1. Caroline Vass Wessex Specialty registrar ST3 Caroline.vass@nhs.net
Addressing health inequalities by reframing concepts of eligibility with reference to housing policy
Caroline Vass
Wessex Specialty registrar ST3

2. Introduction Homelessness, a public health issue
Housing provision and the role of the ‘state’ (local authority)
Some ethical perspectives regarding policy and housing provision
A public health way forward

3. Significant inequalities
Life expectancy: 43 47
82.8
79.1

4. Homelessness – a public health issue
Physical health problems
Mental health problems
The highest rates of alcohol and substance dependence (Alcohol dependence 38-73%)
Complex needs

5. Complex needs Stephen Jones 35 years old Prison Drug user No family
Chris Parker
33 years old
No communications with mother for 5 years
Highlight the complexity of the need

6. Eligibility criteria: Homeless Priority need Intentionality
1977 Homeless Persons Act - a statutory responsibility for local authorities to provide for the homeless.
Eligibility criteria:
Homeless
Priority need
Intentionality
2016 Act to help eligible people at risk of homelessness to secure accommodation, 56 days before potential homelessness
Before the end of 1966, councils stopped the practice of splitting up families at housing hostels. Two years later, the Seebohm report on the future of the social services recommended that housing departments should be made responsible for tackling homelessness.
1977 that the government passed the Homeless Persons Act,

7. First two criteria
Homeless: various definitions sleeping rough, ad hoc or temporary solution – sofa surfing etc
Priority need:
Stock availability
Community agreement
Supply and demand

8. Prioritising
Prioritisation for available supply, but would lead to others being disadvantaged.
If LAs apply a systematic way of prioritising (and disadvantaging) their community in their decisions, this must be broadly acceptable to the community they serve.
Within the sub population or the whole population.

9. Utilitarianism – greatest net benefit
Historically accepted approach, where the LA determines what constitutes the net benefit
Prioritising and decision making within the mandate of inequalities.

10. Civic virtue Bruce Jennings
Jennings suggests that a dynamic relationship exists between the actions and interventions of the state (local authority), and the expectations and social mores of the community.
And that they influence each other
Concept of moral deservedness is so entrenched.

11. Intentionality
Intentionality is applied to understand the degree to which a person is responsible for their own homeless state. (and as a consequence, where the state’s duty of care is then reduced)
Intentionality starts to bring in a moral judgement, concepts of deservedness.
Eg:
Abstinence in homeless hostels.
What if you are a dependent drinker,
Are you making yourself homeless?
This reduces the LAs duty of care
Not saying we shouldn’t have these places, but what are we doing for the people who cant access these?

12. Ethical perspectives of deservedness
The libertarian argument suggests a ‘lifestyle hazard’, that homelessness is the logical (accepted) outcome of the behaviour.
Rational behaviour and societal norms argue a character defect if you don’t want to address the ‘lifestyle hazard’.

13. Community expectations and local authority mandate
Jennings
By identifying the explicit need to reduce inequalities in this population, we can influence the broader understanding and expectations for intervention.
The concepts of deservedness in this population will, it is hoped, develop to lead to an understanding that it is their inequality which roots them in a position of homelessness in the first place

14. Mandate to reduce inequalities
Local authority approach influenced by community mores
LA decisions influencing community expectations
Change to concepts of deservedness
Reduction in inequalities

15. Summary
LAs currently discharge their duties towards homeless people according to guidelines that include an ethical stance of deservedness (intentionality)
In reviewing the ethical stance and reframing the concept of deservedness and intentionality we are then able to extend decisions of housing eligibility to the chronically homeless, (with all the additional needs required to maintain the roof)
Chaotic or hazardous behaviours to be seen as an indication of vulnerability, rather than intentionality
Which will start to address the stated aim of reducing inequalities

16. Any questions?