Title: Delivering primary health care to homeless people: an evaluation of the integration, effectiveness and costs of different models
Funder: Department of Health and Social Care

Abstract: Primary health care for homeless people is delivered in various ways: health centres specifically for homeless people; mobile teams in homeless services such as hostels; GP practices with special services for homeless people; and generic GP practices that provide ‘usual care’ to homeless people. There is no evidence, however, about which schemes are more effective in addressing homeless people’s health needs. This study aims to evaluate the effectiveness and cost-effectiveness of these different models, with special reference to their integration with other services and how this impacts on a range of health, social and economic outcomes. The objectives are: 1. To identify the extent of provision of specialist primary health care services for homeless people in England, and the types of models that are found in different NHS Area Teams and in areas with different population sizes. 2. To examine the integration of the primary health care services with other services, particularly primary dental care, mental health, secondary health, substance misuse, homelessness sector, housing and social care. 3. To examine the effectiveness of the different models in engaging homeless people in health screening, in responding to their health and social care needs, and in providing continuity of care for health problems including long term conditions. 4. To evaluate over time the impact of the different models on service-users’ health and well-being, and their utilisation of other health and social care services including dental, emergency and secondary care. 5. To investigate the resource implications and costs of delivering services for the various models. 6. To compare the various models across a range of outcomes, reflecting service-user and NHS perspectives, using a cost-consequences framework. 7. To provide evidence for local commissioners of NHS services and service proivders regarding cost effective organisation and delivery of primary health care to homeless people. A mapping exercise will be undertaken to identify the location of specialist homeless health services in England and the services they provide. Eight case study sites (CSS) that represent the four models (described above) will then be evaluated to assess their effectiveness in providing care and treatment to homeless people. A case study design based on the principles of ‘realist evaluation’ (context + mechanism = outcome) will examine the effectiveness of the different models in terms of ‘what works, for whom, how and in what circumstances?’ The primary outcome is the engagement of homeless people in health screening, and this will be measured using six ‘Health Screening Indicators’. One of the secondary outcomes is continuity of care and outcomes over 12 months for five ‘Specific Health Conditions’ (hypertension; chronic chest disease;depression; alcohol related problems; drug problems). Other secondary outcomes are: oral health status and receipt of dental care; self-ratings of general health status and well-being; satisfaction with the CSS; and utilisation of health and social care services and costs. Differences in outcomes between models will be investigated in relation to the particular contexts and mechanisms of care, and the resource implications and costs. Outputs include a Guide on the integration, effectiveness and cost-effectiveness of the various models, targeted at health and social care service-commissioners, managers and practitioners.

Lay abstract: Many homeless people have poor health and experience difficulties in accessing primary health care services. Since the 1980s the NHS has funded specialist primary health care services for homeless people, including health centres, mobile teams in hostels, and special services within GP practices. Some areas with a homeless population have no special service and generic GPs attend to their health needs. There is little evidence, however, about the best ways to deliver primary health care to homeless people and which schemes are more effective. This study aims to address this knowledge gap by evaluating the different models of primary health care provision for homeless people. It will provide evidence for local NHS and Health and Well-being Board commissioners and primary health care workers about the best ways to deliver health care to homeless people, in terms of effectiveness and good value for money. Firstly, a mapping exercise will be undertaken across England to identify the location of the specialist homeless health services and the services they provide and areas where there are unmet needs. We will then study in more detail eight services that represent all models of delivery (health centres, mobile teams, special services in GP practices and generic GP practices that treat homeless people). Information will be collected about how each service works, the help that is given to homeless people by the health team and by other agencies such as primary dental care services, and the extent to which their health and other needs are met. In particular we will examine the effectiveness of the health schemes in engaging homeless people in health screening, and in providing continuity of care over 12 months for five specific health conditions (hypertension; chronic chest disease; depression; alcohol related problems; and drug problems). The resources and costs required to deliver health care will also be examined. The homeless people in the study will be interviewed three times over 8 months. Approval will be obtained from a National Research Ethics Comittee before fieldwork and data collection begins. Throughout the study, interviews will only be conducted with homeless people and workers who give informed and written consent. The study will be carried out by a strong multi-disciplinary team of experts in homelessness research, in the delivery of health care and dental services to homeless people, and in health economics. Members of the research team have extensive experience of maintaining contact with homeless people over a long period. A PPI Group of homeless and formerly homeless people has been formed, and they will be involved in advisory and interviewing roles throughout the study. The costs cover staff salaries, travel, and overnight accommodation when collecting data at sites distant from London. To minimise travel and accommodation costs, 2 of the case study sites will be in daily commuting distance of London (where the researchers are based), and 2 will be in north England (in commuting distance for our freelance interviewer). In appreciation of their time and to encourage them to keep in contact, the homeless people in the study will be given a small incentive payment for each interview. From our experience, this assists recruitment and follow up. We are including costs for the staff of the participating health services to help with some aspects of the study and to extract data from patient records.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE