15/10/2024

Patients at risk of or experiencing homelessness typically have much longer stays in hospital after they become medically fit for discharge than other patient cohorts. We look at Guidance - Discharging People at Risk of or Experiencing Homelessness (“the Guidance”) published on 26 January 2024.  That Guidance seeks to help tackle the challenges of discharging patients who are homeless, and includes those living in insecure or inadequate housing. The key emphasis of this Guidance is that admission and discharge in health settings are a ‘window of opportunity’ to address individuals’ complex needs and support a move out of homelessness.

The Department of Health and Social Care and the Department for Levelling Up, Housing and Communities issued that Guidance for staff working in the NHS, local authority, housing and other partners, who are involved in the discharge of patients at risk of or experiencing homelessness.  The Guidance builds upon 2022 NICE Guidance and the 2023 Home First Report

The Guidance also provides advice in relation to patients with no recourse to public funds, and who are experiencing, or who are at risk of homelessness. This is therefore likely to encompass anyone who is subject to immigration control (meaning they need permission to enter or remain in the UK), as often those individuals will not have recourse to public funds, and, as such, are unable to claim benefits or housing assistance unless an exemption applies.

What does the Duty to Refer Require? 

The process for arranging a person’s leaving of the health or social care setting can be complex. 

Experiencing homelessness (including hidden homelessness such as sofa surfing) should not mean that an individual is unable to access the health and social care support that they need.  Safeguarding Adult Reviews undertaken in relation to deaths where homelessness was an issue note circumstances where agencies may have missed opportunities to protect adults at risk.  Potentially deaths could be prevented with timely access to services.  The importance of multi-agency working and the interface with safeguarding, as well as seeing a person holistically and understanding the wider safeguarding perspective (which could include other needs – i.e. around addition or domestic abuse for example) is relevant.

Under the Homelessness Reduction Act 2017, NHS bodies have a duty to refer users of their service who are at risk of or experiencing homelessness to a local housing authority of the service user’s choice within 56 days. The service user must consent to the referral being made (see below for those who lack capacity) and those working for other public authorities which are not subject to the duty can still make a referral.

Local authorities also have additional referral duties under the Care Act 2014. They must carry out assessments where it appears someone needs care and support, or make enquiries as to whether any action should be taken in respect of adults who are at risk of abuse, neglect or self-neglect. 

The Guidance has a step-by-step guide to determine whether to refer a patient to the local authority for a needs assessment or for a safeguarding concern as follows:

Section 9 assessment under the Care Act 2014: If the patient appears to have care and support requirements and has provided their consent, the appropriate referral will be a Care Act 2014 section 9 needs assessment.

Section 11 referral under the Care Act 2014: If the patient refuses a needs assessment, a referral should be made to the local authority citing section 11 of the Care Act 2014 if the responsible clinician believes the patient either (1) lacks mental capacity to refuse the assessment or (2) is at risk of neglect or self-neglect.

Section 42(1) referral – the Care Act 2014: An adult safeguarding concern referral should be made to both the local authority and the NHS Trust’s safeguarding representatives if the patient meets the full criteria for section 42(1) of the Care Act 2014:

  • the patient has needs for care and support,
  • they are experiencing or are at risk of abuse or neglect, and
  • as a result of those needs, they are unable to protect themselves against the abuse or neglect or the risk of it.

Which Pathway for Post Discharge Care and Support?

Patients that are at risk of experiencing homelessness will require involvement of the care transfer hub – this is a physical or virtual co-ordination hub or single point of access whereby all relevant services are linked together to co-ordinate health and social care support. The hub should hold local information on available services and accommodation for these patients, and a decision can also be made about which pathway is most suitable for each individual. 

When to assess - the Care Act 2014?

Usual practice is for any assessment (for example the section 9 assessment) under the Care Act 2014 to take place in a person’s home after a period of recovery and rehabilitation.  However, for those at risk of experiencing homelessness the local authority has a responsibility to provide temporary accommodation where this, or any other relevant assessments under the Care Act 2014, can take place. It may however be necessary to carry out an assessment under the Care Act 2014 before discharge from hospital where it is considered that discharging an individual without having done so could cause a safeguarding risk to that individual.

The Guidance: Which pathway?

There are three pathways under Annex B of the Guidance dedicated to supporting patients in these circumstances. 

  • Pathway 1: includes discharging a patient to temporary accommodation and should include a welfare check on the day of discharge making sure that the individual is safe and are confident living independently. Pathway 1 also includes settle-in support for the individual by providing sustenance arrangements and essential home items.
  • Pathway 2:  involves discharging a patient to a community bedded setting with health/social care support. This support continues until longer-term accommodation for the patient is in place, for example, the Oxfordshire Homeless Movement provides step down housing for patients ready for discharge but who lack suitable accommodation.
  • Pathway 3: is designed for patients with more complex needs. It involves placing them in a care home or similar type placements and is for those that are more likely to need residential/nursing care on a longer-term basis. 

Once a pathway has been commenced for a patient, continuous monitoring and evaluation should be undertaken by the care transfer hubs and integrated into management dashboards. For further information, Bradford Respite and Intermediate Care Support Service (BRICSS) mentioned in the Guidance is an example of a Pathway 2 service. 

Conclusion

The Guidance is clear that bodies need to proactively work with patients from admission. The care transfer hubs play a key role in facilitating successful discharges and ensuring that patients are placed on the right pathway for their circumstances. The different pathways allow for patients at risk of experiencing homelessness with varying needs to be cared for at appropriate levels and provides clear  information on how this can be achieved. Ensuring patients get the right support to be safely discharged in a timely manner will help individuals rebuild their lives, and in turn reduce pressures on health and care services, particularly where caused by repeat attendances.  There is a clear requirement for multi-agency working.

Additionally, the Housing Ombudsman has released a spotlight report Relationship of Equals, and calls for a Royal Commission to create a long-term plan for social housing and to review what it means to be “vulnerable” in social housing in 2024.  To view this article, please click on the following link: Housing Ombudsman identifies the meaning of 'vulnerability'.

This article was contributed to by Clare Johnson (trainee solicitor) and Franceska Barnard (trainee solicitor). For further information, please contact Julia Jones, Partner or Jane Bennett, Associate.

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