Earlier this year, Centre for Mental Health and Homeless Link co-hosted a roundtable that brought together key stakeholders from across sectors to explore the barriers faced by people experiencing both poor mental health and homelessness, and potential opportunities to create change. This article by Andy Bell, CEO of Centre for Mental Health and Homeless Link's Head of Policy and Research Sophie Boobis summarises these discussions.
The links between mental health problems and homelessness
The relationship between being precariously housed (or not housed at all) and poor mental health is well documented, not least in the recent Darzi Review of the NHS. Homeless Link’s Unhealthy State of Homelessness research found that 82% of people experiencing homelessness have a mental health diagnosis.
Despite this, there is stark evidence to suggest that homeless people are not able to access effective support to meet their mental health needs. 90% of homelessness services state their clients experience barriers to mental health care, and many report decreased collaboration with mental health services. People experiencing homelessness report receiving support only once their mental health deteriorated significantly, when they were in crisis or when they had attempted suicide.
The reasons for this are inevitably the result of an overstretched health service, but are also related to a lack of awareness about, and stigma towards, those with more complex needs. Services tailored to this group do exist, but are the exception rather than the norm, and often funded outside of mainstream health commissioning (e.g. through homelessness and rough sleeping grants).
Inaccessible or unsuitable mental health care is not the only compounding factor. Only 9% of accommodation providers state they are capable of supporting people with high or complex needs, despite poor mental health reported to be the most prevalent of those accessing homelessness support. Large numbers of people in mental health hospitals are clinically ready for discharge but have nowhere to go.
The consequences of inadequate housing and inaccessible mental health care are devastating and costly. People experiencing homelessness access A&E three times more often than the general population – often because of suicidality, self-harm and poor mental health. Tragically, some 13% of registered deaths among homeless people are the result of suicide.
How can we tackle the toxic cycle of homelessness and poor mental health?
Tackling this requires action on multiple levels. To start with, adequate housing is essential. A safe, suitable and secure home for everyone is irreplaceable as a foundation for both addressing the housing crisis and, as a result, improving health. Boosting the supply of supported housing for people who need it is also necessary to provide for those currently stuck in hospital or trapped in homelessness accommodation not suitable for their needs.
Being homeless, having a mental illness, and having substance misuse problems all still carry stigma, and discriminatory behaviours are still experienced in people’s interactions with a range of public services. This remains especially acute for people with a ‘dual diagnosis’ of mental health and substance use problems. Peer-led services and peer support roles within mainstream services can help to reduce stigmatising attitudes as well as improving people’s experiences of support. Embedding trauma-informed approaches across the system can enhance services’ understanding of how people’s lived experiences affect the way they engage with services, and consequently improve the offer.
Holistic support can also help to meet people’s needs better than separate bodies: Calderdale’s ‘complex lives’ service for people at risk of homelessness found, for example, that treating pressing physical health needs helped to build people’s trust in health care that facilitated later engagement with mental health support.
Systemic changes are also needed in public services and systems. From mental health hospitals discharging people to homelessness, to prisons that release people to the streets or sofa-surfing, addressing the harms caused by state powers will help to prevent people being made homeless as a result of their interactions with public services. Locally, governance and accountability are crucial to bring agencies together to meet people’s needs more effectively – for example, through Safeguarding Adults Boards.
Currently, promising approaches or tailored services are patched together with small-scale, short-lived funds, making them especially vulnerable to cuts. Alongside this, most homelessness supported accommodation services are subject to the same funding environment of ongoing destabilising, re-commissioning, and changes to providers, all of which undermine their ability to build long-term, sustainable models of support. The long-forgotten Supporting People programme briefly found a way of sweeping this aside, before it was stopped in its tracks, but the principle of a holistic funding stream for people with complex needs remains a good one, as long as it reflects the cross-departmental accountability needed to provide comprehensive and effective support and housing.
How should the Government and NHS work to address homelessness and mental ill health?
Since the roundtable, we’ve seen a new Government take power with pledges to address the housing crisis, tackle child poverty, and improve access to mental health care. The new administration has the opportunity to take a new approach to addressing homelessness and its links with mental (ill) health. That must start with both increasing the supply of affordable housing and preventing homelessness where possible. The upcoming Spending Review is also a vital opportunity to look ahead and ensure that the funding system enables effective practice rather than promoting dysfunction. We also need to see mental health and multiple, complex needs at the heart of the new Inter-Ministerial Group on Homelessness and Rough Sleeping.
Across the country, integrated care boards and partnerships could, with the right impetus, take decisive action at scale to address this ongoing crisis. If integrated care is to have any meaning, holistic support for people who are homeless or at risk of it must be at its heart, drawing on models like Housing First that put people’s rights and dignity first. And locally, within mental health services and their local government counterparts for homelessness, housing and substance use, greater understanding of people’s whole needs and efforts to remove stigma remain essential.
Homelessness is a social injustice. And its relationship with mental ill health is rooted in deep structural inequalities and inequities. It’s time to make a commitment to change this and leave no one without the support or the home they need.
