Hope, Health, Homelessness and Habits Neil Hamlet – Consultant, Public Health Medicine, NHS Fife - National Public Health Lead for Homelessness

Housing ADPs NHS HSCP Personalised Paths and Potholes

Rafters Relationships

Proportionate Contribution by Cause - Males External Causes, Chronic Liver Disease

Proportionate Contribution by Cause - Males A/E, Mental Health, Orthopaedics Diseases of ‘dis – ease ’ Alcohol Services Stroke Unit Respiratory Unit Cardiology Cancer Services

‘ Despite the common sense… we still categorise people in separate boxes defined by single issues… Each of these labels triggers a different response from statutory and voluntary systems, different attitudes from the public and media, different theoretical approaches from universities, different prescriptions from policy makers’ Hard Edges 2015, Lankelly Chase Foundation

Key Learning Multiple Exclusion Homelessness – overlap with mental ill-health, alcohol and substance misuse, offending and prison Early childhood trauma often lies at the root Visible homelessness happens late The need for ‘psychologically informed practice’ The contribution of housing and ADP actions to health and social care Importance of ‘home’ and environment - Home as bedrock of security, dignity, relationship and opportunity High costs of ‘failure demand’ – to individuals, families, services and society ScotPHN is hosted by

Novel Approach ‘Do things differently – do different things’ Till – Sow – Nurture – Reap – (Repeat) Boundary Spanning & ‘Housing Speak’ Wide engagement and conversations Soaked in evidence – lived and published Snowballing the passion From a ‘Report’ to an ‘Movement’ ScotPHN is hosted by What other ‘professional’ or ‘service’ languages are you using ? What ’boundaries’ have you spanned recently?

The impact of homelessness on health care – proving the case ‘Insecurely Housed’‘Securely Housed’

‘Insecurely Housed’‘Securely Housed’ Cryers

Changed address Fearful to open official mail Appointment too early No money for the bus ‘it won’t do any good’ Access / Expectation ‘Insecurely Housed’‘Securely Housed’

Over 50% are under 30 yrs Over 80% are under 40 yrs

Clear role for Community Safety Partnerships ? Violence +++ & Self Harm

The cost of ‘Churn’ -Source data from Lankelly Chase Foundation Data is English – but directly transferable -Estimate is considered conservative. -General estimates of lifetime costs (to society) per individual range from £250k to over £1m.

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Chief Scientist funded pilot to test Fife approach nationally

The Integration Landscape Scottish Government funded initiative Support Integration Authorities with Strategic Planning by; Providing data and analytical support Help to evaluate services, through providing evidence for change Help to transform data into evidence for action

A&E Outpatients Inpatients Day cases Deaths Prescribing Age/gender CHI Linked File SPARRA Social Care SIMD Linked Health and Social care file at an individual service user level (Aggregated Activity & Costs) Partnership Access Via secure platform Integrated Data: Health & Social Care Integration and Information Platform £ costed Community Housing & Homelessness data Where are you re sharing ADP data with partners ?

Forecasting / Scenario Planning Pathway Analysis Impact analysis (evaluation) Care Group Development Continued Dashboard development The Future Data Gaps and Data Set Evolution – include linked Community Nursing activity from April 2016 and Homelessness and Housing from April 2017 Links to Other Areas (Third Sector) Personal Outcomes 2015 to 2017

We need both knowledge and know-how With social interventions: –there is no single method or formula –what is done and achieved will vary from case to case –routinisation often hinders performance –flexibility, responsiveness, and context-specific approaches are essential Know-how “moulds and supports the practice used in a field as performed by those skilled in the art” (Nelson, 2010)

An alternative ‘solution space’ (Wilber’s integral model) Problem labelling Service solutions Inner Trauma Sharing Caring

What Now Iceberg of vulnerability Sticky Scotch Pies Home as salutogenic ‘Place’ Home

A HOME Homeless Problem Alcohol Problem Drug Problem Domestic Abuse Problem Criminal Justice Problem Wounded Lonely Soul Paddington Bear

Lonely, Unloved The most terrible poverty is loneliness, and the feeling of being unloved. (Mother Teresa) When you're surrounded by all these people, it can be lonelier than when you're by yourself. You can be in a huge crowd, but if you don't feel like you can trust anyone or talk to anybody, you feel like you're really alone. (Fiona Apple) If one's different, one's bound to be lonely. (Aldous Huxley)

The Enquiry has recognised the size and relatively recent emergence of Scotland’s drug and alcohol problems. Its judgement is that we need to look to the whole of Scottish society – our inequalities, our consumer culture, our failure to protect young people and much else – for the underlying causes. We heard a strong critique of Scotland’s drugs and alcohol policies in recent years. To date, drug policy in Scotland has swayed between a focus on health and a focus on criminal justice concerns. There is a need to accept that alcohol and drug problems are fundamentally social problems. This means moving beyond medicalised or criminal justice approaches to creating a new holistic response that addresses a much wider agenda. This has to focus on purpose and meaning, child and family welfare, employability, family support and community will.

In the face of complexity and the understandable desire to make a plethora of recommendations, the Enquiry took a conscious decision to limit its suggestions to two major thrusts. The first is the adoption of a ‘whole population approach’ – melt the iceberg of drugs and alcohol by raising the temperature of the water; and the second is a personalised approach to supporting those with ‘overwhelming involvement’ – ‘the circle of care’.

Warm the water Keep chipping away Statutory Homeless Domestic Abuse Childhood Trauma Addiction Criminal Justice Relational Breakdown

'Houseless and Hungry' by Luke Fildes depicting homeless paupers queuing outside the casual ward of a London workhouse Meeting the deep needs of safety, relationship, dignity, belonging and purpose What part can ADPs play in helping to change the causes and consequences of homelessness in Scotland ?

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12 Proposed Actions: 1.At-risk population groups, circumstances and key transition points 1.At-risk population groups, circumstances and key transition points - for prevention and mitigation 2.Health Inequalities Strategies 2.Health Inequalities Strategies - to include homelessness underpinned by needs assessments 3.Housing and health literacy 3.Housing and health literacy - workforce development on risk factors and routes into homelessness 4.Psychologically informed environments and services 4.Psychologically informed environments and services – accessible person-centred approach

12 Proposed Actions: 5. Partnership Pilots 5. Partnership Pilots – linking housing, ADPs, mental health, criminal justice and SPS 6. Housing First 6. Housing First – spread across Councils and further evidence the Scottish model for MEH community 7. Engagement with early-years, schools and colleges 7. Engagement with early-years, schools and colleges – on awareness of transition points and routes into homelessness 8. Integration of housing into HSCPs 8. Integration of housing into HSCPs – focussing on those with most complex needs

12 Proposed Actions: 9. Data sharing 9. Data sharing - sign up to pilot data linkage 10. Data analysis 10. Data analysis - for prevention and mitigation 11. Faculty of Homelessness & Inclusion Health 11. Faculty of Homelessness & Inclusion Health - workforce development, peer support and shared learning 12. Executive leadership 12. Executive leadership – to champion the home as the key salutogenic place factor for wellbeing