Dear Senedd Health, Social Care and Sport Committee,

Please see for your consideration, my submission below for the current Hospital Discharge Processes consultation.

“The identification of practical frontline solutions and initiatives that work, enabling effective, appropriate and timely hospital discharge; how these are rolled out and mainstreamed.”

One group of people who I believe should receive significant focus during this process is the homeless.

Homeless people often have poorer levels of mental and physical health compared to the general population [1], often presenting with multiple morbidities and are four times more likely to use A&E than the general population [2,3,4,5,6,7,8]. This overrepresentation in unscheduled care for homeless patients costs the NHS 8 times more than the general population [5].  One of the major challenges in providing care for the homeless population is often after they leave hospital. As soon as they are not in command of a hospital bed and are discharged; they often find themselves in an environment that can rarely facilitate effective recuperation. The underlining health inequities that the homeless experience can be further exacerbated by inappropriate hospital admission and discharge protocols; especially when homeless people’s multiple health and social needs are never fully addressed. This often leads to long hospital admissions, loss of housing/accommodation and most prevalent in these cases, regular readmissions. Fundamentally, discharging to no fixed abode often leads to a quick deterioration in health and readmission [2,3,4,7,9,10].

The relationship between ill health and lack of suitable housing is significant, yet substantial empirical and anecdotal evidence suggest that this may not be being considered by healthcare professionals [3,4,6,9,10].

Examples of Inappropriate discharge can take place in all in-patient adult general wards, medical assessment units, surgical triage units and urgent care centres but is most likely to happen in acute or emergency departments. The reasons behind this vary and include: 

· Lack of communication between relevant services (hostels may be unaware that a resident has been admitted to hospital)

· Lack of appropriate procedures (including healthcare staff failing to ask about housing status directly at first point of contact)

· Not all homeless people being recorded as no fixed abode (NFA)

· Hostels and other homelessness support service being unaware of a service user being admitted to hospital

· Reluctance from the homeless individuals’ themselves disclosing their housing status.

· Homeless people self-discharge due to unrecognised mental health or substance misuse problems

· Referral to housing services from hospital without realising the notice period needed to find a hostel bed or other types of accommodation

Joint working across the sectors is pivotal to a successful and appropriate discharge for a homeless person. Several case studies in various reports show that positive outcomes can be achieved through efficient joint working and that in some large urban areas it can be worth creating a specialist discharge coordinator post to manage large numbers of homeless people that access their health services [9,11].

Ultimately, an efficient and pragmatic homeless discharge protocol that creates a positive collaborative environment will ensure an effectual provision of services to patients, whether they are being admitted or discharged from hospital. It can also act as a platform for homeless people to access services and organisations to facilitate routes out of homelessness, to create new lives, improve health and wellbeing and prevent readmissions

An example evidenced informed protocol below:

Step 1

Identify relevant organisations:

· Hospitals

· Housing and social services departments

· Voluntary sector organisations, including local homelessness hostels and day centres.

Develop a sense of ownership:

· It is essential that all agencies feel ownership of the protocol. Involving key people within the stakeholders and demonstrate to them the good practice and cost-effectiveness of such protocols is integral.

Identify Champions in each sector or service

Step 2

Form a steering group:

· Ensure that all relevant groups are represented within the membership

· Establish roles and responsibilities

· Establish Terms of Reference

· Set progress review dates including dates after the protocol has been implemented.

· Consider the long term need for such a group.

Step 3

Review existing systems / protocols:

· What currently happens when homeless people are admitted and discharged (is there variance between individual wards?)

· Consider potential gaps and the need for new systems and protocols (e.g. record keeping, notifying local authority and voluntary sector organisations)

Step 4

Develop a protocol by building on existing systems

· Link Homelessness protocol to current hospital protocol

·  Identify key people / champions to lead on implementation of homelessness protocol

· Acquire current and active Homelessness Discharge Protocols from other Hospitals /Health Boards

Step 5

Ensure that the new protocol is fit for purpose:

· Establish patients’ housing status on admission

· Obtain consent to share relevant information

· Ensuring accommodation is not lost (communicating with local authority, hostels, landlords etc)

· Notify key agencies

· Develop resources needed

· Facilitate training needed

Step 6

Identify training / key skills and extra resources needed to successfully implement the new protocol:

· Training for hospital staff on understanding and awareness of homelessness

· Resource book / leaflet / poster / homeless intranet page with relevant information and ‘key contacts’ etc

· Consider a updatable directory of services mechanism (intranet or paper folder)

Step 7

Test and monitor the protocol:

· Pilot the protocol  ensuring complete involvement from key stakeholders throughout process

· Monitor impact of protocol (sustained tenancy rates, length of stay, re-admittance range, housing services feedback etc)

· Ensure appropriate staff are briefed

Step 8

Ensure that an audit procedure is in place to monitor the protocol’s impact on:

· Patterns of admission

· Patterns of discharge

· Patterns of self discharge

· Patterns of readmission (length between discharge and readmission)

· Actual date of discharge compared to predicted date of discharge

Step 9

Review and refine the protocol:

· Feedback from homeless people

· Feedback from NHS staff

· Feedback from local authority staff

· Feedback from voluntary sector staff / volunteers

· Feedback from other key stakeholder staff

References:

[1] Bradley. J. (2018). Health of Homelessness. BMJ Rapid Responses. https://www.bmj.com/content/360/bmj.k902/rapid-responses

[2] Crisis. (2012). Homelessness Kills. An Analysis of the Mortality of Homeless People in Early First Twenty First Century England. London. Witherbys

[3] Deloitte. (2012). Healthcare for the Homeless. Homelessness is Bad for your Health. London. Deloitte Centre for Health Solutions

[4] Fisher. K. and Collins. J. (eds) (1993). Homelessness Health Care and Welfare Provision. OXON: Routledge.

[5] Great Britain: The Faculty for Homeless and Inclusion Health. (2013). Standards for Commissioners and Service Providers: Version 2. London. The Faculty for Homeless and Inclusion Health.

[6] Homeless Link. (2010). The Health and Wellbeing of People who are Homeless. Evidence from a National Audit. London. Homeless Link.

[7] Quilgars, D. and Pleace. N. (2003). Delivering Health Care to Homeless People. An Effectiveness Review. University of York.

[8] Wright. N. and Tompkins. C. (2006). How can Health Services Effectively Meet the Health Needs of Homeless People. British Journal of General Practice. (56). P.286-293.

[9] Great Britain: Homeless Link and St Mungo’s Peer Researchers. (2012). Improving Hospital Admission and Discharge for People who are Homeless. London. Homeless Link and St Mungo’s.

[10] NHS Choices. (2012). Discharging homeless patients ‘need overhaul’ [Online]. Available from: http://www.nhs.uk/news/2012/05may/Pages/nhs-care-for-homeless-patients.aspx [Accessed: 18 June 2014]

[11] England. East Lancashire Hospitals NHS Trust. (2010). Hospital Admission and Discharge Protocol to Prevent Homelessness. East Lancashire Hospitals NHS Trust

 Regards