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Grampian NHS Health and Homeless Action Plan
Foreword
The number of homeless people in Scotland has risen, although levels of rough sleeping are falling, and the Scottish Executive has pledged to eliminate homelessness by 2010, as part of the drive to tackle health inequalities and promote social justice.
Homelessness includes those who have no shelter and are effectively ‘roofless’; those living in emergency and temporary accommodation including Bed and Breakfast premises or in institutions only because they have nowhere else to stay; those whose accommodation is, in reality, insecure including young people asked to leave the family home; and those involuntarily sharing housing in unreasonable circumstances.
Statutory homelessness in Scotland is now nearly 50% higher than in England. However, across Scotland rates vary considerably. The last decade has seen an overall increase in the numbers of homeless people in Grampian. The scale and nature of homelessness in Aberdeen City and in Aberdeenshire has been fairly constant over the last five years, whilst Moray has seen a steady increase, especially in the number of women presenting as homeless. The scale and significance of domestic abuse in generating homelessness within Grampian has also been a feature in recent years.
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In Grampian in 2001-02, 3105 people presented as homeless though many have argued that ‘hidden homelessness’ would suggest that double that number would represent a more realistic figure. Numbers of young people presenting as homeless are of particular concern and comprise in Aberdeen City 38% of all applicants, in Aberdeenshire 25% and in Moray 20%. In addition, most recent data on the medical problems of homeless applicants indicates that the majority of applicants with medical priority need are under 40 years old.
The Grampian data suggests that health needs are not dissimilar to those which national research has identified. Homelessness carries a significant risk of higher levels of morbidity and mortality. It is frequently associated with a range of health problems, to a greater extent than those suffered in the general population. Homeless people are more likely to have mental health problems, have a higher incidence of chronic diseases such as asthma. Often, these can also be compounded by drug or alcohol misuse.
There is no simple solution to the problems associated with homelessness. NHS Grampian is committed to working with our partners to address the overall needs of homeless people. In particular we aim to provide an evidence-based response to meet clinical need. It is our ultimate aim to re-engage homeless people with the mainstream NHS, and facilitate the pursuit of routes out of homelessness. To achieve this, in line with the Effectiveness Review, we need to retain a clear focus on improving the health of homeless people and to deliver effective health care which meets the needs of homeless people and other vulnerable groups within our population.
We have established an effective infrastructure, embedding health within each of the three Homelessness Strategies in Moray, Aberdeenshire, and Aberdeen City. Together, colleagues in the voluntary sector, local authority and health have prepared action plans to address progressively, weaknesses in our current support structures. Over the life of this plan we will increase our understanding of the needs of, and support for homeless people. Through effective training we will apply our understanding in our day to day practice. We will formalise and make more visible, accessible and co-ordinated our existing networks of services, and ensure that health improvement is integral.
In these ways, we will maximise our collective resource to improve the health of homeless people to support them in their pursuit of routes out of homelessness.
Alec Cumming
Chief Operating officer
NHS Grampian
EXECUTIVE SUMMARY
Decent Housing is a basic human need. Homes should be safe, warm, dry, secure and affordable. Whilst Grampian does not have a large homeless population (approx. 4,000), homeless people are among the most excluded and disadvantaged in our communities, making this a priority group for health improvement and a priority group within NHS Grampian’s framework for tackling Health Inequalities. It is estimated that at least twice as many homeless as those with homes will suffer some form of mental illness. Single homeless people experience excessive rates of psychiatric and physical illnesses such as drug and alcohol-related problems, accidents and assaults, and chronic disease. Despite high levels of contact with health services, much ill-health remains hidden and untreated. Ill health is both a cause and an effect of homelessness.
In line with national guidance, NHS Grampian has produced this three-year Health and Homelessness Action Plan in collaboration with our partners. The Plan comprises detailed action that the NHS will take in partnership with the three local authority based Health and Homelessness Strategy Groups. The original submission to the Scottish Executive in 2002 was approved for the Aberdeen City element and we have worked hard with partners to address concerns raised about the Aberdeenshire and Moray components. Ownership and commitment has now been established. The evolving NHS Community Health Partnerships will work with and as part of the Community Planning Partnerships to implement and monitor the relevant plan of this Grampian wide framework.
The action plans reflect local needs. Evidence suggests that homelessness is concentrated in major cities. Homelessness undoubtedly exists within rural areas and is likely to be scattered or focused on the nearest population centre of any size. Within large cities it may be logistically easier to plan for a larger but relatively close community than a small geographically dispersed group. Grampian comprises urban and rural communities presenting different challenges requiring local solutions. Whilst the solutions may vary the overall aim is the same to ensure:
- An evidence-based response in meeting clinical needs
- That homeless people have appropriate access to quality health and healthcare services, which fully integrate with, and include, mainstream health care
- We strengthen our understanding of health needs of our homeless population and the services available locally to address identified need
- Our staff – both specialist and generic – have the necessary skills
- We are able to demonstrate progress towards our commitments
Specific activity over the last twelve months to inform development of this plan has included:
- An analysis of statutory data augmented by locally commissioned research and local experience to establish a profile of the homeless in Grampian Health Board Workshops in each local authority area to consider and enhance data, to inform action plan development and to review progress to date and to build capacity for the health agenda
- The available data and workshops have informed the development of these refined action plans and we have clarified the gaps in existing knowledge to be addressed
- Embedding the Health and Homelessness agenda within the evolving Community Planning and NHS Grampian structures identifying lead individuals and groups to implement and monitor progress of the component parts of the Health and Homelessness Action Plan
- Moray has identified the foci of research to inform policy and practice
- Aberdeenshire has focused on identifying areas of good practice to be rolled out across the patch
- Aberdeen City will go live on the 1st April on the development of premises to support the multi-disciplinary Health and Homelessness project Team. It is anticipated that in due course this project will evolve as a Centre of Excellence for the area, supporting in particular staff development
As part of the NHS Grampian strategic framework for tackling Health Inequalities, activity to address homelessness will be a key component of our overall programme to promote social inclusion. Structural review within the NHS and with partners has enabled resource to be identified to take forward action on a local basis, supported by Grampian-wide co-ordination. Performance indicators have been agreed, enabling us to report back on the progress we have made – to the Scottish Executive, to partners and to the people we serve.
For further information or to access supporting documentation for the Plan, contact the Health Information Team 01224 551347 or via
CONTENTS
Foreword NHSG Chief Operating Officer
1 INTRODUCTION
1.1 Background to the Grampian HHAP
Specific steps to address Scottish Executive requirements
Contribution of Homelessness Strategies
Contribution of Public Health Re-design
Context of NHS Reform (Scotland)
1.2 Accountability
Planning framework for Health and Homelessness in Grampian
1.3 Principles
1.4 Evidence Base
National
Local
Grampian in a national context
2 LOCAL PROFILES & ACTION PLANS
Guide to profiles and action plans
2.1 Aberdeen City
Demography
Profile of homelessness
Key features
Profile of Health and homelessness
General Health
Healthcare Services
Mainstream and Project
Drugs and Alcohol Misuse
General Health
Healthcare Services Usage
Service Development
Aberdeen City Health and Homelessness Action Plan
2.2 Aberdeenshire
Demography
Profile of homelessness
Key features
Profile of health and homelessness
Vulnerability – main reasons
General Health
Healthcare Services
Network of mainstream and project services
Healthcare related development
Aberdeenshire Health and Homelessness Action Plan
2.3 Moray
Demography
Profile of homelessness and health needs
Key features
Network of mainstream and project services
Service Development
Moray Health and Homelessness Action Plan
3 Action Plans in Summary
4 Resources
Appendices
Appendix AComposition and Remit for Grampian Health & Homelessness Group
Appendix BHealth & Homelessness Planning Framework
Appendix B1Health & Homelessness Planning Framework – Aberdeen City
Appendix B2Health & Homelessness Planning Framework – Aberdeenshire
Appendix B3Health & Homelessness Planning Framework - Moray
Appendix COutcomes – Monitoring against existing Homelessness & Health Action
Plan
Appendix DWorkshop Example: revising the action plan
Appendix ESocial inclusion portfolio
Appendix FAberdeenCity JHIP – Health & Homelessness
Appendix GHealth & Homelessness Taskforce Definition of Homelessness
Appendix HHealth & Homelessness Project in Aberdeen (PMS+project)
Appendix IPharmacy-support for Homeless
Appendix J HL1 data
Appendix KMedical Problems – Homeless Applications
Table 1 Number of applications to Local Authorities made by households under the
Homeless Persons Legislation
- INTRODUCTION
As part of the Scottish Executive’s drive to tackle health inequalities and promote social justice in September 20011, NHS Boards were required to develop Health and Homelessness Action Plans (HHAP). The report of the Homelessness Taskforce made clear the extent of the challenge, stated the unequivocal need for Local Authorities and NHS Boards to work in common cause, and appointed a Scottish Health and Homelessness Co-ordinator to support development and implementation.[1]Homelessness is not limited to housing issues but includes unmet health needs which trap people and for which partnership will be a critical vehicle to facilitate their release.
The need to improve the health of homeless people had also been identified in Our National Health: A Plan for Action A Plan for Change[2] as a priority for NHS Scotland. This was most recently reinforced in Improving Health in Scotland: The Challenge [3] which acknowledged the complexities of homelessness, the heterogeneity of 'the homeless' and the inextricable links between health and homelessness; 'ill health is both a cause and an effect of homelessness' (2003:35).
Specifically, The Health & Homelessness Guidance requires Boards to:
- Develop a H&H Action Plan as part of the Local Health Plan in partnership with Local Authorities, the voluntary sector and homeless people
- Ensure the Action Plan is effective from 2002
- Provide clear mechanisms for linking the Action Plan with Local Authorities’ Homelessness Strategies in 2003, and with local Community Plans
In improving the health of homeless people, and reducing the barriers to care experienced by this group, NHS Boards are required to have developed action plans outlining service improvements and including:
- A profile of the homeless
- An initial assessment of homeless people's health and health care needs
- An understanding of the network of health care services within primary and secondary care supporting homeless people
- An identification of strengths, weaknesses and gaps and a plan for addressing any areas of key concern
- Links with other relevant strategies which encompass social inclusion, including Social Justice
1.1Background to the Grampian Health and Homeless Action Plan (HHAP)
Following submission of the NHS Grampian HHAP in November 2002, sign off from the Scottish Executive was achieved in February 2003 for the Aberdeen City element of the Action Plan.
Outstanding concerns in relation to Moray and Aberdeenshire were:
lack of comprehensive needs assessment
need to demonstrate more clearly improved communication, consultation and
involvement of partners
1.1.1Specific Steps to Address Scottish Executive Requirements
- We have addressed these criticisms by identifying key stakeholders and securing an appropriate remit for an NHSG Strategic Group (Appendix A), including the important function of monitoring the Grampian HHAP.
- We have ensured appropriate membership and connections with our LA and voluntary sector partners by developing a meaningful planning framework. This framework has been incorporated in Aberdeen City, Moray and Aberdeenshire Homelessness Strategies (Annex B).
- Our initial focus during the period of resubmission has been on achieving an effective, transparent, infrastructure from which to agree our objectives. We now have the platform from which to deliver, and monitor jointly, our progress against these. Progress has been made against the original Grampian submission (Appendix C), and we believe that these changes create more effective drivers.
- We sought Scottish Executive agreement that we would revise actions for all three areas to reflect changes in Aberdeen City.
- To address issues of communication and engagement, we established workshops with key LA, NHS and voluntary agency staff at both strategic and operational levels to review plans and share intelligence and examples of good practice, in each of the Local Authority areas (Appendix D).
- We have disaggregated the original Grampian HHAP in order to focus further on the requirements specific to each of the three areas: Aberdeen City, Aberdeenshire and Moray. The respective action plans are contained together, in a companion document.
- We have maintained our cross - Grampian structure, retaining core objectives across each Action Plan.
- We have sharpened our focus and reduced the number of objectives from eight to five.
- We have introduced outcomes within our high level plans and, for each priority action to be progressed within Community Health Partnerships (CHPs), performance indicators have been developed to ensure effective monitoring of progress and reporting to the NHS Grampian (NHSG) Group.
1.1.2Contribution of Homelessness Strategies
The potential to strengthen the planning framework arose from the requirement on each Local Authority, under the provisions of the Housing (Scotland) Act 2001, to produce a Homelessness Strategy. The NHSG Group agreed to ‘nest’ health within the respective Local Authority strategies and work to achieve ownership of the health action plans amongst the groups which have devised, and will monitor, the Homelessness Strategies in each of the three Local Authorities.
1.1.3Contribution of Public Health Re-design
Developing and sustaining this planning framework has been optimised by changes resulting in part from the re-design of Public Health in Grampian (2003).
NHS Grampian affirmed its commitment to the homeless and other vulnerable groups with the establishment of a new portfolio to address the Scottish Executive’s Social Justice agenda. The social inclusion portfolio is enabling NHS Grampian now to draw together the various strands of work through which it is addressing health inequalities (Appendix E). For example, in addition to its commitment to Health & Homelessness NHSG is:
-Developing a strategic framework for Health Inequalities
-Developing an action plan for Domestic Abuse
-Leading the health contribution to the Social Inclusion Partnerships (SIPS)
-Leading the health contribution to the Regeneration Strategy commissioned by the
City Alliance (Aberdeen City Community Planning Partnership)
-Developing and implementing an action plan to meet Quality Improvement Scotland
(QIS) standards that takes account of the diverse needs of people with physical
disabilities
-Identifying within the Grampian H&H Action Plan the potential for a framework
which will enable an increasingly systematic delivery of a range of health improvement interventions which address the health and social inclusion needs of specific groups within the population.
Responsibility for the strategic lead role for Health and Homelessness resides with NHSG’s Social Inclusion Manager. The delivery role is the responsibility of the Community Health Partnerships, which are coterminous with the three Local Authorities. The Chief Operating Officer for NHS Grampian will, utilising existing performance monitoring mechanisms ensure delivery.
The Shadow Community Health Partnerships will build on the work of NHS Grampian Collectives and are therefore well placed to progress the Health & Homelessness agenda through the existing partnerships
These roles provide us with key drivers and focal points for Health and Homelessness within the NHSG system and make transparent NHSG’s commitment to tackling issues of inclusion and health inequalities.
1.1.4Context of NHS Reform (Scotland)
The HHAP is being re-submitted at a time when the dissolution of the Primary Care Trust and Grampian University Hospitals Trust is imminent. Consistent with the requirements of Partnership for Care[4], and the NHS Reform (Scotland) Bill, from 1 April 2004 NHS
Grampian will become a single legal entity.
The clear role of the NHS Board as a board of governance and the Community Health Partnerships and acute sector the key deliverers, introduces clarity both within the NHS, and for voluntary agency and Local Authority staff working with the NHS.
Grampian structures post 1 April will comprise a single operating division led by one Chief Executive, with one Chief Operating Officer (reporting to the Chief Executive) who will be responsible for operational management across the whole of NHS Grampian. The delivery of all services will be brought together in a single operating division of four sectors: