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Home > Delivering health and care for people who sleep rough: going above and beyond.

Cream, Julia and Fenney, Deborah and Williams, Ethan and Baylis, Alex and Dahir, Siham and Wyatt, Harry (2020) Delivering health and care for people who sleep rough: going above and beyond. London: Kings Fund.

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Key messages:

  • People who sleep rough have complex and multiple health and care needs that all too often are not met. As a result, they have some of the worst health outcomes in England.
  • Although good progress was made in reducing rough sleeping in the 2000s, this has reversed since 2010 and the number of people sleeping rough continues to increase. The government is committed to eliminating rough sleeping by the end of this parliament and has outlined action to achieve this in its Rough Sleeping Strategy, including a focus on improving health services for people sleeping rough.
  • Health needs are closely intertwined with housing and other support needs. The solutions to improving health outcomes for people sleeping rough do not rest with the NHS alone – local authorities and the voluntary and community sector are essential partners. A population health approach is needed to address the full range of factors that influence the health and wellbeing of people sleeping rough.
  • People who sleep rough face a range of barriers to accessing health and care, so services need to reach out proactively to find and engage them. It is important to involve people with lived experience of sleeping rough in co‑producing services to ensure they are designed to meet the needs of this group effectively.
  • A generic, ‘off-the-shelf’ approach to improving health outcomes for people sleeping rough will not work. A local, place-based approach is needed, recognising that the rough sleeping population is not static and geographical boundaries shape access and entitlement to services.
  • Delivering integrated services that truly address the complexity of need among the population who sleep rough requires commissioners to work together across the NHS and local authorities, using the full range of powers available to them. Contracting has a particularly important role to play in ensuring services are effectively co-ordinated.
  • Harnessing the commitment and passion of frontline staff to go ‘above and beyond’ is key. This can be achieved by fostering a safe, supportive environment that enables staff to use reasonable flexibility in their clients’ best interests and by developing a shared sense of purpose across local systems. Staff need support to maintain the understanding, confidence and resilience needed to work effectively with this population.
  • Local leaders need to manage complex interdependencies across multiple organisations and sectors. This requires them to take shared ownership and responsibility for tackling rough sleeping, and to model partnership working across different professional cultures.
  • The NHS long-term plan identifies people sleeping rough as a priority group. The local implementation plans of sustainability and transformation partnerships/ integrated care systems are an opportunity to join up health services with housing and social care and set local goals for improvement in the health of people sleeping rough. NHS England and NHS Improvement should support this ambition and consider how to ensure accountability for improving the health of people sleeping rough in local plans for reducing health inequalities.
  • Continuing commitment across government is needed, with secure resources in place to deliver the government’s Rough Sleeping Strategy over multiple years across housing, social care and public health, as well as health services. Arrangements for sharing good practice and learning need to be improved and should be supported by government departments and national bodies.

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