Presentation given by Bill Edgar at a FEANTSA conference on "The Right to Health is a Human Right: Ensuring access to health for homeless people", Wroclaw, Poland, 2006

1. Joint Centre for Scottish
Housing Research
Access Barriers to Health Services
for Homeless People
Conference Wroclaw, Poland
Bill Edgar
European Observatory on Homelessness

2. Overview of Presentation
Health Service Needs and Use
Barriers to Access
Policy Responses
Differences across Europe
Factors or Drivers of change

3. Health Needs are Different
Homeless Families with Children
Rough Sleepers
Mental Health Problems
Substance Abuse Problems
People with Multiple Needs

4. Health Services Accessed
Emergency and Outreach Services
Mainstream (GP, Hospital)
After-care services
Specialist Services
Long-term Care

5. Factors leading to Homelessness
CAUSES FACTORS TRIGGERS HEALTH ISSUES
STRUCTURAL Poverty Debts
GP Registration
Unemployment Financial Crisis
Housing Eviction (arrears)
Eviction (behaviour)
INSTITUTIONAL Institutional Living Leaving care Discharge Procedures
Foster / State Care Leaving Care
Prison Experience Leaving prison
Armed Forces Forces discharge
RELATIONSHIP Abusive relationship Leaving family After Care
(childhood) home (women and children)
Abusive relationship
(with a partner) Fleeing violent
Family Breakdown relationship
(death or Coping with living
separation) alone
PERSONAL Mental Illness Deterioration /
Undiagnosed condition
illness episode
Learning Difficulty Support breakdown Housing and Support
Drug Dependency Substance Misuse
Specialist care
Alcohol Dependency Substance Misuse

6. Homelessness factors creating
barriers
Living Situation
– No abode
– Family and friends
– Overnight hostel, temporary
accommodation
– Supported accommodation
Lifestyle
– Social / family support
– Self-esteem and self-neglect
– Behaviour

7. Health factors creating barriers
Structural
– Funding of health services
– Health Structures
– Targeted Policies
Institutional
– Family Doctor Registration
– Organisational rules of referral to mainstream
– Organisational rules of referral to specialist
Agency
– Individual capacity (esteem, lifestyle)
– Professional attitudes and capacity (training)

8. What are the policy responses ?
Enhance Mainstream Services
– Within GP practices, Hospitals
– Within Hostels
– Within Specialist units
Provide Alternative Services
– Hostel based provision
– Walk-in centres
– Outreach and mobile services
Improve Access to Specialist Services
– Co-ordination / Partnership / Joint Working
– Discharge and aftercare
– Referral and Tracking

9. Mechanisms for Improving
Access
Structural
– Improved planning and guidance (state)
– Address finance issues
– Availability of services (provision, rural areas)
Institutional
– Facilitate registration with doctor
– Adapt or enhance mainstream services
– Provide specialist staff or units in mainstream
– Provide specialist services
Agency
– Support the individual (care plan, aftercare, referral)
– Changing attitudes and performance (training)
– Tailored services

10. NHS
Portugal Denmark
UK
H
E
A
L Austria
T
H Estonia Integrated
F
I None SHI
N
A
N
C
E
Greece Netherlands
PHI
HOMELESS STRATEGIES

11. National Health Services
Portugal
– No Homeless Strategy, Health not an issue
– NGO limited health services role
– Emergency treatment most accessible
– Family doctors in local health clinics
Denmark, UK
– Central Planning and Guidance
– Mainstream services dominate
– Continuity of treatment, aftercare issues
– Hostels (medical staff, sick wards)
– Supported housing services, residential care

12. Social Health Insurance
Estonia
– No homeless strategy
– Ambulance Service (3% calls to homeless)
– homeless centres and shelters main locus
– Tallinn City funds nurses in shelters
Austria
– Regional / Municipal strategies
– Rural provision problems
– E-card administration, immigrants
– NGOs key to co-ordination

13. Results of a Survey of Services
Improved planning, research and
tracking
Improved coordination
Resources for servicing the uninsured
persons
Medical workers specialised in
homeless needs
More finances

14. Private Health Insurance
Netherlands
– Homeless strategies in main cities
– Medical Expenses Act funds homeless services
– Enhanced care, sick bays, nursing homes (since
1993)
– Health Care Insurance Legislation (2006)
– Non-insured, debt recovery, what is necessary care
Greece
– No homeless strategies
– Psychargos discharge (EU funded)
– NGO services (psychiatric in origin – Klimaka)

15. What are the Factors Driving
change?
Developments in Policy
– Positive : health and homeless action plans
– Negative : insurance debt and recovery
Improvements in Service Provision
– NGOs : in hostels services
– Support Finance: long term care
Improvements in Delivery of Services
– Targets : family doctors
– Local Projects: innovation, coordination
– Improved Training and attitudes

16. ARE HOMELESS SERVICES
A SERVICE OF LAST RESORT
FOR PEOPLE WHO
ARE FAILED BY
THE HEALTH SERVICES ?