Homelessness: a barometer of social justice
Authors: Rob Aldridge
Journal: The Lancet Public Health (2019)

The 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 2010.1UK Ministry of HousingCommunities & Local GovernmentRough sleeping statistics: autumn 2018, England (revised).https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/781567/Rough_Sleeping_Statistics_2018_release.pdfDate: Feb 25, 2019Date accessed: November 20, 2019Google Scholar 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 2018.2Homeless LinkAnnual review of single homelessness support in England.https://www.homeless.org.uk/facts/our-research/annual-review-of-single-homelessness-support-in-englandDate accessed: November 20, 2019Google Scholar 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.3National Housing FederationHow many people need a social rented home?.http://s3-eu-west-1.amazonaws.com/img.housing.org.uk/NHF_Briefing_How_many_people_need_a_social_rented_home_FINAL.pdfDate: September, 2019Date accessed: November 20, 2019Google Scholar Homelessness can have fatal consequences. The UK Office for National Statistics (ONS) estimated that 726 people experiencing homelessness died in England and Wales in 2018.4Office for National StatisticsDeaths of homeless people in England and Wales: 2018.https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsofhomelesspeopleinenglandandwales/2018Date: Oct 1, 2019Date accessed: November 21, 2019Google Scholar 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.5Aldridge 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: 49Crossref PubMed Scopus (47) Google Scholar 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.5Aldridge 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: 49Crossref PubMed Scopus (47) Google Scholar Collectively, 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.5Aldridge 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: 49Crossref PubMed Scopus (47) Google Scholar 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.6Martineau S Cornes M Manthorpe J Ornelas B Fuller J Safeguarding, homelessness and rough sleeping: an analysis of Safeguarding Adults Reviews.https://kclpure.kcl.ac.uk/portal/files/116649790/SARs_and_Homelessness_HSCWRU_Report_2019.pdfDate: Sept 3, 2019Date accessed: November 20, 2019Google Scholar 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.7Cornes 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.https://kclpure.kcl.ac.uk/portal/files/119151993/HHD_SUPPORT_TOOL_Nov_2019.pdfDate: Nov 18, 2019Date accessed: November 20, 2019Google Scholar 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.8King's College LondonEffectiveness 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/hospitaldischargeDate accessed: November 21, 2019Google Scholar 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.8King's College LondonEffectiveness 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/hospitaldischargeDate accessed: November 21, 2019Google Scholar 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.9Nobody Left OutsideNLO checklist guidance document.https://nobodyleftoutside.eu/nlo-checklist-guidance-documentDate: October, 2019Date accessed: November 22, 2019Google Scholar Fourth, 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.10Baxter 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: 379-387Crossref PubMed Scopus (133) Google Scholar 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 the political determinants of homelessness, including child poverty, poor education and employment opportunities, criminalisation, invisibility, and stigma. Everyone has a right to dignity and respect. Homelessness is a barometer of social justice that reflects a serious problem in our society, the remedy to which is within our grasp. I declare no competing interests. A public health prescription for the UK GovernmentOn Dec 12, the people of the UK voted and elected a Conservative party government for the next 5 years. The Conservative party's biggest electoral victory since the 1980s, predominantly based on the promise to “get Brexit done”, raises a number of questions about the UK's future. Full-Text PDF Open Access