Title: Preventing health problems among people experiencing homelessness: a mixed-methods study
Funder: Health Education England

Abstract: Background People who are homeless experience some of the poorest health outcomes in society, but they often access services in a crisis. Hospital healthcare contacts are an opportunity to increase access to preventive services for homeless patients. In the context of this Fellowship, preventive services are defined as interventions to prevent future ill health and unplanned hospital admissions that fall outside management of the immediate problem. It includes action on wider determinants of health (e.g. improve liaison to access housing), primary prevention of disease (e.g. vaccination), and secondary and tertiary prevention (e.g. screening and linking to primary care for disease management). Aim To provide evidence and tools to increase access to preventive services for people who are homeless. Plan of Investigation This mixed-methods study is comprised of parallel quantitative and qualitative work packages (WPs) that will inform development of a prevention toolkit for NHS hospitals. My proposed work is supported by a scoping review and an innovative multidisciplinary collaboration between public health researchers and practitioners, specialist homeless clinicians, and people with experience of homelessness. WP1- Quantifying need and opportunities for prevention WP1 aims to provide evidence for planning preventive services for people who are homeless by quantifying their patterns of secondary healthcare utilisation. I will use national Hospital Episodes Statistics (HES) to measure numbers of people who are homeless using hospital services including those: 1) coded as homeless; 2) registered with a specialist homeless GP; 3) whose postcode is recorded as either no fixed abode' or as a homeless hostel, day centre, or advice centre. Three-source capture-recapture methods will account for under-ascertainment by this method and produce adjusted estimates. I will use healthcare contacts within HES to identify opportunities and priorities for prevention, describing them in terms of: emergency or planned, admission or attendance, clinical specialities, clinical diagnoses, and length of stay. WP2 Understanding barriers and facilitators to preventive services in hospitals WP2 aims to identify barriers and facilitators to increasing preventive services in hospitals. I will undertake interactive workshops with people who are homeless to explore their experience of preventive healthcare services and hospital care and to support development of questions for semi-structured interviews (SSIs) with healthcare staff. I will use a combination of purposive and convenience sampling to recruit healthcare workers for interview to explore variations by geographical region, clinical speciality and role. SSIs will investigate needs, opportunities and experience of delivering preventive services in secondary care, the interface between primary and secondary care, and barriers and facilitators to service improvement for homeless patients. I will continue interviews with a view to achieving data saturation and use the Framework method for analysis. I will present findings to homeless patient groups in further workshops to support interpretation and inform service development. WP3 Developing the Prevention Toolkit WP3 aims to integrate quantitative and qualitative findings to develop a practical prevention toolkit for NHS hospitals. I will publish a report in collaboration with specialist homeless teams, electronic health record (EHR) experts, and The Faculty for Homeless and Inclusion Health. Key components will include: an evidence summary on the importance of prevention services, guidance for producing a local EHR registry of homeless patients, standards for prevention, and an audit checklist. Potential Benefits to Patients and the NHS This Fellowship will draw together evidence of needs, opportunities, barriers, and facilitators for hospital teams to implement evidence-based preventive services for homeless patients. By providing evidence and operational tools, I hope to improve access to preventive services, and with sufficient scale-up, contribute to a reduction in preventable disease, inequalities, and NHS costs within this marginalised population.

Lay abstract: Homeless people experience some of the worst health problems in society. Many of these can be prevented through better housing and getting a job, vaccinations, reducing drug and alcohol problems, finding and dealing with illness sooner, and treatment of conditions like high blood pressure. For many homeless people their main contact with health services is in a crisis when they may need an emergency hospital stay. My research will try to understand how hospitals can do more to prevent health problems for homeless people and it will also develop practical advice to help them do this. To plan hospital services that work well, it is important to know how many homeless people use hospitals and why, how often they use them, and which medical teams get involved. This information is held in electronic records but it is not easy to identify homeless people from these. My research will work with the team that looks after these records to produce a national dataset. It will include people recorded as having no regular place to stay, people who have given a homeless hostel or day centre address, people who are registered with a specialist homeless GP, and people who have been specifically recorded as homeless in their notes. This dataset will be anonymous and used to find out how homeless people use hospital services. It is also important to know what the experiences of people in the NHS are when they try to plan better services. I will gather information on this through talking to NHS staff in different parts of England and small group events to talk to homeless people. Staff will be asked to talk about what has worked and what has not worked in hospitals that have tried to deliver services that can prevent future health problems, as well as treating immediate problems. They will also discuss how NHS hospital staff can work better with homeless patients and with GPs and other services outside hospitals to prevent future problems for homeless people. Small group sessions will be run with homeless people to understand what they would like from hospital services that try to prevent future health problems, and what has not worked well for them in the past. Two people who have been homeless before will help to plan and run these events. These two people will also be asked regularly to give their views about the overall project and how we are doing. An end of project meeting will bring together the people who have contributed to this project, people who are or have been homeless, and key people who make decisions. This meeting will be a place to discuss how the results from this project might be shared and used to change the way that services are delivered for homeless people. I will write a report for NHS staff. This will describe what I find out to help hospitals understand what needs to be done to prevent future health problems and why they should do it. It will also give practical advice about how to find homeless people in hospital records systems so that they know who they should be improving services for. Finally, hospitals will be given a list of ways to prevent future health problems, and ways for them to see how well they are doing.I will also work as a public health specialist with the Pathway charity (a specialist homeless health service in hospitals). Pathway works closely with the NHS as well as national and local government. I will work to influence these organisations with the results from my research to improve homeless health care. The Faculty for Homeless and Inclusion Health is a national network of over 700 health workers and people who have been homeless. The Faculty is hosted by Pathway. The Faculty has an annual conference, a website, regular meetings, and a newsletter where results from my research will be shared. Homeless charities, such as Crisis, Homeless Link, and Groundswell, will also be asked to promote the results of my research by including the final report on their websites. Social media, such as Twitter and a project website, will also be used to share the advice and overall results. Finally, results will be shared through publication of scientific papers and at national and international scientific meetings.

Research activity codes: 4.3 INFLUENCES AND IMPACT;8.4 RESEARCH DESIGN AND METHODOLOGIES (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE