Changes

February 2025 — minor update. Added detail relating to the NICE guidance Gambling-related harms: identification, assessment and management [NICE, 2025]. 

Update

Goals

To support primary healthcare professionals to:

• Be aware of the barriers to engagement with health and social care services experienced by people experiencing homelessness (PEH).
• Ensure that all members of the practice team facilitate access to primary care by PEH.
• Offer care of the same standard and quality as others in the general population.
• Offer referral to specialist primary healthcare centres or to a local homelessness multidisciplinary team where locally available and if the person prefers this.
• Be aware of the physical and mental health problems that are more common in PEH and manage or refer appropriately.
• Recognize that long-term support will be required to promote recovery, stability, and lasting positive outcomes.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• The National Institute of Health and Care Excellence (NICE) defines 'people experiencing homelessness' (PEH) as people aged 16 years and over who:
  
  • Are sleeping rough.
  • Are temporary residents of hostels, B&Bs, nightly-paid, privately managed accommodation, and other types of temporary accommodation.
  • Use day centres which provide support for people experiencing homelessness.
  • Are obliged to stay temporarily with other people.
  • Are squatting.
  • Are newly homeless.
  • Have a history of homelessness (as defined above), and are at high risk of becoming homeless again because of ongoing severe and multiple health and social care needs.

[NICE, 2022]

What are the causes and risk factors?

• People experiencing homelessness (PEH) often experience severe and multiple disadvantage and unmet health and social care needs that may be contributing factors for becoming homeless as well as consequences of homelessness.
  • The underlying causes of homelessness include structural, societal, and economic factors such as:
    • Inequality.
    • Poverty and deprivation.
    • Unaffordable housing.
    • Unemployment.
    • Exclusion.
    • Discrimination.
  • In addition, the following features are more common in people experiencing homelessness than in the background population:
    
    • Lack of a 'safety net'.
    • Psychological trauma.
    • Adverse childhood events (including neglect and physical, sexual, and/or psychological abuse).
    • Physical health problems.
    • Mental health problems.
    • Substance misuse.
    • Neurodiversity.
    • Brain injury.
    • History of being in the care of a local authority or in prison.
    • Family conflict/breakdown.
    • Experience of violence, abuse, harassment, or hate crime.
    • Being a refugee.
    • Involvement with the criminal justice system.
  • Severe and multiple disadvantage is a term encompassing overlapping disadvantages that are often persistent, interrelated, and have severe adverse effects on quality of life.
    • As well as the experience of homelessness, other disadvantages that are likely to be present include harmful drug or alcohol use, criminal justice involvement, poor mental health, and domestic violence and abuse.
    • Severe and multiple disadvantage is associated with adverse childhood experiences, poverty, psychological trauma, stigma, and discrimination. 

[Edidin, 2012; Fazel, 2014; Lankelly Chase Foundation, 2015; Local Government Association, 2017; PHE, 2019; NICE, 2022]

What is the prevalence?

• In England in 2020/21, 282,000 single people, couples, and families were judged by local authorities as homeless or threatened with homelessness.
  • While this represents an 8% fall on the previous year, the number of households assessed as homeless rose by 7% during the same time period.
• Between October to December 2021, 64,890 households were assessed as either homeless or threatened with homelessness. Of these, 33,800 households were assessed as homeless.
• It should be noted that official statistics are thought to only capture a limited proportion of people experiencing homelessness.

[Local Government Association, 2017; Crisis, 2022; Department for Levelling Up, Housing and Communities, 2022]

What are the complications?

Homelessness is associated with:

• Increased mortality:
  • Mortality rates in people experiencing homelessness (PEH) are 8 times higher than the general population for men and 12 times higher for women.
  • In England and Wales in 2018, for PEH the mean age of death was 45 years for men and 43 years for women, compared with 76 and 81 years respectively, in the general population.
  • In 2019, the Office for National Statistics reported that the causes of most deaths of PEH in England and Wales were drug-related poisonings, suicides, and alcohol-specific deaths (including liver disease).
  • Deaths following accidents, and cardiovascular and/or respiratory disease are also over-represented among PEH.
• Inability to access primary and preventative healthcare services:
  • Barriers to access and engagement with preventive, primary care and social care services can mean that problems remain untreated until they become very severe and complex.
  • These barriers include stigma and discrimination, lack of trusted contacts, inflexibility of healthcare services, strict eligibility criteria, and lack of information sharing and appropriate communication.
    • Specifically, the most common barrier to accessing primary care has been cited as absence of a fixed abode and related lack of identification documents.
  • PEH are approximately 40 times less likely to be registered with a general practice than people in the general population.
  • PEH who have been refused GP registration are 33% less likely to be admitted to hospital or use ambulance services. However, it is associated with increased use of acute hospital services and emergency care:
    • PEH are 60-fold more likely to attend an accident and emergency department (A&E) than people in the background population. Frequent A&E attendance is also more common for PEH.
    • When admitted to a hospital, the length of hospital stay is usually much longer because of multiple unmet needs.
• Higher social care needs.
• Higher risk of physical health conditions:
  • One study included 1336 PEH who were either sleeping rough, or were residing in hostels and had a history of rough sleeping. Compared to housed people in the most deprived quintile, PEH exhibited statistically significant increased rates of:
    • Asthma.
    • Epilepsy.
    • Chronic obstructive pulmonary disease (COPD).
    • Heart problems.
    • Stroke.
    • Pain.
    • Mobility problems.
• One study assessed rates of cardiovascular disease in 8492 PEH and 32,134 age and sex-matched housed controls. PEH exhibited statistically significantly higher rates of:
• • • All cardiovascular disease.
    • Cardiac disease.
    • Peripheral cardiovascular disease.
    • Cerebrovascular disease.
    • Death within 1 year of diagnosis of all cardiovascular disease or cardiac disease.
• Greater incidence of long-term physical health conditions.
  • It has been estimated that 41% of people classified as 'rough sleepers' have a long-term health condition compared to 28% of the general population.
• Higher risk of mental health problems.
  • The charity Crisis has reported that homeless people are almost twice as likely to have experienced mental health problems compared to the general population.
• 'Trimorbidity' — the combination of physical ill-health, mental ill-health, and drug or alcohol misuse.
• High risk of dental problems.
  • 32% of PEH report dental pain. Missing and decayed teeth are common.
• In school-aged children, homelessness (and related poverty, exposure to stressful life events, limited access to healthcare, and reduced access to education) has been associated with increased risks of:
  • Mental health problems, developmental disorders, and conduct disorders.
  • Lower educational attainment.
  • Malnutrition.
  • Obesity.
  • Infectious vaccine-preventable disease.
  • Asthma, respiratory infections, and ear infections.
  • Scabies and head lice infestation.
  • Poor dental and ocular health.
  • Iron deficiency anaemia.
  • Reduced growth.
• Unaccompanied adolescents experiencing homelessness are at increased risk of:
  • Food insecurity.
  • Unsafe sex, STIs, pregnancy, and miscarriage.
  • Mental health problems (including post-traumatic stress disorder), substance misuse.
  • Sexual abuse.
  • Involvement with the criminal justice system.

[Elwell-Sutton, 2017; Local Government Association, 2017; Faculty for Inclusion and Homeless Health, 2018; Gunner et al, 2019; Jayawardana, 2019; Lewer, 2019; Gultekin, 2020; Nanjo, 2020; Strashun, 2020; NICE, 2022]

Management of people experiencing homelessness in primary care

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of integrated health and social care for people experiencing homelessness.

Search dates

January 2012 – June 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• Health Protection Agency
• World Health Organization
• National Guidelines Clearinghouse
• Guidelines International Network
• TRIP database
• GAIN
• NHS Scotland National Patient Pathways
• New Zealand Guidelines Group
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• Patient UK Guideline links
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug & Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalkonline
• BMJ - Patient Journeys
• Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.