Living on the streets is frightening, tough and isolating. It is well documented that people who live on the streets have significantly poorer health and die on average some 30 years before the general population.
Lee, who has lived experience of rough sleeping and who is now a resident at one of our CQC-registered care homes, Hilldrop Road, described what rough sleeping can be like: ‘When the weather was good it was tolerable but when it snowed or there was torrential rain, getting dry was a real difficulty, waking up in the sleeping bag all wet. You just have to sit there, it’s all you can do.’
For people like Lee, sleeping rough takes a huge toll on their physical and mental health. This can mean premature ageing, a legacy of frailty and life-limiting conditions, but we simply don’t hear about this and the life-changing consequences that living on the streets can have.
A growing need
In order to recover from homelessness and to go on to live a happy and fulfilling life, people will often need support. This support comes in all shapes and sizes and St Mungo’s provides most types – from being a ‘safety net’ for people managing their own tenancies to hostels with staff on-site 24 hours a day.
However, some people will need more care than many homelessness services are able to provide. There is also the question of what options are available for people who need additional support with eating and/or washing and for people living with dementia.
This question was at the heart of the Life Changing Care review, which we published in August 2022. St Mungo’s undertook the Life Changing Care review first and foremost to improve the care and support we provide to our clients. We chose to publish the results to shine a spotlight on this issue and for this to lead to a wider conversation with key partners to ensure action.
Our research was developed in partnership with the co-clinical lead of the Homeless Health Programme at Healthy London Partnerships, Dr Caroline Shulman. It collates data from 31 of our non-CQC-registered services and reflects the needs of our 1,442 clients. What we confirmed was what we knew anecdotally – that there is a significant number of clients across our organisation who have additional physical or health care needs. Our survey found these include people requiring support with dementia (5%) and people who experience poor mobility (8%).
The review also found that despite a significant level of need, many of our clients are not receiving the care that meets these needs. There are a number of reasons for this. The key reason is that there is a very limited supply of specialist care homes that are able to cater for the full range of needs common to people with experience of homelessness.
At St Mungo’s we know how much expertise and experience is needed – we run two registered care homes for people who have been homeless. We also know that because our clients have often been exposed to multiple traumas, they may have drug or alcohol dependencies and may have significant mental health issues as well as physical care needs.
Due to the significant level of need, mainstream care homes are often unsuitable.
And then there is demand – a lot of demand. As one of our care managers said, ‘We could fill this home twice over with the referrals we get’.
We also have a stretched adult social care system and while there is progressive and positive work going on – such as the Local Government Association and Association of Directors of Adult Social Services guidance and the work of the Greater London Authority and London Councils’ ‘Life off the streets’ group – we know that getting our clients’ care needs recognised and responding to them can be challenging.
Promoting best practice
There can be a lack of awareness and understanding of this as a specific issue among some social service and health care professionals.
We need to address this and improve efficacy of adult social care teams when working with people experiencing complex needs. The charity has been pleased to see the new Rough Sleeping Strategy make a commitment to promote best practice for social workers and social care staff.
The Government should also emphasise the importance of timely and thorough care needs and adult safeguarding assessments for people experiencing complex need. These must recognise the different circumstances of people who are experiencing rough sleeping or homelessness.
In delivering the future vision for adult social care, including the delivery of the Integration White Paper and the Adult Social Care White Paper, the Government should encourage the integration of funding. The funding should be made available to all the different partners, including social care, health and homelessness.
Local authorities, sub regions and/or regions should also jointly commission and pool budgets with health when targeting this cohort, integrating homelessness into local health and care strategies. The health and care needs of people with experience of homelessness, are often equivalent to much older populations. It is therefore important that older people who find themselves homeless are supported with appropriate health and care provision. This should include multidisciplinary peripatetic inclusion health teams that provide in-reach into supported accommodation and specialist care homes for people with complex care needs.
Homelessness organisations are an integral part of creating life-changing care and enabling those with lived experience of homelessness to access it. We recommend embedding the Voices of Stoke Care Act Toolkit into existing case management processes, in order to support staff and clients to communicate with adult social care in their own language. This will increase the likelihood of a successful referral by clearly specifying how presenting needs map against the ‘eligibility regulations’ contained in the Care Act 2014.
It is also important that homelessness organisations also develop Care Act policies and procedures to help standardise their approach where Care Act eligible needs are identified and to raise awareness and understanding of the availability of care support. This should include mechanisms for escalation where individual needs continue to go unmet. This will support organisations in ensuring that people experiencing homelessness and rough sleeping are provided with appropriate support.
Strengthening strategies
Further research should be commissioned on the barriers people with experience of homelessness face when accessing a Care Act pathway, to inform the best solutions to this issue. In addition, there is a need to build evidence on the outcomes and cost effectiveness of social care interventions for people with lived experience of homelessness.
We sent an early copy of Life Changing Care to the Department of Levelling Up, Housing and Communities (DLUHC), to inform the development of the new Rough Sleeping Strategy which was published on 3rd September. The Government took note of some of our recommendations which we welcome. The strategy recognised that many people sleeping rough experience early onset frailty equivalent to people who are in their 80s. However, people struggle to access the long-term care and support (including through Care Act Assessments) that they need or do not access primary care services. The Government has now set an expectation in the strategy – that the Housing Transformation Fund should expand the supply of specialist care for this group over the next three years.
The strategy will also improve how different services work together for people sleeping rough, including supporting partners within the new Integrated Care Systems (ICSs) to develop joined-up local strategies that bring together housing, healthcare and homelessness. This will be supported by new statutory guidance: Duty to Cooperate
Guidance on Inclusion by NHS bodies and local authorities, which will highlight the needs of people who sleep rough and be explicit in how partners should work to address them.
The strategy has also secured a commitment from the Chief Social Worker’s office to promote best practice guidance for engaging, assessing and providing support to someone experiencing homelessness, including rough sleeping. This will help to ensure that social workers and social care staff are empowered to deliver the highest-quality care and, in turn, improve the experience and outcomes for those people in need.
Changing lives
The new Rough Sleeping Strategy is a welcome step forward on this important issue. The challenge now is delivering on its ambitions. There are pressing issues on the Government’s agenda, notwithstanding the cost-of-living crisis which could easily transform into a homelessness crisis.
We strive to reach our aim of ending rough sleeping in this country and to prevent it happening in the first place. We will continue to get more people off the streets and into accommodation. However, we must make sure that we all work together to enable the right care and accommodation for people and a place to call home. The right care is truly life changing.
For more information about St Mungo’s, visit
www.mungos.org.uk/