Authors' objectives: There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services. This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants’ use of health care and social care services over 12 months, and costs were calculated. There is a high prevalence of health problems among single people who are homeless; since the 1980s, specialist primary health care services have been developed in several locations across England for them. These include dedicated health centres and mobile health teams that visit hostels and day centres. There have been very few evaluations of these services, however, and their effectiveness is unknown. In 2010, the Department of Health (now Department of Health and Social Care) reported a lack of systematic data on the use of health services by people who are homeless and on the costs of such services, and a lack of evidence of the potential to improve primary care and health outcomes, and thus reduce secondary costs. This study aimed to address these knowledge gaps. The study’s overall aim was to evaluate the effectiveness and costs of different models of primary health care provision for people who are homeless. The research questions were as follows. Which models or service elements are more effective in engaging people who are homeless in health screening and health care? Which models are more effective in providing continuity of care for long-term or complex health conditions? What are the associations between integration of the models with other services and health outcomes for people who are homeless? How satisfied are service users, primary health care staff and other agencies with the services?

Authors' results and conclusions: The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services. Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, ‘drop-in’ services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services. In this study, participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Analyses have mainly focused on differences between the four Health Service Models, but there were key differences between CSSs within the same model, which are also reported. Overall, outcomes for Dedicated Centres and Specialist GPs (particularly Specialist GP 1) were relatively favourable, especially in relation to continuity of care for health conditions and service use by participants. Their relative success is likely to be attributable to service delivery factors. They had dedicated staff working with patients who were homeless, and provided flexible ‘drop-in’ services. Multidisciplinary working was prominent, with on-site mental health and substance misuse services, and the sites were well integrated with local hospitals, street outreach teams and homelessness sector services. With no GP in the Mobile Teams, patients received health care from both Mobile Team nurses and local GPs. The less favourable scores associated with this arrangement for health screening and continuity of care for health conditions suggest poor co-ordination between the services. Health care by Dedicated Centres and Specialist GPs was delivered by GPs and nurses from the same practice, and patients were registered with a single primary health care provider, whereas the Mobile Team model involved the delivery of primary health care by multiple providers at different sites. This may have negatively affected collaborative working among staff and led to uncertainty and confusion among patients. Although the mean number of nurse consultations was considerably higher among Mobile Team participants than in other models, their number of GP contacts was less than that of participants in the Dedicated Centre and Specialist GP models. Usual Care GPs operated very differently to other models, and service delivery factors are likely to have been crucial in contributing to their relatively poor performance for some outcomes. Their practice list sizes were large; they had no dedicated staff or targeted services for patients who were homeless; they did not offer drop-in clinics, meaning patients were required to book appointments; and they were not well integrated with homelessness services. However, positive scores for health screening at two sites, and higher satisfaction ratings at one site, suggest that some mainstream general practices can accommodate the needs of patients who are homeless, given the right circumstances. Implications Implications for NHS commissioners and health care service managers and practitioners arise from the study’s findings. In areas with unmet health needs among people who are homeless, commissioners need to consider what models of provision are most appropriate, taking into account the scale and nature of local homelessness. Questions arise as to the function of Mobile Teams and their collaboration with GPs, and whether or not a more effective service could be delivered if they operated as part of a general practice, rather than as a separate service. Likewise, different configurations of dental care delivery need to be explored, and consideration given to the poor availability of mental health services. There needs to be improved health screening for people who are homeless, leading to an intervention when indicated. Awareness needs to be raised of the links between homelessness and chronic respiratory problems and depression, and assessments should be undertaken to detect these conditions and initiate treatment if required. The relatively poor performance of Usual Care GPs for some outcomes raises questions about their role in providing health care to patients who are homeless, and when the practices might require additional support. Consideration should be given to the introduction of a ‘homelessness lead’ at these practices to enable more focused work to be undertaken with patients who are homeless. Finally, the evaluation of services is critical, including their performance against national and local indicators, comparisons of different service delivery models, and monitoring of longer-term outcomes.

Authors' methods: The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model. People who had been homeless during the previous 12 months were recruited as ‘case study participants’; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders. There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. There were limitations to the study. One of the main difficulties was recruiting mainstream general practices with enough patients who were homeless for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. Given the innovative nature of this study, various measures were used for the first time to assess the performance of the CSS. Screening for the primary outcome and the management of SHCs did not rely on validated tools for scoring (as none could be found). Instead they depended on the expertise of the research team and other clinicians. Various ‘rules’ were adopted for the scoring, which undoubtedly had an influence on outcomes.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/13/156/03

Year Published: 2023

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/WXUW5103

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/WXUW5103

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk