The number of rough sleepers on the streets of England and Wales has risen over 140% since 2010 and they are being badly let down by health and care services. In 2018, 726 rough sleepers died, up 22% on the previous year, with the average age of death at 45 for males and 43 for females, that is three decades younger than the general population.

As part of the government’s Rough Sleeping Strategy announced in 2018, The King’s Fund was commissioned to determine why healthcare systems are failing rough sleepers so badly and report on good practice. The report, released in early March, noted that ultimately the poor health and reduced life expectancy of rough sleepers can not be fixed by the NHS alone, tackling rough sleeping involves improving people’s health, social wellbeing and housing situation as well as supporting them to find long-term solutions. However, the report also highlights good practice that can help improve access to the NHS for rough sleepers who currently face many barriers.

Barriers to access include the attitude of some staff, complex administration processes and previous negative experiences. Often the health problems of rough sleepers are not picked up until the issue is acute and rough sleepers are far more likely to visit A&E. A study from the University of Birmingham in 2019 found homeless people in England are 60 times more likely to visit A&E than the general population.

This propensity to visit A&E is not surprising – it is relatively anonymous and the first question is not “what’s your address?” The complexity of the NHS is baffling to many who don’t have the additional difficulties of those sleeping on the streets. Continuity of care is made extremely difficult due to the need for an address for letters about appointments.

Richard Vize writing in The Guardian about this subject, noted that while “the NHS and local government talk about “hard to reach groups”, their champions in the public sector argue it is the services themselves that are hard to reach.” 

The King’s Fund’s report identified five common principles of delivering effective health care to people sleeping rough, which can be summarised as follows: “find and engage people sleeping rough”; “build and support the workforce to go above and beyond” to encourage integrated and flexible working practices; “tailor the response” as a “generic ‘off-the shelf’ approach to improving health and care outcomes for people sleeping rough will not work”; and “use the power of commissioning” with commissioners working together across the NHS and local authorities to deliver integrated services that address the complexity of need among the population who sleep rough.

These approaches are all commonsense, however in the real world NHS services have to work with a host of other services for the homeless provided by local councils and since 2010 these services have been cut to the bone. 

Council spending on supporting single homeless people in England fell 53% from 2008-9 and 2017-18. Local authorities are spending £1 billion less a year on homelessnesss services compared to ten years ago. During the same period, homelessness in England has risen dramatically. Entirely down to government policy – prior to 2010, the number of rough sleepers was falling then in 2009 the ring-fence that protected the funding for the Supporting People programme – a programme for people struggling to live independently to avoid and escape homelessness – was removed and the levels of housing-related support funding was reduced. The result has been the massive increase in homelessness and rough sleepers and a decrease in places for them to seek shelter and help. In December 2019, the charity St Mungo’s reported that there were 8,755 fewer places in accommodation services for people compared with nine years ago. 

The government’s answer to the escalating problem is the Rough Sleeping Strategy announced in 2018, part of which was the report by the King’s Fund. Whilst this has provided some additional funding for homelessness services, it falls short of replacing the lost £1 billion per year funding. The strategy commits £1.2 billion over five years, with £100 million earmarked to halve rough sleeping by 2022 and end it by 2027.


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