Homelessness and Health: A Window of Opportunity for All

Discharging People at Risk of or Experiencing Homelessness: A Window of Opportunity to address an Individual’s Complex Needs

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 (or are at risk of homelessness), 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 with key stakeholders 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.

The Duty to Refer – To the Local Authority

The process for arranging a person’s leaving of a health or social care setting can be complex. Experiencing homelessness 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 noted 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 is relevant.

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

The public authorities which are subject to the duty to refer are specified in the Homelessness (Review Procedure) Regulations 2018 (“the Regulations”), and include (a) prisons, (b) youth offender institutions, (c) secure training centres, (d) secure colleges, (e) youth offending teams, (f) probation services, (g) the job centre, (h) social service authorities, (i) emergency departments, (j) urgent treatment centres and (k) hospitals in their function for providing inpatient care. The Secretary of State for Defence also has a duty to refer in relation to members of regular forces.

The approach to discharging the above duty varies between Local Authorities, and each Authority has the responsibility to decide how best to do so. Typically however, where a person is homeless, or at risk of homelessness, the usual response is for that public authority to refer the case (with consent) to the relevant Local Authority identified by the individual. It does not have to be in the area in which the individual is currently located.

Local Authorities are responsible for ensuring local procedures for managing referrals, and must incorporate the duty to refer into their wider homelessness strategy. Additionally, Local Authorities are encouraged to establish arrangements with partner organisations that aim to maximise the impact of shared efforts for individuals who may have multiple needs.

For further information in respect of the duty to refer, please see Chapter 4 of the Homelessness Code of Guidance for Local Authorities.

Safeguarding and Care Needs Assessments

Local Authorities also have additional 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 helps and reminds staff in care transfer hubs (including the NHS, Local Authorities and housing and other partners) to determine whether an individual should be referred 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 individual 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 individual refuses a needs assessment, a referral should be made to the Local Authority citing section 11 of the Care Act 2014 if the individual 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 the Local Authority if an individual meets the criteria for section 42(1) of the Care Act 2014, namely:
  
  • They have 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 Ongoing Care and Support?

Individuals 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, including Local Authority services are linked together to co-ordinate health and social care support. The hub should hold local information on available services and accommodation for individuals, and a decision can also be made about which ongoing care pathway is most suitable for each individual – see below. 

Where 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. However, for those at risk of, or experiencing homelessness the Local Authority has a responsibility to provide temporary accommodation as needed, 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 in hospital for example, where it is considered that discharging an individual without having done so, could pose or cause a safeguarding risk to that individual.

The Guidance: Which Pathway?

There are three pathways outlined under Annex B of the Guidance dedicated to supporting patients / individuals in these circumstances: 

Pathway 1: includes placing an individual in temporary accommodation and should include a welfare check on the day of placement 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 placing an individual into a community bedded setting with health/social care support, which continues until longer-term accommodation for the individual is in place.

Pathway 3: is designed for individuals 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 hub(s). 

Conclusion

The Guidance is clear that all public bodies need to work proactively with individuals from the point of admission. The care transfer hubs play a key role in facilitating successful discharges and ensuring that patients / individuals are placed on the right pathway for their circumstances. The different pathways allow for individuals 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 by all stakeholders. Ensuring patients get the right support to be safely discharged in a timely manner will help individuals rebuild their lives. There is a clear requirement for multi-agency working, particularly between health bodies and the Local Authority.

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'.

For further information, please contact Julia Jones or Jane Bennett.