Homeless health care: not so universal
Civitas, 8 May 2009
The NHS is supposed to be a universal healthcare system. There is one group however – one of the most vulnerable in society – who get a particularly raw deal: the homeless. The NHS funds services, not individuals. With no fixed abode, the homeless far too often fall through the net. As a discussion hosted by Civitas a couple of weeks ago showed, the homeless get caught in a catch-22 situation where, to quote Charles Fraser, CEO of St Mungo’s, ‘homeless people avoid health services and health services avoid them’.
Here are some of the hard statistics:
– The average age of death of the homeless is 40.2 years.
– The cost of secondary care for the homeless is approximately eight times that of the non-homeless.
– The homeless attend A&E six times more frequently than the non-homeless, are admitted four times more frequently and stay in hospital twice as long – not because it is difficult to discharge these patients, but because they are at least twice as sick as the non-homeless on admission.
– The homeless have twice the incidence of cancer of the non-homeless.
Some of this, of course, has to do with lifestyle choices, but it also has much to do with patchy (and at time woefully inadequate) services, a ‘pass-the-parcel’ attitude to taking responsibility for homeless health care and, above all, a lack of caring. At the heart of this dynamic, human contact has been undervalued; the target culture rewards moving people on, rather than helping them to solve their problems.
A central issue that surfaced time and time again referred to the benefits that could be brought by pan-London commissioning for homeless health, housing and social care – and the possibility of personal budgets. That way the homeless come with the money, helping to restore dignity and giving services the incentive to look after them rather than pass the buck. Parochial, adversarial commissioning arrangements for small geographical areas are made a nonsense by mobile patients with high needs who migrate into and around London.
In the current world, commissioners, concerned that their services may attract users from other areas and overwhelm their budgets, have the incentive to ‘free-ride’ on others, or create industries confirming entitlement: to housing and to health care services. People are too often lost in meaningless bureaucracy.
Jim O’Connell, an inspirational doctor who helped set up a comprehensive homeless health service in Boston, USA, put it that ‘we’ve all failed and we all own that failure’. ‘We need’, he said, ‘to take responsibility and be held to account for our performance’.
Read the full transcript to see how we might do just this.