Hope, Health, Homelessnes

s and Habits

Neil Hamlet – Consultant, Public Health Medicine, NHS Fife

- National Public Health Lead for Homelessness

HousingADPsNHS

HSCP

Personalised Paths and Potholes

Rafters

Relationships

Proportionate Contribution by Cause - Males

External Causes, Chronic Liver Disease

Proportionate Contribution by Cause - Males

A/E, Mental Health, Orthopaedics

Diseases of

‘dis – ease’

Alcohol Services

Stroke Unit

Respiratory Unit

Cardiology

Cancer Services

‘Despite the common sense… we still categorise people in separate boxes defined by single issues… Each of

these labels triggers a different response from statutory and voluntary systems, different

attitudes from the public and media, different theoretical approaches from

universities, different prescriptions from policy makers’

Hard Edges 2015, Lankelly Chase Foundation

Key Learning• Multiple Exclusion Homelessness – overlap with

mental ill-health, alcohol and substance misuse, offending and prison

• Early childhood trauma often lies at the root• Visible homelessness happens late• The need for ‘psychologically informed practice’• The contribution of housing and ADP actions to

health and social care• Importance of ‘home’ and environment -

Home as bedrock of security, dignity , relationship and opportunity

• High costs of ‘failure demand’ – to individuals, families, services and society

ScotPHN is hosted by

Novel Approach‘Do things differently – do different

things’• Till – Sow – Nurture – Reap – (Repeat)• Boundary Spanning & ‘Housing Speak’ • Wide engagement and conversations• Soaked in evidence – lived and

published• Snowballing the passion• From a ‘Report’ to an ‘Movement’ScotPHN is hosted by

•What other ‘professional’ or ‘service’ languages are you using ?

•What ’boundaries’ have you spanned recently?

2006 2007 2008 2009 2010 2011 2012 2013 2006 2007 2008 2009 2010 2011 2012 2013HL1 Fife (Aged 15 - 64)

-

200

400

600

800

1,000

1,200

1,400

A&E Attendance Rate per 1,000 Popula-tion

Attendances at Queen Margaret Hospital (Dunfermline) and Victoria Hospital

(Kirkcaldy)

MaleFemale

The impact of homelessness on health care – proving the case

‘Insecurely Housed’ ‘Securely Housed’

2006 2007 2008 2009 2010 2011 2012 2013 2006 2007 2008 2009 2010 2011 2012 2013HL1 Fife (Aged 15 - 64)

-

50

100

150

200

250

Patient Multiple Attendance Rate per 1,000 PopulationPatients who have attended A&E more than once within

specified year

Male Female

The FrequentFliers

‘Insecurely Housed’ ‘Securely Housed’

Cryers

2006 2007 2008 2009 2010 2011 2012 2013 2006 2007 2008 2009 2010 2011 2012 2013HL1 Fife (Aged 15 - 64)

0%

5%

10%

15%

20%

25%

30%

35%

40%

% New Outpatient Appointments DNANew appointments who Did Not Attend

(excludes cancellations by hospital or patient)

• Changed address• Fearful to open official

mail• Appointment too early• No money for the bus• ‘it won’t do any good’Access / Expectation

‘Insecurely Housed’ ‘Securely Housed’

HL1

Fife

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Age Distribution of A&E Attendances; 2013Age of patient attending A&E

Under 15 15 to 19 20 to 29 30 to 3940 to 49 50 to 64 65+

Over 50% are under 30 yrs

Over 80% are under 40 yrs

2006 2007 2008 2009 2010 2011 2012 2013 2006 2007 2008 2009 2010 2011 2012 2013HL1 Fife (Aged 15 - 64)

-

15

30

45

60

75

90

0%

5%

10%

15%

20%

25%

30%

Alcohol-related Admissions rate per 1,000 and % of AdmissionsAdmissions with diagnosis related to alcohol based on ISD definition

%Rate

Rate

per

1,0

00 P

opul

ation

% of Adm

issions

2006 2007 2008 2009 2010 2011 2012 2013 2006 2007 2008 2009 2010 2011 2012 2013HL1 Fife (Aged 15 - 64)

-

10

20

30

40

50

60

0%

5%

10%

15%

20%

Drug Misuse-related Admissions rate per 1,000 and % of AdmissionsAdmissions with diagnosis related to drug misuse based on ISD def-

inition

%

Rate

Rate

per

1,0

00 P

opul

ation

% of Adm

issions

Clear role for Community Safety Partnerships ?

2006 2007 2008 2009 2010 2011 2012 2013 2006 2007 2008 2009 2010 2011 2012 2013HL1 Fife (Aged 15 - 64)

-

10

20

30

40

50

60

70

80

90

100

Emergency Admission Rate relating to Injury & Poisoning per 1,000 PopPatients admitted as emergency relating to injury and poisoning (ICD10 codes

S00 - T99)

Violence +++& Self Harm

The cost of ‘Churn’

- Source data from Lankelly Chase Foundation 2015.

- Data is English – but directly transferable

- Estimate is considered conservative.

- General estimates of lifetime costs (to society) per individual range from £250k to over £1m.

Chief Scientist funded pilot to test Fife approach nationally

The Integration Landscape

• Scottish Government funded initiative

• Support Integration Authorities with Strategic Planning by;

Providing data and analytical support

Help to evaluate services, through providing evidence for change

Help to transform data into evidence for action

A&E Outpatients

InpatientsDay cases

Deaths

Prescribing

Age/gender

CHI

Linked File

SPARRA

Social Care

SIMD

Linked Health and Social care

file at an individual service

user level (Aggregated

Activity & Costs)

Partnership

Access

Via secure

platform

Integrated Data:Health & Social Care Integration and

Information Platform

£costed

CommunityHousing & Homelessness

data

Where are you re sharing ADP

data with partners ?

• Forecasting / Scenario Planning

• Pathway Analysis

• Impact analysis (evaluation)

• Care Group Development

• Continued Dashboard development

The Future

Data Gaps and Data Set Evolution – include linked Community Nursing activity from April 2016

and Homelessness and Housing from April 2017

Links to Other Areas (Third Sector)

• Personal Outcomes

2015 to 2017

We need both knowledge and know-how

• With social interventions:– there is no single method or formula– what is done and achieved will vary from case to case– routinisation often hinders performance– flexibility, responsiveness, and context-specific approaches

are essential

• Know-how “moulds and supports the practice used in a field as performed by those skilled in the art”

(Nelson, 2010)

An alternative ‘solution space’(Wilber’s integral model)

Problem labelling

Service solutions

Inner Trauma

SharingCaring

What Now .......• Iceberg of vulnerability

•Sticky Scotch Pies

•Home as salutogenic ‘Place’

Home

A HOME

Homeless

Problem

Alcohol

Proble

m

Drug

Prob

lem

Domestic

Abuse

Problem

Criminal Justice

Problem

Wounded Lonely Soul

Paddington

Bear

Lonely, Unloved• The most terrible poverty is loneliness, and

the feeling of being unloved. (Mother Teresa)

• When you're surrounded by all these people, it can be lonelier than when you're by yourself. You can be in a huge crowd, but if you don't feel like you can trust anyone or talk to anybody, you feel like you're really alone. (Fiona Apple)

• If one's different, one's bound to be lonely. (Aldous Huxley)

The Enquiry has recognised the size and relatively recent emergence of Scotland’s drug and alcohol problems. Its judgement is that we need to look to the whole of Scottish society – our inequalities, our consumer culture, our failure to protect young people and much else – for the underlying causes.

We heard a strong critique of Scotland’s drugs and alcohol policies in recent years. To date, drug policy in Scotland has swayed between a focus on health and a focus on criminal justice concerns. There is a need to accept that alcohol and drug problems are fundamentally social problems. This means moving beyond medicalised or criminal justice approaches to creating a new holistic response that addresses a much wider agenda. This has to focus on purpose and meaning, child and family welfare, employability, family support and community will.

In the face of complexity and the understandable desire to make a plethora of recommendations, the Enquiry took a conscious decision to limit its suggestions to two major thrusts. The first is the adoption of a ‘whole population approach’ – melt the iceberg of drugs and alcohol by raising the temperature of the water; and the second is a personalised approach to supporting those with ‘overwhelming involvement’ – ‘the circle of care’.

Warm the water

Keep chipping

away

Statutory Homeless

Domestic Abuse

Childhood Trauma

AddictionCriminal Justice

Relational Breakdown

'Houseless and Hungry' by Luke Fildes depicting homeless paupers queuing outside the casual ward of a London

workhouse

Meeting the deep needs of safety, relationship, dignity, belonging and

purpose

What part can ADPs play in helping to change the

causes and consequences of

homelessness in Scotland ?

neil.hamlet@nhs.nhs

www.housingandwellbeing.org

http://www.scotphn.net/projects/previous_projects/homelessness_guidance_for_public_health

12 Proposed Actions:1. At-risk population groups,

circumstances and key transition points - for prevention and mitigation

2. Health Inequalities Strategies - to include homelessness underpinned by needs assessments

3. Housing and health literacy - workforce development on risk factors and routes into homelessness

4. Psychologically informed environments and services – accessible person-centred approach

12 Proposed Actions:5. Partnership Pilots – linking housing, ADPs,

mental health, criminal justice and SPS

6. Housing First – spread across Councils and further evidence the Scottish model for MEH community

7. Engagement with early-years, schools and colleges – on awareness of transition points and routes into homelessness

8. Integration of housing into HSCPs – focussing on those with most complex needs

12 Proposed Actions:

9. Data sharing - sign up to pilot data linkage

10. Data analysis - for prevention and mitigation

11. Faculty of Homelessness & Inclusion

Health - workforce development, peer support and

shared learning

12. Executive leadership – to champion the

home as the key salutogenic place factor for

wellbeing