of multiple-morbidity or combinations of long-term conditions or illnesses, with 8% having five or more conditions compared to 3% in the comparator group.
In the comparator group, women and men were nearly two times more likely to die than the general population. In the homeless hospital discharge group, women were nine times and men seven times more likely to die than the general population. In the homeless hospital discharge group, 600 patients died between 1st November 2013 and 30th November 2016. Males made up 78% of deaths. The median age of death was 52 for the homeless hospital discharge group and 72 for the comparator group.
The top three underlying causes of death in the homeless hospital discharge group were external causes of death, such as drugs, alcohol and suicide (22%), cancer (19%) and digestive disease (19%). When age and sex are accounted for, the top three underlying causes of death in the homeless hospital discharge group were cardiovascular problems (30%), cancer (22%) and respiratory disease (17%). The percentage of deaths with an amenable cause of mortality was higher in the homeless hospital discharge group (30%) compared to the comparator group (23%).
This means that nearly one in three deaths might have been prevented with better access to healthcare.
Cornes et al (2021)6 observed many instances where professional discretion and negotiation were used to decide whether a homeless patient might stay in a hospital bed once they were identified as medically optimised, or well enough to be discharged (i.e. have their transfer delayed rather than be discharged to the street). Evidence came from different perspectives:
‘We would rather have someone in an extra night or two while they are waiting for placement as opposed to, “Let’s discharge them now”. If they are going onto the street, they are only going to come back to A&E two hours later. What’s the point? Everybody wins [this way] especially the patient’ (Staff Nurse).
‘[The doctor] is totally ignorant and it was on the Wednesday I saw [the nurse] and I said: “Look, I’m disabled, I can’t handle [being discharged homeless]”. The nurse says, “Look don’t worry” and he put his hand on my shoulder and he said, “You will not be homeless, we will not kick you out onto the street” which is what the doctor wanted – he wanted me out. Well, I didn’t want to be in the hospital. I was taking up a bed that someone desperately needed. All I wanted was a roof over my head’ (Homeless Patient).
Frontline staff on the wards talked openly about the need to ‘pick their battles’ with consultants and hospital managers about which patients might be permitted to stay an extra few nights. As a result, some homeless patients had more opportunity to remain in hospital than others.
The observations pointed out that those with drug and alcohol issues, and those whose behaviour was perceived to be challenging, were more likely to be discharged prematurely. This may reflect that substance use is a highly stigmatised condition, and that when resources are stretched there is less tolerance of the challenging behaviour that can be associated with this. In addition, it was unusual for older patients to be discharged unsafely on ‘behavioural grounds’ which highlighted how different conditions and vulnerabilities gather more or less sympathy:
‘[Discussing homeless patients] Some of them feel judged and that the whole aim of their admission is to get them out because they are difficult to manage on the ward. If you have got a drug-dependent patient who’s constantly leaving the ward to score that’s really difficult to manage from a practical point of view’ (Staff Nurse).
‘Some of the nurses are brilliant, but there’s a hell of a lot of nurses that talk down to you as soon as they find out you are on the gear [illicit drug-using] … It’s not as bad if they see you are in a hostel but if they know that you are actually living on the street and you’re on the gear or on the ale [alcohol] and that’s when they [staff] change they really do look on it as like “Well they put themselves out there”’ (Homeless Patient).
Commissioning specialist homeless hospital discharge schemes with ‘step-down’ created an alternative pathway out of the hospital which reduced stigma, improved patient experiences and led to safer transfers of care:
‘Before we had a homeless team, homeless patients were referred to the social work team, but the social work team would say its housing not care and signpost them to outside…. Now that we have a [homeless worker based at the hospital] it’s a massive bonus for the Trust, someone we can turn to, specialising in homelessness and who knows the processes, policies, laws, benefits and everything that comes with that than an everyday nurse wouldn’t be able to deal with… It’s a massive bonus’ (Ward Manager).
‘Prior to going into the hospital, I was living in a homeless hostel. It was noisy, doors slamming all night long and there were stairs I couldn’t manage… This place [a dedicated step-down unit] is completely quieter, nicer, there’s medical care and it’s just lovely’ (Homeless patient).
When comparing specialist versus standard care: The economic evaluation6 conducted as part of this study provides strong evidence that specialist homeless hospital discharge schemes are more cost-effective than standard care (which is provided in sites that do not have access to a specialist Homeless Hospital Discharge scheme).The results did not vary over a three-year period.
While patients in the homeless hospital discharge intervention groups had higher hospital costs and increased numbers of readmissions (planned and unplanned), this was associated with greater quality-adjusted life year gains (i.e. better outcomes) when compared to standard care. Specialist homeless hospital discharge schemes also used slightly fewer bed days than standard care.
When comparing clinically-led versus housing-led: Both clinically-led (multi-disciplinary) and housing-led (uniprofessional schemes) are cost-effective when compared to standard care, with housing-led schemes being more cost-effective than clinically-led schemes on most measures.
When comparing with and without step-down: Homeless Hospital Discharge schemes with and without ‘step-down’ are both cost-effective. However, the differences in annual NHS costs per patient (vs. standard care) were higher for no ‘step down’ compared with ‘step down’.
Comparative ‘drill-down’ across 3 sites (vs. standard care 9): Site 1 (a clinically led scheme providing patient in-reach and discharge coordination, with no ‘step-down’ service. These schemes are usually nurse or general practitioner (GP)-led and include in-reach (hospital ward rounds) and discharge coordination) and site 2 (comprised clinical and housing in-reach, discharge coordination and access to ‘step-down’ intermediate care) sites were cost-effective on most measures.
Site 3 (comprised a housing-led scheme which primarily focused on providing accommodation to individuals with experience of homelessness on discharge from the hospital. This included a group of housing support workers providing patient in-reach, discharge coordination and community-based step-down) was cost-effective on all measures.
Of the three schemes, Site 1 was the least cost-effective. However, when shifting costs from non-elective (emergency) to elective readmissions (as an indicator of appropriate care pathway treatment) site 1 performed better than site 2. However, site 3 was still the best performing site.
If a threshold of £30,000 is applied, site 1 is not cost-effective, whereas sites 2 and 3 are cost-effective and well within the National Institute for Health and Care Excellence recommendations.
In the last 11 years, Homeless Link has produced an annual review of the available support for single homelessness in England.10 Its report presents a detailed overview of the nature and availability of key services, the challenges and opportunities faced by the sector, the needs and circumstances of the people accessing services, and the various ways in which the sector helps people move out of homelessness and achieve other positive outcomes in their lives.
Despite evidence demonstrating the benefit of specialist homeless hospital discharge schemes6, many were reduced in scale or closed once the Homeless Hospital Discharge Fund ended in March 2014. This may be due to the schemes often being developed in isolation from other work to improve ‘patient flow’.
Developing pathways out of hospital (or Home First) is a key objective of the government’s programme for ‘Integration and Better Care Funding ’.11 The Better Care Funding places clear expectations on Health and Wellbeing Boards to oversee health and social care and to work on: (i) pooling budgets, (ii) integrating services to ensure more people can leave hospital when they are ready, and (iii) following guidelines laid down by the Homeless Intensive Case Management.
The National Institute for Health and Care Excellence (2017)12 guideline for intermediate care recommends that commissioners should consider making home-based intermediate care, reablement, bed-based intermediate care and crisis response all available locally. These services need to be delivered in an integrated way so that people can move seamlessly between them, depending on their changing needs. It is accepted that no one model can meet all the needs of all patients leaving the hospital and that the aim should be to develop a ‘complex adaptive system’ which involves simple rules to function rather than rigid inflexible criteria.
Drawing on findings from the research project presented in this summary, new Guidance from the National Institute for Health and Care Excellence for integrated health and social care for people experiencing homelessness is now published.13 It confirms that more targeted approaches should be in place to ensure people experiencing homelessness have access to the same standard of health and social care as the general population. It also supports the strong evidence about the effectiveness and cost-effectiveness of specialist out-of-hospital care services and specialist multidisciplinary teams (spanning all sectors of care tailored to meet local needs). The guidance also states that these should be in place locally to support the complex needs of people who experience homelessness.
Cornes et al (2019)14 published a tool to outline how commissioners and providers can develop ‘out of hospital’ care that will consistently deliver safe, timely transfers of care for adults who are homeless. The toolkit also presents evidence on the effectiveness and cost-effectiveness of different models and configurations of specialist services piloted through the Homeless Hospital Discharge Fund. It also provides a ‘road map’ or checklist of the complex set of factors that decision-makers should consider in order to make services as inclusive as possible. The checklist can also be used to highlight existing areas of weaker provision and as a sensitivity tool for the ‘High Impact Change Model for Improving Transfers of Care Between Hospital and Home’.4
In 2020, the Department of Health and Social Care, Ministry for Housing and Local Government and Ministry of Justice allocated £16 million through the Shared Outcomes Fund (SOF) to further develop and test out of hospital care for people experiencing homelessness. The out of hospital care model (OOHCM) programme is seeking to scale successful hospital discharge models that were shown to be effective and cost-effective in an earlier pilot programme (Cornes et al, 2021)6 by adapting them for new contexts and circumstances post COVID-19.
Evaluation of the implementation of the OOHCM is currently underway in 18 local authority test sites across England. The overall aim of the evaluation, co-led by Cornes and Tinelli, is to capture the learnings from the OOHCM programme and to provide evidence the outcomes being delivered. Findings will be available in autumn 2023.
Dr Michelle Cornes (michellecornes@aol.com), King’s College London.
Cornes M, Aldridge R, Tinelli M, et al (2019) Transforming Out of Hospital Care for People who are Homeless. Support Tool & Briefing Notes: complementing the High Impact Change Model for Transfers Between Hospital and Home. NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King’s College London.
https://doi.org/10.18742/pub01-007 [Last accessed 10 March 2022]
This article is based on independent research commissioned and funded by the NIHR Health Service and Delivery Programme. The views expressed in the publication are those of the author(s) and not necessarily those of the NHS, the NIHR, the Wellcome Trust, the Department of Health and Social Care, Public Health England or other arm’s length bodies and other government departments.
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