Health and Homelessness Policy: crossing the hurdles Isobel Anderson

Origin of links with oral health research team. Two comparative research studies 1. Reconceptualising approaches to meeting the health needs of homeless people. Isobel Anderson and Siri Ytrehus, Journal of Social Policy Meeting the needs of homeless people: interprofessional work in Norway and Scotland. Isobel Anderson, Evelyn Dyb and Siri Ytrehus, 2012, Norwegian Institute for Urban and Regional Research. Funded by Norwegian Housing Bank

1: Reconceptualising approaches to meeting the health needs of homeless people Aim – look at health and homelessness policies, drawing on international context Objectives Analyse and compare housing, homelessness and health care systems in the two countries Set within context of wider international research literature on health and homelessness Method – ‘Back to basics’ Literature review – in-country and international Policy analysis/review – in country Exchange visits & conference presentations – develop comparisons and conceptual framework Reconceptualising approaches to meeting the health needs of homeless people Isobel Anderson and Siri Ytrehus Research for Norwegian Housing Bank Published in Journal of Social Policy 2012

Health and homelessness: international research evidence Substantial research literature, numerous reviews – Health characteristics of homeless people – Access to services to meet health care needs ‘Lack of rigorous evaluation of the effectiveness of housing interventions in improving health outcomes in vulnerable groups such as homeless people’ (Pleace and Quilgars, 2004).

Universal or selective provision? Universal Full range of services in non- segregated environment Specialist Overcome ‘managerial disincentives’? Preferences of homeless people? Overcome lack of joint working in main service? Bridge to mainstream ?

Health Care Systems and Homelessness Strategies NorwayScotland Universalistic WelfareLiberal Welfare (universal legacy?) Decentralised health care system – state grants and municipal taxes (434 municipalities) Centralised health care system (devolved) – central taxation - (14 boards, 32 municipalities) High home ownership, very limited social rented housing, Med-high home ownership, relatively high social rented housing Single comprehensive homelessness strategy (inter- ministry) Comprehensive legal framework for homelessness, (‘corporate’ but housing led) No new or separate health services for homeless people (or indeed any group) Some long standing and recently funded specialist separate health services for homeless people

Health care in homelessness initiatives NorwayScotland Goals for output (local autonomy on implementation) National Health and Homelessness Standards for Health Boards – with performance requirements (2005) Homelessness strategy – no specific guidance on health Joint health and homelessness action plans – NHS boards and municipalities Guidance on mental health care includes housing Top-down approach to multi- agency working Competence enhancing education programmes (homelessness) Professional education and some new training for health workers re homelessness Homelessness grant rarely used to strengthen health care delivery Some NHS boards have funded specialist health services for homeless people

FEANTSA (2006) Right to health, access for homeless people All EU nations reported some specialist provision to reach homeless people not in regular contact with general healthcare system Meeting all health needs through emergency or specialist services – not quality health care Specialist structures ‘legitimise’ exclusion? Mainstream ideal/specialist – temporary/bridge So - Is Norway unique? Process of optimising mainstream service access?

Impact of strategic responses to homelessness? Norway – universal approach – less attention to distinct health and homelessness issues – Might some homeless people be receiving less good access to health care? Scotland – liberal – recognises exclusion but lacks effective evaluation of integrative strategies – Creates more exclusion and therefore necessitates more complex interventions.

Important to take account of changes over time (especially in literature reviews) EU: consensus on some need for specialist provision, but goal remains settled accommodation and mainstream health care Both countries – need for evaluation of changing practice Integration rather than conflicting strategies? – Scotland – moving from exclusion to integration; model for Conclusions (study 1) NorwayScotland Still achieving integration? Variable practice/outcomes? Moving from exclusion to integration Standard bearer for universalism Model for transitional services?

2) Meeting the needs of homeless people: inter-professional working in Norway & Scotland Pilot project aims and methods: – identify factors that influence integration of housing into inter-professional welfare work (Norway) – Scotland – established housing profession – Literature review – Interviews with health and social work professional in both countries – Develop a larger scale study (?)

What is inter-professional work? Ambiguous? Distinct from inter-organisational work? Inter/multi- disciplinary work? Roles of housing, health, social work professionals? – Meeting needs of homeless people – Individually and jointly?

Findings from literature review Emerging conceptual analysis of collaborative working Self-evident good? – Become the ‘norm’ but rarely rigorously evaluated More challenging at operational level than policy/strategic level? Much more literature on health and social care, compared to housing Care Management approach very significant Emergent role of housing support Vulnerable groups still face exclusion

Participant Interviewees and discussants Norway (9) – Mental Health/Alcoholism Team leader (4); Nursing and Care Area Managers (2); Social Services Manager (2); Housing Service Environment Worker (1) Scotland (11 – 6 individual interviews and group discussion with 5) – Community Psychiatric Nurse (1); Occupational Therapists (3); Nursing Addictions Team Leader (1); H&H liaison (1); Care Manager (2); Case Workers (2); Social Work Addictions Worker (1).

Findings from interviews NorwayScotland Need for co-operation, little work time allocated. Social housing not mainstream to health and welfare work. Joint working across health, housing and social care very much the norm. Variable understanding of ‘housing profession’ by health and social care professionals. Varied opinions of where housing fitted in inter-professional working. Issues around training, understanding how best to resolve service users needs. Understanding of housing needs and contributions from other professions more consistent. Lack of strategies, guidelines for inter-professional work. Process of increasingly embedding inter-professional working in everyday working life – but still scope for improvement.

Further work needed Norway – possible further work on better integrating housing issues into welfare service provision Scotland – Effectiveness of health and homelessness standards? – ‘Reintegration’ into mainstream health care (parallel to housing resettlement)? Fits with conclusions of oral health and homelessness reseach.