Hospital In-reach - a Public Health Approach to Tackling Homelessness
Rachael Kenyon is the Hospital In-reach Manager at Cyrenians. In this blog she reflects on the journey of the project since its pilot in 2020, and how we're taking a public health approach to tackling homelessness.
Through our experience tackling homelessness, we knew that we were supporting people who were facing serious health problems and had a lot of hospital admissions. We also knew that the systems available to support these people didn't match up. For example, a key worker working in the community might not be able to track down a client if they have been admitted to hospital, or NHS medical staff might not even know that a patient is homeless or that they have a support worker. Both third sector and NHS workers had no way of connecting the dots to support the patient through the admission and discharge process. The result of this was that people would be admitted for a short period of time and then they would be discharged back into the community, oftentimes, back into homelessness without adequate support.
Day to day, we’re there to support people during their time in hospital. We manage the environment to help them engage in and complete treatment, to link in with their existing support, and help clinical staff with discharge planning - making sure that the clinical staff are aware right from the beginning the situation their patient is in, and how we can work together to best support them. Helping with the patient's discharge can often mean ensuring that their current temporary accommodation remains open to them. Unfortunately, since lots of temporary accommodation services close access to a person’s room if the occupant is not using it for a night or two, people admitted to hospital lose their place to sleep, and lose track of their worldly possessions. Imagine being in hospital overnight because you've been unwell - you're discharged at 4:00 in the afternoon and you turn up at your accommodation to find your room has been closed, leaving you with nowhere to sleep that night. It’s a terrible position to find yourself in, and one that only serves to worsen your health.
That’s why when patients have accommodation, we ensure that they keep it. If people don't have accommodation, or it’s not suitable, we try to secure accommodation for them on discharge.
For those who don’t have community support and have complex health and support needs, we step in - doing what we can to support them to return for any outpatient appointments they may have, to engage with their GP and refer them to ongoing support in the community to lessen the chance that they’ll be readmitted.
Whilst patients are in hospital receiving treatment, we handle loads of little practical things that make a massive difference; like those who are admitted with nothing other than the clothes on their back (and sometimes these are removed during medical emergencies). This is a really undignified position to be in - and a very difficult one for those who've experienced trauma in their past. By its very nature, the hospital environment can be really daunting. If a person with pre-existing trauma finds themselves not only unclothed and vulnerable, but then also surrounded by unfamiliar medical professionals and maybe even a group of medical students talking in terms you don't understand about you and your health, the situation can become petrifying. We support people to manage that environment - our work is about reassurance and about dignity, and ensuring people understand what’s happening and feel safe.
The support we give depends on the support that people need. We can bring clothes and pyjamas for a woman who may have experienced sexual trauma and is in a mixed ward wearing only a paper gown, or we can be that person who pops in and listens to what you have to say. We bring newspapers, magazines, a drink of juice or snacks, and we can even lend people tablets so they can watch TV and go on the internet. These little things make a real impact on our sense of human dignity and wellbeing. For those of us who are lucky enough, they’re the things we can rely on our friends or family members for. It helps people cope and to feel less stigmatised - less like they’re standing out.
We also provide vital means of communication for people so they can keep in touch with their support worker or loved ones. What might be most important to people is getting some of their belongings back and ensuring that their key worker knows where they are. If somebody has a trusted worker in the community that they've got a long-term relationship with, it's more important for us in the first instance to connect with them - oftentimes, the people we work with have already had to recount their often really difficult stories to many workers and medical professionals. It’s best to have a familiar, trusted face around to manage and support their admission.
We also support people to understand their treatment. We can translate between the medical professionals and the patient, acting as a kind of bridge between the person in hospital for treatment and the hospital itself - reassuring the patient, but also setting boundaries and expectations for their stay so that the patient can engage with treatment and NHS staff.
We provide the support that allows the patient to achieve the best possible health outcome and reduce the likelihood they’ll end up back on the street or back in the hospital.
One story really stands out from my time managing Cyrenians Hospital in reach service. One of our clients was really frightened of the hospital - he was already frustrated, scared and at the end of his rope when he arrived. We reached out to him through a really simple gesture - a gift of some of the basics and a conversation. But we built a relationship with him and ensured that he completed his treatment and then saw him into accommodation and away from rough sleeping. With our support he moved very quickly into proper long term supported accommodation - all whilst managing substance misuse issues and remaining abstinent for a year. Then he joined a training course with Cross Reach to become a peer support worker. He reconnected with his family, started taking driving lessons, took up a role as a voluntary peer support worker, gained a whole new circle of friends and adopted his own dog. When he got back in touch with us to let us know how well he was doing he stressed that if we hadn’t reached out to him, he wouldn’t be here. He said he’d have left the hospital and not looked back.
That one interaction at the hospital saved his life. It just goes to show how important it is to have someone to listen to you, understand what you’re dealing with, and get what matters to you.
The NHS staff are brilliant - but they’re there to do their job of caring for patients' medical needs. For patients who are stressed, worried about their possessions, pets, their housing, and feeling isolated and unsupported – how can we expect them to engage in treatment? That’s where we come in.
Often, when patients facing homelessness are discharged, they have to immediately contend with a temporary housing system that’s already highly strained. There just aren’t the beds available for people that need a place to sleep, so most end up bunking with someone or sleeping rough. Our in-reach team works wonders to link in with housing organisations to ensure that people have an actual destination upon leaving hospital - not a housing office, and not a temporary housing provider that will likely have to turn them away. But in the last year, achieving that has become harder and harder as the pressure for housing increases.
We’re there to catch people whose health problems and discharge might have been straightforward - if they had a warm house, a fridge full of food and a support network around them. But in reality, they might be going back to a bed and breakfast on the fourth floor of a building with no lift, without money and no cooking facilities, and no means to get to the doctor or the pharmacy. Someone might be medically fit for discharge, but they're not medically fit to return to bed and breakfast, let alone to sleeping rough.
Often people are discharged only to return to hospital. A patient facing homelessness might be discharged from the ward in the afternoon and return to A&E hours later, at a loss as to where to go to stay safe, warm and healthy - which is heartbreaking.
The pressures on the NHS are a tremendous challenge too - since Covid the demand for beds is worse, and increasingly we’re seeing surge wards filled to capacity - it’s the perfect storm. We are so fortunate for the wonderful NHS team we work with – through the relationships we’ve built together to best support the patients we meet.
We don’t want to turn people away into the street with nowhere to go - and we’ll never knowingly discharge people to rough sleeping.
Cyrenians take a public health approach to homelessness. Housing is a health issue - you can't have good health without housing. You cannot recover from an acute hospital admission without a safe place to be. We also can't fix the NHS if we don't fix housing - none of these systems standalone - they’re part of a network. We’re working to bring those services together and build that network. Cyrenians Hospital in-reach service has a great level of flexibility - we can connect people with other Cyrenians services to give the best and most holistic support we can offer. For example, we have people accessing the Cook School and have referred women on to our WiSH (Women in Safe Homes) Project, and we supply people food parcels through FareShare. We make the most of what Cyrenians have to offer patients who are at the really rough end of homelessness, although to the public that support may probably look quite far away from the front line of homelessness. We have so many brilliant resources that we can draw on to benefit the patient and support them - as varied as the individual is complex.
