Homelessness

1 Introduction

The aims of this health needs assessment are:

• To analyse the health needs of Richmond’s homeless population
• To appraise current service delivery against models of best practice
• To understand the causes of homelessness to inform prevention work by health services

The report is presented in four main parts: a Background section; a description of the Local Picture; a summary of the Key Points and the Recommendations of the work. The Background section provides information about the categories of homelessness, the routes to homelessness, and models of best practice for addressing the issues associated with homelessness.  The Background section also describes the profound differences in health outcomes between those that are non-statutorily homeless and “sleep rough” and those that are statutorily homeless and are offered temporary housing, when compared to the settled population. The Local Picture section provides data available on homelessness in Richmond upon Thames, including the demographics and health needs of local homeless populations and the services provided in the borough. A summary is provided in the Key Points section and the overall assessment has been used to inform the Recommendations section, which considers how best to build on current work. 

2 Background

The 2012 Health and Social Care Act placed a statutory duty on the secretary of state, NHS England and local CCGs to reduce health inequalities.

The homeless are at the extreme end on a scale of deprivation.  The impact on health is severe: rough sleepers have an average age of death of 47 years; the cost of inpatient services to this group is eight times the cost for the general population.

Homelessness is preventable and there is much that can be done to improve outcomes.  This work will consider how to improve the health of this population and supplements Richmond’s Homelessness Strategy 2012-2016.

Terminology

There are two broad categories of homelessness which are defined in relation to the local authority’s statutory duty. These are:

• Non-statutory homelessness:

The local authority has no duty to house this population.  They may move between rough sleeping, sofa surfing, squatting and staying in a hostel for homeless people.  The term ‘rough sleeping’ is also used to indicate this broad group.

• Statutory homelessness

The local authority has a statutory duty to house this group.  They must be:

• Unintentionally homeless
• Eligible for help and have a local connection
• In priority need

Eligible for help relates to migration status and having a ‘local connection’ is defined as being resident or employed in the area or having a close family connection. The priority need groups are: families with children; pregnant women; 16-17 year olds and older young people who have been in local authority care; someone vulnerable as the result of age, mental or physical disability; someone homeless as the result of an emergency such as a fire or flood; those vulnerable due to leaving prison or the armed forces; those fleeing domestic violence or threat of domestic violence.

Figure 1: An individual-centred pathway through homelessness

Source: Local authority information

The route to homelessness

The causes of homelessness are complex, see Figure 1.  There is no consistent single trigger and individual, interpersonal, societal and environmental factors all play a role, and affect each other.  Unemployment, unmanageable debt and an unaffordable housing market are factors that can increase the risk of homelessness but these are buffered by welfare provision.  Another buffer that affects the risk of homelessness is a person’s social support network.  Migration status can be a risk factor for homelessness as it affects an individual’s access to public funds, and recent migrants may also lack social support networks. [1]

Interpersonal factors which can increase risk of homelessness include relationship breakdown, violence and discrimination, while individual factors that increase risk include physical and mental health problems, substance misuse, and alcoholism.  Experience in institutions such as local authority care, the armed forces and prison also increases risk of homelessness. [2]

Over time societal factors, such as increased rates of unemployment, can generate more ‘individual’ and ‘interpersonal’ vulnerabilities to homelessness, for example relationships can become strained under economic circumstances.  The second highest reason for application to Richmond Council as homeless is ‘parents, relatives or friends no longer able to accommodate’. 

Fitzpatrick et al. define multiple exclusion homelessness as “a form of ‘deep’ social exclusion involving not just homelessness but also substance misuse, institutional care (e.g. prison) and/or involvement in ‘street culture’ activities.” [1] Her team explored the sequence of events leading to multiple exclusion homelessness.  They found that respondents have multiple and different experiences but the sequence of events reported is remarkably consistent, see Table 1. [3]

Table 1: Pathway to multiple exclusion homelessness and complex needs, n=452

Source: Fitzpatrick et al. Extended Interview Surveys 2010 ³

The concept of cycles of poverty is important, and Table 2 shows childhood experiences of those who experience multiple exclusion homelessness.  Over one in six was from a family which experienced homelessness, over one in five was physically abused as a child and almost a quarter were sexually abused. ³

Table 2: Experiences in childhood (under 16 years) for multiple exclusion homelessness, n=452

Source: Fitzpatrick et al. Extended Interview Surveys 2010 ³

The impact of welfare reforms

The link between rising unemployment with economic recession and homelessness is most direct for countries with limited welfare protection and for groups who do not have full access to welfare provision, especially certain immigrant groups. [4] Concerns were raised in 2011 that welfare reforms, in combination with economic recession, would lead to an increase in homelessness. ¹ Figures 11 and 12 in the Local Picture section on Statutory Homelessness demonstrate the extent to which this has occurred.  There are multiple factors influencing rates of homelessness, as previously discussed, but there is good evidence that effective welfare provision prevents increased homelessness during an economic downturn. ⁴

Box 1: An overview of the welfare reforms

Source: Adapted from the Joseph Rowntree Foundation with addition of local information [5]^{, 51}

The Housing Committee at the London Assembly recently released a report in April 2014 examining the consequences of the welfare reforms in terms of:

• affordability and access to accommodation
• movement of households within and out of London
• rising homelessness and increased use of temporary accommodation in the capital [6]

The report is relevant to the situation in Richmond upon Thames, where there has been a rise in rough sleepers without a local connection to the borough.  From 2011/12 to 2012/13 there was a rise in the numbers rough sleeping from 57 to 113; in the same period the numbers rough sleeping who had no local connection to the borough rose from 7 to 55.  The findings of the report are detailed below.

• There is a widening gap between benefit payments and market rents
  • Part of the rationale behind changes to payments of local housing allowance (LHA) was to address spiralling rents in the private rented sector, however evidence shows that so far 94% of cuts have fallen on tenants and 6% on landlords
  • Boroughs, London Councils and other organisations have used Valuation Office Agency snapshots of London rents to point out rent increases as high as 8% to 14% per year and there was cross-party agreement from borough representatives which indicated that rent increases did not appear to be slowing
  • There is some discrepancy in evidence related to increases in rent: ONS calculated an annual rent increase in London of 1.6% per year, which was a reduction on previous increases

• The benefits cap and social sector size criteria have particularly affected London residents
  • Over 15,340 households in London were initially affected by the benefits cap, which is almost half of all the households affected in the UK
  • Around 52,000 households were affected by the social sector size criteria with an average reduction in housing benefit of £20 per week

• Many claimants of housing benefit are forced to make up shortfalls in rent themselves
  • The Joseph Rowntree Foundation highlights the fact that welfare reforms are not occurring in isolation: concurrent with the rising cost of accommodation are increasing costs of fuel and food and increased over-indebtedness. More households are reliant on food banks and at high risk of falling into rent arrears and becoming homeless. ⁵

• Landlords are increasingly reluctant to rent property to households in receipt of housing benefit, including those who are in work and receive housing benefit to only cover part of the rent
  • The number of terminations of assured shorthold tenancy agreements in the private rented sector has increased more than fourfold since 2010, from around 300 terminations per quarter to over 1400
  • Termination of an assured shorthold tenancy has become the leading reason for application to a council as homeless in many parts of London, including in Richmond.

• Discretionary Housing Payments (DHPs) have played a crucial role in mitigating the impact of welfare reforms so far. However, they are intended to be time-limited and offer transitional relief.  There is uncertainty around the funding of these payments from 2015/16. 

• There is concern that direct payment of the rental element of Universal Credit to tenants will increase the risk of rent arrears for social landlords.

• There is increasing concentration of housing benefit claimants within each borough and in certain areas of Outer London. Movement of households can have negative impacts where there are reduced opportunities for employment and reduced family and other support networks in the new area.

• The numbers placed in temporary accommodation have increased since 2010
  • There is a shortage in the availability of suitable and affordable temporary accommodation, which has led to an increase in the numbers placed in bed and breakfast
  • Difficulties in sourcing suitable private rented sector accommodation is limiting the ability of boroughs to discharge homeless duties to the private rented sector, so households remain in temporary accommodation for longer
  • There has been a rising number of temporary accommodation placements out of borough, particularly in Outer London
  • There is a shortage of ‘move-on’ accommodation for individuals in supported accommodation ⁶

Models of best practice

Figure 2 presents a model for the integrated delivery of care to rough sleepers developed by the Faculty of Homeless and Inclusion Health. This Faculty is part of the College of Medicine, a charity and collaboration of health professionals with a focus on prevention and partnership between health practitioners and patients.  Primary care led multi-disciplinary teams (MDTs) agree a care plan with the individual and this caters for the person’s health, housing and wider social needs.  The aim is proactive and effective delivery of care to rough sleepers, who currently rely heavily on secondary care facilities.  Intermediate/respite care facilities are being piloted in parts of London: these facilities offer accommodation, the opportunity for recovery and the organising of onward care and resettlement for rough sleepers who would otherwise be discharged to the streets or occupy a hospital bed to allow recovery. [7]

Figure 2: A model for the integrated delivery of services for rough sleepers

Source: Faculty of Homeless Health ⁷

Other Faculty of Homeless Health recommendations include the naming of an officer accountable for commissioning of homeless healthcare at director level.  The Faculty has also issued specific guidance for delivery of primary care, mental health services, substance misuse and alcohol services, dental care and podiatry. ⁷

It may be best practice to give people housing first and then to consider their wider health needs. The Camden Housing First approach was effective in ending chronic homelessness among those with recurrent homelessness, severe mental illness, poor physical health and problematic use of drugs and alcohol.  The project worked on the assumption that a homeless individual’s first and primary need is to obtain stable housing.  Once this has been achieved, other issues can be addressed and there was no need to demonstrate ‘housing readiness’ prior to allocating accommodation.  Private rented accommodation was procured and intensive support was available after individuals moved into their new accommodation.  As well as achieving housing stability, improvements were also noted in well-being, with reductions in drug and alcohol use and antisocial behaviour and increased engagement with treatment. [8]

Health needs of the non-statutory homeless population

Rough sleepers experience higher rates of serious and multiple morbidity than the housed population. [9] The most common health needs of rough sleepers relate to drug dependence, alcohol dependence or mental ill-health.  Dual diagnosis is common, as is tri-morbidity of physical ill-health, mental ill-health and drug or alcohol misuse. ⁷

A study by Fitzpatrick et al. identified clusters of experiences among those experiencing multiple exclusion homelessness.  These clusters are listed in Box 2 and highlight potential sub-groups of rough sleepers with differing health and social needs. Complexity was assessed by the overall number of experiences reported from a pre-defined list, and experiences were grouped under sub-headings ‘homelessness’, ‘substance misuse’, ‘institutional care’, ‘street culture activities’, ‘adverse life events’ and ‘extreme exclusion/distress’.  The group with least complexity reported an average of five experiences, while the group with most complexity Cluster 5, reported an average 16 experiences. ³

Box 2: Clusters of Multiple Exclusion Homelessness

Source: Fitzpatrick et al. Extended Interview Surveys 2010 ³

Alcohol and substance use

Compared to the general population there is a much higher prevalence of ever having used any illicit substances.  The relative risk is greatest for ever having used heroin at 21.5 times the rate in the general population and crack cocaine at 19 times the rate in the general population. [10]

A survey of 389 rough sleepers in inner London in 2002 found that four-fifths had used a drug excluding alcohol in the last month.  Around two-thirds of respondents had used cannabis or alcohol in the past month and nearly a half had used heroin and/or crack cocaine.  Over half of respondents reported that their biggest expenditure was drugs, while nearly a quarter reported alcohol to be their largest expenditure.  When asked which substance was most preferred heroin came top (32%) followed by alcohol (26%) and cannabis (21%). [11]

Mental health

Mental ill health is both a cause and consequence of rough sleeping.  A Homeless Link health audit for England in 2010 found that 72% of rough sleepers reported suffering some form of mental distress, compared to 30% of the general population. [12] Rough sleepers have a higher prevalence of common mental health problems, severe depression, psychotic disorders and personality disorder, see Table 3. ^{12, 13, 14, 15, 16, 17}

Table 3: Mental health symptoms reported in audit of rough sleepers for England 2010

Source: Homeless Link report ‘The Health and Wellbeing of People who are Homeless’(n=727)¹², Adult Psychiatric Morbidity in England [13] NICE [14]^, [15]^, [16] Beavan et al. (2011) [17]

The rate of severe depression among rough sleepers is around eight times that of the general population. ^{12, 13} The prevalence of psychosis is estimated to be 50-100 times the rate in the general population. [18] Similarly, one study found that just under a third of British patients with schizophrenia had experienced homelessness in their lifetime. ¹⁸

Rates of mental illness, including self-harm and suicidal ideation, appear to be greater in women than in men who are rough sleeping.  Another group with specific mental health needs is asylum seekers, of whom many have experienced significant trauma and are living with the impact of this on mental health. [19] In particular, there are higher rates of depression, anxiety and post-traumatic stress disorder in this group, and prevalence is even higher among those who have experienced war and torture. ¹⁸

Mental ill-health can affect a person’s access to services, depending on the service design and training of staff.  Many mainstream services and staff without specific training find it difficult to cope with rough sleepers with personality disorders, for instance.  Individuals who are quick to resort to aggression or threats of aggression when confronted with interpersonal difficulties are more likely to become excluded from mainstream services and banned from premises.  Their condition can lead to social isolation and the negative impact on access applies to housing and social services as well as healthcare services. ⁵¹

Physical health

In a Homeless Link health audit for England, published in 2010, more than four fifths of rough sleepers (N>700) reported having one or more physical health need and over half (56%) reported having a long-term physical illness.  The latter figure compares to 29% of the general population. ¹²

Box 3: Physical illnesses among rough sleepers

Sources: multiple ^{9, 12 ,}[20]^, [21]^, [22]^, [23]^, [24]^, [25]^, [26]^, [27]  

Other lifestyle factors

Prevalence of smoking among rough sleepers is 77% compared to 21% for the general population. ¹² It is higher for younger age groups: 96% of 20-24 year old rough sleepers surveyed in 2003 smoked compared to 35% of 20-24 year olds in the general population at that time. ¹⁰

Almost a third of rough sleepers eat less than two meals per day; only one in four eat three or more portions of fruit or vegetables per day. ¹² The proportion eating five or more fruit and vegetables per day is around four times lower than the general population. ¹² Potential barriers to good nutrition include lack of money, no place for storage of food, impacts on absorption of nutrients through alcoholism and drugs, the effect of mental or physical ill health, food as a low priority and the chaotic lifestyles of many rough sleepers. [28]

Health needs of the statutory homeless population

The health needs of the statutory homeless population are not as severe as rough sleepers. The health needs of the statutory homeless population relate to the circumstances which precipitate homelessness and to the consequences of living in temporary accommodation.  Homelessness is closely linked with other markers of deprivation such as unemployment and over-indebtedness and deprivation is associated with reduced life expectancy and fewer years of life without disability. [29]

Mental health

Being made homeless and a prolonged stay in temporary accommodation can precipitate or exacerbate mental ill health. A survey by Shelter in 2004 of those living in temporary accommodation found that over half were suffering with depression.  Rates were higher for those living in a bed and breakfast, hostel or women’s shelter compared to those housed temporarily in a house, flat or bedsit. [30] A further survey found that two-thirds of those already diagnosed with depression experienced a worsening of symptoms. [31] Other ways in which households reported that the health of their family had suffered included stress and anxiety, isolation and loneliness, being unsettled and increased consumption of anti-depressants. ³¹

For children, two or more housing moves within 12 months increases the likelihood of experiencing emotional and behavioural problems. [32] Housing instability can lead to negative effects on learning and refusal to attend school. ² Physical illness, anxiety, stress, and hunger which may be more prevalent among children in temporary accommodation similarly cause difficulties in concentration and worsened cognition. ² Effects can be long-lasting: one study showed them to persist a year after children were re-housed. [33]

Physical health

Surveys carried out nationally by Shelter in 2004 found over half (58%) of families reported their health or their family’s health to have worsened as a result of moving into temporary accommodation.  The longer families had lived in temporary accommodation, the more likely they were to attribute worsening of health to their housing situation.  Physical health conditions reported included worsened eczema and skin conditions, asthma and chest or breathing difficulties.  Almost half of respondents reported increased frequency of visits to the GP since the move to temporary accommodation. ³¹ The physical health problems reported may be closely related to the quality of housing provided, and hence it would be difficult to extrapolate findings to Richmond upon Thames without full assessment of the quality of temporary accommodation provided.  Self-rated health is also linked to mental wellbeing, however, and so physical ill health may also arise from the stress of being made homeless and moving to temporary accommodation. [34]

In children, studies have found worsened dental health, asthma, skin problems, vision problems and recurrent headaches to be more commonly experienced by those living with uncertainty and instability in their housing arrangements compared to children in permanent housing. ²

Other lifestyle factors

There are multiple barriers to ensuring adequate nutrition for families in temporary accommodation which include finances, access to cooking facilities, concurrent mental or physical ill-health, and access to healthy fresh food and unhealthy fast food or ready meals.  One study showed that women living in temporary accommodation in north-west England failed to meet recommended intake for energy, protein, fibre, calcium, iron, vitamin C and folate. [35]

Cost of healthcare provision for the non-statutory homeless

The total cost of healthcare delivery to rough sleepers in England has been estimated to be around £85 million.  £76 million of this is due to in-patient hospital costs, and this figure is eight times higher than for the general population (where costs are also concentrated in the older population).  This is a minimum estimate. [36]

Rates of A&E attendance among rough sleepers are six times that of the general population; rates of admission are four times higher and average length of stay in hospital is three times higher.  Delivery of care to this group has been characterised as “crisis management” as opposed to a proactive and preventative approach. ³⁶

3  Local Picture

The information in this section is presented separately for non-statutory and statutory homeless. The health needs of these two population groups differ.

Non-statutory homelessness

Occurrence

The CHAIN database for London is one of the most comprehensive databases available for rough sleepers and equivalent sources of information are not available for the rest of the country. 

• 6,437 people are recorded as having slept rough in London at some point in 2012/13.
• This was an increase of 13% on the previous year and 62% on the previous two years

There is an uneven distribution of rough sleepers in London: boroughs with the highest numbers of rough sleepers for 2012/13 were the central boroughs of Westminster (2,442), Lambeth (585), Camden (468), Southwark (393) and Tower Hamlets (326). [37]

In Richmond upon Thames, figures provided by the local charity SPEAR indicate that there were 150 rough sleepers in the borough in 2013/14.  This represents a 12% increase on the previous year (134 rough sleepers in 2012/13) and a 163% increase on figures from 2011/12 (when there were 57 rough sleepers recorded). [38]

Demographics

Gender

In 2012/13, 84% of rough sleepers in Richmond upon Thames were male. ³⁸ This is similar to the figure of 88% for London as a whole. [39]

Age

Figure 3 shows the age distribution of rough sleepers for Richmond upon Thames and London. In 2012/2013 there was a larger proportion of those aged over 45 in Richmond compared to London (45% and 31% respectively). ^{38, 39}

Figure 3: Age distribution of rough sleepers in London and Richmond 2012/13

Source: SPEAR and CHAIN database ^{38, 39}

Nationality

Figure 4 shows the nationality of rough sleepers in London and Richmond upon Thames. A greater proportion of rough sleepers in Richmond were born in the UK compared to those in London for 2012-13 (62% and 45% respectively).  A larger proportion of rough sleepers in London were from Central and Eastern Europe (CEE): 28% compared to 7% in Richmond upon Thames. ^{38, 39}

Figure 4: Country of origin of rough sleepers in Richmond and London, 2012-13

Source: SPEAR and CHAIN database ^{38, 39}

Ethnicity

The ethnicity of rough sleepers in London and Richmond is broadly similar, see Figure 5.  The most significant difference is in nationality of those categorised as white: 61% of rough sleepers in Richmond are white British compared to 32% in London. ^{38, 39}

Figure 5: Ethnicity of rough sleepers in Richmond and London, 2012-13

Source: SPEAR and CHAIN database ^{38, 39}

Sexual orientation

Data on sexual orientation is not routinely collected for rough sleepers.  One national survey indicated that approximately 7% of rough sleepers identified as LGBT, equating to approximately 9 rough sleepers in Richmond. [40]  The prevalence varies for different age groups: as many as one in three young homeless people aged 18-25 years old identifies as gay or lesbian. [41] Statistics often underestimate the prevalence of LGBT groups due to issues with reporting, monitoring and stigma. 

Disability

The local authority has a statutory duty to house those who are vulnerable due to physical or mental disability and who are also unintentionally homeless and eligible for assistance.  Since eligibility criteria exclude many migrant groups, rates of disability may be higher for these groups.

Marital status

The majority of rough sleepers are single and male.  The local authority has a statutory duty to accommodate households with children and pregnant women.  For this reason the concept of ‘single homelessness’ has been equated with rough sleeping.  There are, however, no explicit criteria for exclusion or inclusion on the basis of marital status.

Mortality

Rough sleepers have an average age at death of 47 years, which is even lower for women at 43 years. [5] These figures are considerably lower than the average age of death for England of 77. [42]

Standardised mortality ratios quantify the increased risk of death at particular ages for rough sleepers compared to the housed population, see figure 6.  Between 16 and 24 years of age rough sleepers have a mortality rate twice that of this age group in the general population (200%); for 25-34 year olds death is over four times more likely (418%); for 35-44 year olds it is over five times (513%); for 45-54 year olds it is over three times more likely (305%); and for 55-64 year olds it is around 1.5 times more likely (153%). ⁴² A rough sleeper admitted to hospital for the same medical condition as a non-rough sleeper is seven times more likely to die over the next five years. ⁷

Figure 6: Standardised Mortality Ratios for Rough Sleepers in England from 2001-2009

Source: Crisis report ‘Homelessness Kills’ ⁴²

Drugs and alcohol account for the single greatest proportion of deaths – over a third among rough sleepers.  Deaths from these causes are 20 times higher than for the general population. ⁴² The occurrence of suicide is nine times higher in rough sleepers than the general population in England; there are twice as many deaths from infection (sepsis); and three times as many deaths occur as the result of a traffic accident. ⁴²

Figure 7 describes the different causes of death in the general population compared to the homeless population. Overall, a lower proportion of deaths among rough sleepers are due to cancer, cardiovascular disease, respiratory disease and other disorders. ^{37, 42} This is because the age distribution of rough sleepers differs from the general population: fewer old people among rough sleepers mean fewer deaths from diseases that are more prevalent in older people. Rough sleepers are dying at younger ages.

Figure 7: Causes of Mortality for the General Population and Homeless Population, 2001-2009

Source: Crisis report ‘Homelessness: A Silent Killer’ (courtesy of QNI report ‘Healthcare for the Homeless’) ^{37, 42}

Deaths from hypothermia among rough sleepers receive much attention since they are preventable and attributable to the person’s lack of accommodation.  From 1993-1997, there were 1,865 deaths from hypothermia in England and Wales.  15 (0.8%) of these deaths were among rough sleepers. [43] Although this is a small percentage, it represents a risk of death from hypothermia which is 40 times greater than the risk for the general population.  The Severe Weather Emergency Protocol (SWEP), which provides night time shelter when the temperature falls below zero degrees for more than three days (and during other defined adverse weather conditions), is designed to prevent these deaths. [44]

Health needs

Figure 8 shows the health needs for rough sleepers in Richmond compared to London.  The differences between Richmond and London are not significant: many rough sleepers will have multiple drugs, alcohol or mental health needs. ^{38, 39}

Figure 8: CHAIN Data on the Support Needs of Rough Sleepers in London 2012/13

Source: CHAIN database, SPEAR ^{38, 39}

SPEAR identified 58 rough sleepers with symptoms of thought disorder, personality disorder or mood disorder from a total of 150 rough sleepers in 2013-14.  The number of rough sleepers with symptoms of each condition, the number with a known psychiatric condition and the health and social care needs of these individuals is listed in Table 4.  As with figures nationally (see Cluster 2 in Box 2 in the Background section), there is a higher level of mental ill health among female rough sleepers: 16 out of 24 female rough sleepers identified by SPEAR in 2013-14 were assessed to have mental health needs. ³⁸

Table 4: Mental health symptoms and diagnoses among rough sleepers engaging with SPEAR services, 2013-14

Source: SPEAR ³⁸

During 2013/14 SPEAR identified 30 individuals engaged in street drinking out of a total of 150 rough sleepers in the borough.  Five of these individuals also had mental ill health and had complex health and social care needs.  Eight rough sleepers were reported by SPEAR to have highly complex substance use, comparable to cluster 5 in Box 2. ³⁸

Rough sleeper services

Figure 9 shows the potential pathways through non-statutory homelessness.  SPEAR is a local charity, some of whose services are commissioned by the council to provide for the non-statutory homeless population.  Other services for rough sleepers in Richmond upon Thames include the Vineyard Community Centre and food banks.

Figure 9: Pathway through non-statutory homelessness

Source: Local authority information

Primary care

Rough sleepers in Richmond upon Thames currently register with mainstream general practices.  There are no regular drop-in services for rough sleepers.  Models 1 and 2 in Figure 10 are most appropriate for areas with a moderate number of rough sleepers. ³⁶

Of 197 rough sleepers engaging with SPEAR services in 2014, 57 were recorded as registered with a GP. ³⁸ No rough sleepers were recorded as registered with a dentist or as using podiatry services. ³⁸ Neither of these services is offered on a drop-in or out-reach basis, as recommended by the Faculty for Homeless Health.

 

Figure 10: Models for provision of primary care to rough sleepers

Source: DH report ‘Healthcare for Single Homeless People’ ³⁶

 

Intermediate care

SPEAR has an intermediate care facility at Penny Wade House for rough sleepers being discharged from acute mental health services.  There are four beds available for patients immediately discharged from secondary care mental health services, with move-on facilities for when individuals are ready.

Pilots of intermediate care facilities to address physical health needs of rough sleepers have been successful in reducing mortality, A&E attendance and hospital admissions. [45]

Secondary care

A report by Homeless Health Link and St Mungo’s in 2012 indicated that more than 70% of rough sleepers were being discharged onto the streets, with further damage to their health. [46] Advice from the report indicated:

• NHS staff need to be equipped to ask the right questions to identify rough sleepers
• Clear guidance must be available for NHS staff to identify and contact key partners, e.g. hostels and in-reach teams
• Agreements must be in place to ensure that healthcare organisations, local authorities and the voluntary sector have strategies for management and discharge of rough sleepers admitted to hospital

The Pathway team at UCH was cited as an example of best practice, offering in-reach services to rough sleepers admitted to hospital.  This service includes a GP led ward round for all homeless patients, collaboration between medical staff and other agencies to plan for discharge and a support and mentoring initiative facilitated by Pathway Care Navigators with previous experience of homelessness. [47] The group now supports nine secondary care teams in hospitals across the country, including a large integrated team working in Guy’s, St Thomas’ and King’s College Hospital in south London.  A needs assessment by the Pathway group highlights the impact of homelessness on these secondary care providers. [48]

In south west London, the Rehab and Placement Review Team work at Queen Mary’s Hospital in Roehampton and Springfield University Hospital with rough sleepers admitted due to mental ill-health.  Clinical staff will identify patients admitted without a home to return to upon discharge, and notify this team.  A multi-disciplinary team (MDT) then works to arrange supported accommodation for when the person is ready for discharge.  The level of support provided is gradually reduced, as the person is ready, with the aim of progression to independent living. [49]

Drug and substance misuse services

In Richmond, the charity SPEAR has been commissioned by the council to run an outreach service and a drop-in service for individuals who use drugs and alcohol.  The service works with rough sleepers/homeless households and uses an outreach approach for those not engaging with treatment or services.

There are other alcohol and substance misuse services, and the overall contract for these services is currently being negotiated.  The service specification takes into account the chaotic lifestyles of many rough sleepers, and makes provision for outreach and drop-in services to ensure access for this group. 

Mental health services

A wide spectrum of mental illness exists among rough sleepers.  Referral is possible on a routine (within four weeks), urgent (within one week) or emergency (within 24 hours) basis.  Referrals are then offered a choice of assessment appointments.  According to the Operational Policy for Adult Community Mental Health Teams, “persistent attempts must be made to assess potential risk and engage with referrals where the service user is avoiding assessment.” [50] No service is routinely operated on an outreach or drop-in model and concerns have been raised by rough sleeper services regarding access to mental health services for rough sleepers.

There is current appraisal and redesign of local community mental health services.  A further issue raised by statutory and non-statutory homeless services is the high turnover of staff within mental health service teams, which disrupted the good professional relationship which had developed.

Statutory Homelessness

Occurrence

In Richmond upon Thames, the number of homeless applications to the local authority and statutory homeless acceptances increased from 2010/11 until 2012/13 and has reduced since.  At the recent peak in 2012/13 there were 582 applications to the council as homeless and 357 acceptances.  In 2013/14 there were 506 applications and 279 statutory homeless acceptances, see Figure 11.

Figure 11: Number of applications as homeless and acceptances for Richmond from 2003/04 to 2013/14

Source: Local authority data [51], Richmond Homeless Review 2012 [52]

This pattern broadly reflects similar trends for homeless applications and acceptances nationally except there has been a proportionately greater increase since 2010/11 and downturn in Richmond upon Thames in the past year – see Figure 12.  The proportion of applications as homeless which were accepted in Richmond upon Thames in 2013/14 was 55%.  This is higher than the national average for the same year which was 47%.  In England, the proportion has ranged from 42-47% from 2001-11. ⁵³

Figure 12: Number of household applications as homeless and acceptances by local authorities in England, 1998 to 2013

 

Source: Homelessness Statistics, DCLG [53] (courtesy of QNI report ‘Healthcare for the Homeless’) ³⁷

Homelessness acceptances since 2011 have been used as part of assessing the impact of welfare reforms.  In England, homelessness acceptances rose by 5% from 107,240 in 2011 to 112,880 in 2013.  There has been a proportionately much greater rise in London and Richmond in the same period.  In London, homelessness acceptances rose by 45% from 11,680 in 2011 to 16,980 (provisional) in 2013.  In Richmond upon Thames the percentage increase was 123% from 160 in 2010/11 to 357 in 2012/13 and 74% from 160 in 2010/11 to 279 in 2013/14. ⁵³

Other markers looking at the impact of welfare reforms locally have not necessarily correlated with the rise in homeless applications.  Richmond was least affected of all London boroughs by the benefits cap (73 households affected up to January 2014) and there was relative sparing in the numbers affected by the social sector size criteria, though 537 households were affected in the borough as of 26^th November 2013. ⁵¹, [54] Whilst loss of an assured shorthold tenancy in the private rented sector has become the leading reason cited for application as homeless to Richmond Council, the percentage of households citing this reason (23%) was lower than the London average for 2013. ^{51, 54} Richmond upon Thames did, however, have the second largest absolute rise in monthly rent for two bedroom properties of any London borough from September 2012 to September 2013, with an average increase of £145 per month. ⁵⁴ As with other areas in London there has been a large increase in discretionary housing payments, which have assisted in homelessness prevention work. ⁶ In 2012/13 there were 1,346 payments which totalled in excess of £260,000. ⁵¹

Table 6: Proportion of newly advertised properties at or below LHA level in Richmond upon Thames, May 2011-May 2012

Source: Cambridge Centre for Housing and Planning Research, using data from home.co.uk [55]

Local housing allowance (LHA) is now calculated for the 30^th centile rather than 50^th centile of market rents in a Broad Market Rental Area.  There are three areas which intersect Richmond, overlapping with neighbouring boroughs.  In terms of affordability, a study by the University of Cambridge found that the percentage of homes affordable with LHA in Richmond ranged from 1.7% to 11.8% depending on size, see Table 6.  If the Broad Market Rental Area covered the borough alone, by definition 30% of properties would be affordable in each category. ⁵⁵

Demographics

Gender

Of those in temporary accommodation in Richmond upon Thames in April 2014, 63% were female. ⁵¹ Data for England reveals that the majority of families accepted as homeless are headed by a lone woman parent with one or two children. [56]

Age

Figure 13 shows the age distribution of those placed in temporary accommodation in Richmond upon Thames.  The highest proportion of residents is in the 0-4 year old and 20-29 year old age groups, reflecting the high number of young families.

Figure 13: Age distribution of those placed in temporary accommodation in Richmond upon Thames, March 2014

Source: Local authority data ⁵¹

Ethnicity

There are fewer households from ethnic minority backgrounds in temporary accommodation in Richmond upon Thames compared to London, and this reflects the ethnic mix of the Richmond population – see Figure 14. ⁵¹ The risk of homelessness among black and minority ethnic (BME) groups is greater, however, and this risk was nearly two and a half times higher than the risk of homelessness for the white population of Richmond upon Thames in 2010-11. ⁵²

Figure 14: Ethnicity of Homeless Acceptances for Richmond, London and England from April-June 2013

Source: Local authority information ⁵¹

Sexual orientation

There is limited information on the sexual orientation of households accepted as homeless because the majority of applicants leave the question unanswered.  A revision to the application process is expected to improve the data collected. ⁵¹

Disability

Vulnerability due to physical or mental disability is a category of priority need and reason for acceptance as statutorily homeless.  In 2013/14 there were 18 individuals recorded as having vulnerability due to physical disability and 12 individuals who were registered disabled among those accepted as statutorily homeless.  In the same year, 11 individuals reported a learning disability and 11 individuals were recorded as having vulnerability due to mental ill health among those accepted as statutorily homeless. ⁵¹

Health needs

There is limited data available on the health needs of statutorily homeless people locally which arise as a result of their situation in temporary accommodation.  Health needs which exist prior to application as homeless are well documented, however: one category of priority need is vulnerability due to physical or mental disability which is recorded by all local authorities. 

Assessment of vulnerability in Richmond upon Thames is carried out by the Housing Options team, who make an assessment and liaise with health professionals.  Those households which are deemed as likely to require assistance in maintaining a tenancy or who need support developing independent living skills are referred to the Resettlement team.  Data in this section has drawn on these two sources. 

As all households will have an assessment by the Housing Options team, the total number of individuals with a health need is shown in each box with the total number of homeless acceptances that year in brackets in Table 7.  In 2008/09, for instance, there were 23 individuals listed as having ‘vulnerability due to physical disability’ from a total of 130 households accepted as homeless that year.  For the health needs of those seen by the Resettlement team, the number of recorded as having a health need is listed, with the total number of individuals referred to the Resettlement team from the Housing Options team that year in brackets.  For 2008 (Resettlement data is for the calendar year), 8 people were recorded to have a physical disability from a total of 128 people seen by the Resettlement team that year. ⁵¹

Table 7: Health needs of statutory homeless households as recorded by council Housing Options and Resettlement teams

Source: Local authority information ⁵¹

Figures for vulnerability due to physical disability show a large degree of variation which broadly correlates with variation in the total number of statutory homeless applications and acceptances – compare with Figure 11.  The proportion of those accepted as statutorily homeless with vulnerability due to physical disability that is referred onto the Resettlement team has varied from 22% to 52% over the past seven years. ⁵¹

The number of those accepted as statutorily homeless with a registered disability again shows significant variation over the past seven years.  The numbers are relatively small, ranging from 6 to 22, but again there is broad correlation with the total number of applications/acceptances taking this into account.  The proportion of registered disability which is accounted for by mental or physical disability is not available. ⁵¹

A higher number of individuals seen by the Resettlement team are recorded as having mental ill health than the number of acceptances because of ‘vulnerability due to mental ill health’ each year.  There is a spectrum of mental ill health and it appears that the threshold used by the Resettlement team, whose concern is linking individuals into relevant services, is lower than the Housing Options team, whose concern is assessment of vulnerability.  With regards vulnerability, Section 10.12 in the Homelessness Code of Guidance states:

“It is a matter of judgment whether the applicant’s circumstances make him or her vulnerable. When determining whether an applicant in any of the categories set out [above] is vulnerable, the local authority should consider whether, when homeless, the applicant would be less able to fend for him/herself than an ordinary homeless person so that he or she would suffer injury or detriment, in circumstances where a less vulnerable person would be able to cope without harmful effects.” [57]

Again, the numbers recorded as ‘vulnerable due to mental ill health’ and recorded as having mental ill health by the Resettlement team broadly reflect overall trends, taking into account increased variability which is more likely with small numbers. ⁵¹

Numbers recorded by the Housing Options team as having learning disability varied from 9 to 30 over the past seven years.  Recording of learning disability is according to an individual’s own perception and disclosure to Housing Options staff.  Numbers are not indicative of individuals who meet the FACS criteria in assessment of need.  Those with severe learning disability who are known to services have their housing needs addressed as part of a wider care plan and through the Housing Provision team which administers supported housing. ⁵¹

Substance misuse

The numbers recorded as treated for issues with substance misuse among statutory homeless acceptances that are referred to the Resettlement team have remained below 10 per year since the service was started in 2006. ⁵¹

Domestic violence

Domestic violence has a significant impact on mental health and wellbeing for survivors.  There are shelters in the borough which specifically cater for survivors of domestic violence, though many are also linked into relevant social and health services whilst being housed in general accommodation.  In Richmond in 2013/14 there were 17 households accepted as statutorily homeless due to relationship violence from a partner, see Table 4. ⁵¹

Statutory homeless services

The focus of this section is to understand how the health needs of the statutory homeless population are catered for by statutory homeless services.

Figure 21: Pathway through statutory homeless services in Richmond upon Thames

Source: Local authority information

 In Richmond upon Thames, the most commonly cited reason for applying as homeless to the local authority in 2013-14 was loss of rented accommodation following a notice to quit in properties rented in the private rented sector with an assured short-hold tenancy.  The next most common reasons were parents or friends and other relatives being unable to accommodate.  The full list of reasons is shown in Table 8. ⁵¹

Table 8: Reasons for presenting to the council as homeless, 2013-14

Source: Local authority information ⁵¹

Council Services

Richmond Council adopts a Housing Options approach to statutory homeless services.  This is a proactive approach to preventing homelessness with the provision of support to those who are made statutorily homeless.  Prevention work includes assisting tenants to secure their existing accommodation or exploring a range of possible routes to secure new accommodation.  This may include a private rented property through a Private Rented Sector Offer (PRSO) or the voluntary Rent Deposit Scheme (RDS), sheltered or supported housing (where appropriate) or temporary accommodation where homelessness cannot be prevented.

Active prevention of homelessness is also tackled through ‘vulnerable client meetings’.  These meetings include the two largest housing associations in the borough, community drugs and alcohol teams, community mental health teams, social services and statutory homeless services.  Residents in housing association property who are at risk of homelessness due to rent arrears, antisocial behaviour or deterioration in mental health, alcohol or substance use are identified. Support to prevent homelessness is offered through a multi-disciplinary approach, with the aim being to manage financial difficulties and engage the required support.

There is also a Richmond Tenants’ Champion. This is a Councillor responsible for supporting tenants living in Housing Association property where they have concerns or complaints about their landlords.  The role aims to promote high standards of management.  The Tenants’ Champion plays a role in complaints resolution and helps to share best practice across the borough. ⁵¹

There has been specific homelessness prevention work taking place in the wake of welfare reforms.  The existing sponsored moves scheme run by the council has assisted households affected by the spare room subsidy and a local housing association, Richmond Housing Partnership, has implemented a similar scheme to assist households in downsizing.  There have also been events held by housing associations designed to help households swap properties, supplementing the existing national home swapping service.  As mentioned previously, discretionary housing payments (DHPs) have been made to prevent rent arrears in certain cases.  In 2012/13 there were 1,346 payments which totalled in excess of £260,000. ⁵¹

Accommodation to suit health needs

There are also services to help those with additional needs.  Those with moderate to severe mental ill-health and learning disabilities are referred to the Housing Provision team by a care manager for supported housing.  Older people can also be referred for sheltered housing rather than temporary accommodation.

For those accepted as statutorily homeless with physical disability, individuals are referred for occupational therapy assessment once potential accommodation has been identified.  The council also refers individuals who are not homeless but have a ‘housing need’ due to physical disability to occupational therapists for assessment.  Modifications to homes are made with disabled facility grants. ⁵¹

The Richmond Housing Register gives additional priority to those housing applicants with medical and social/welfare needs through its Allocation Scheme.  Assessments are made with input where appropriate from relevant health and social care professionals.

Health promotion

Housing Options and Resettlement teams provide health promotion signposting and advice to statutorily homeless households.  Signposting includes to a subsidised leisure card scheme to promote exercise and sexual health services. These are particularly aimed at young people.  Advice leaflets are offered to households about eating healthily on a budget. ⁵¹

Primary care

The Housing Options team asks all households if they are registered with a general practitioner.  Those who are not registered are given advice of where and how to register.  There is no protocol in place to screen households for registration with a dentist.

All households receive an initial interview and assessment by the Housing Options team.  Households which may require support to maintain a tenancy are referred to the Resettlement team.  This includes those with wider health and social care needs who are not well engaged with relevant services.  The Resettlement team then links individuals in with these services, including providing guidance around GP registration. ⁵¹

Secondary care

Richmond Council has a discharge policy agreed with local hospitals.  Recommendation includes notifying the Homelessness Assessment Team at least 24 hours in advance of discharge of a homeless patient from hospital.  There have been instances of discharge from hospital without notifying the Homelessness Assessment Team of patients with significant health needs and this agreement is currently under review. ⁵¹

The service level agreement between Hounslow local authority and West Middlesex University Hospital is summarised diagrammatically in Figure 22. [58]

Additionally, issues can arise when vulnerable tenants are discharged to their homes which may be unsuitable, with the appropriate levels of support not in place.  This can lead to tenancy breakdown as individuals fail to manage the requirements of their tenancy agreements and homelessness may result.  Better communication is required between hospitals, community staff and housing providers.

Those working at the Pathway group have highlighted difficulties in establishing a local connection for many rough sleepers admitted to hospital and subsequent barriers to linking these patients in with relevant homeless services.  Furthermore, there is a significant subgroup of homeless patients who are made homeless during their hospital stay and it can be problematic to link these patients in with local homeless services when they have not had previous contact. [59]

Figure 22: West Middlesex University Hospital protocol for support of patients admitted with no fixed abode

Source: Adapted from ’Joint Working Protocol’ agreed between West Middlesex University Hospital and London Borough of Hounslow ⁵⁸

Mental health, drug and alcohol services

Community mental health teams are contacted as required for individuals perceived as having an unmet need.  Many individuals engaging with statutory homeless services will already be linked into community mental health services.  Recent restructuring of services has led to a lack of clarity in the protocol for accessing and referring to mental health services. ⁵¹

The Housing Options and Resettlement teams contact drug and alcohol services in assessing vulnerability and gauging previous needs.  Individuals who have current problems with drugs or alcohol which they wish to address are linked into relevant services through CRI (the Crime Reduction Initiative).  The service operates on an appointment basis which individuals with chaotic lifestyles have failed to attend on occasions. ⁵¹

4 Key Points

1. There are multiple routes to homelessness but many homeless people will have experienced troubled childhoods and been exposed to disadvantage from a young age.
2. In 2013/14 there were 150 rough sleepers in Richmond upon Thames. The majority (84% of rough sleepers in Richmond in 2012/13) are single men of working age.
3. Rough sleepers have higher death rates than the general population, with an average age of death of 47 years. They are more likely to die from substance misuse, alcoholism and suicide.
4. Rough sleepers also have significant physical health needs, including problems with feet and eyes, poor dentition, skin infections and infestations, and higher rates of tuberculosis and blood borne viruses.
5. Current delivery of health services to rough sleepers relies heavily on expensive secondary care services. In-patient costs are eight times those of the general population.
6. There are models for improved delivery of healthcare to rough sleepers which include hospital in-reach teams; health services which operate on a drop-in/outreach basis; GP centred multi-disciplinary teams and clear responsibilities in local public health and commissioning groups.
7. The number of homeless applications to the local authority and statutory homeless acceptances has increased over the past few years. In 2010/11 there were 279 applications to the council and 160 acceptances.  In 2013/14 there were 582 applications and 357 statutory homeless acceptances.
8. Homeless acceptances by local authorities have been monitored since 2011 as part of monitoring the impact of welfare reforms. The increase in homeless acceptances in Richmond upon Thames has been proportionately greater than comparable figures for London and England.  Richmond has fared better than other London boroughs in markers such as those affected by the benefits cap and social sector size criteria, but rent increases from 2012 to 2013 were the second highest of any London borough.  Discretionary Housing Payments have played a large role in homelessness prevention since 2011; the future of these payments is unclear.
9. The majority of those housed in temporary accommodation by Richmond council are young families. The majority age group in temporary accommodation are children aged 0-4 years old.  Research suggests that children with complex childhoods are at greater risk of homelessness in the future. 
10. Those at higher risk of statutory homelessness are exposed to wider forms of deprivation, which lead to negative health consequences including reduced life expectancy and reduced healthy life expectancy.
11. Being made homeless can cause considerable stress to a person and household, with effects on physical and mental health. Length of stay in temporary accommodation affects a person’s self-rated health.
12. Currently, the Resettlement team in the Richmond Council works with vulnerable households and links them in with other services – including health and social care teams – and provide households with the skills to maintain a tenancy.
13. A potential area for public health improvement of the statutory homeless population includes cross-agency agreement of and monitoring of key health markers; provision of guidance regarding dentistry registration and the implementing of service level agreements, particularly with local hospitals, and mental health and alcohol and substance misuse teams.

5 Recommendations

Responsibilities

The responsibilities of the CCG, NHS London and NHS England for commissioning homeless healthcare services in Richmond upon Thames are currently unclear.  It is recommended that we clarify commissioning responsibilities by working with these groups and other stakeholders.

The responsibility for monitoring the health needs of homeless people in Richmond upon Thames is currently unclear. It is recommended that a single officer is responsible for this monitoring. We should work with stakeholders to clarify responsibilities for monitoring health needs of homeless people and the role of public health within the council.

Indicators and data collection

SPEAR is commissioned by the council to provide services for rough sleepers. It is recommended that the public health team work with SPEAR to agree health indicators and measures of engagement with health services to help improve health monitoring and access to appropriate services.

Statutory homeless services in the council link households in with appropriate services and monitor the health and social care needs of this population.  It is recommended that we work together to agree a process of reporting health indicators and measures of engagement with health services to identify and address gaps in delivery.

Public Health England are progressing work to enable local areas to develop robust JSNAs.  It is recommended that the public health team work with other public health professionals at a regional and national level to ensure robust systems of data collection and monitoring.

Service level agreements and referral pathways

Currently 70% of homeless people are discharged from hospital without having their wider social and housing needs addressed.  It is recommended that we work with statutory and non-statutory homeless services to implement a service level agreement regarding discharge from local hospitals.

Issues have been raised by statutory and non-statutory homeless services around the accessibility of mental health services for some clients who either fail to engage with services or attend appointments due to chaotic lifestyles or are discharged due to challenging behaviour, but still require support.  It is recommended that the protocol for referral and engagement between mental health services and homeless/housing association services is clarified by commissioners as part of the current redesign of mental health services.

Service provision

It is recommended that we adopt the model of service provision that is put forward by the Pathway group.  This model focuses on the provision of care to rough sleepers through primary care led multi-disciplinary teams with care plans to reduce reliance on secondary care services.  Implementing this model means facilitating registration with general practices locally and working with general practitioners and other stakeholders to ensure forums for agreeing care plans for rough sleepers.

It is recommended that CCG commissioners work with rough sleeper services to facilitate registration of rough sleepers with GPs and dentists.

Homeless people have not been directly consulted regarding their own perception of need.  It is recommended that we consider including the voices of homeless people to inform the services provided locally.

There is currently no podiatry service for rough sleepers in Richmond upon Thames.  It is recommended that commissioners consider the provision of a podiatry service for this group. 

There are low levels of registration of rough sleepers with local dentists.  It is recommended that CCG commissioners work with non-statutory homeless services to provide guidance on sign-posting for registration.

The Pathway group recommends developing hospital in-reach services to ensure the social and housing needs of homeless patients are addressed.  Intermediate care facilities are also recommended to allow respite and recovery and to reduce readmission rates.  It is recommended that commissioners consider working with CCGs in south west London to develop these services.

Authors

Benjamin Bouquet

Anthony Threlfall

Acknowledgements

Alex Bax (Pathway)

Louise Brice (London Borough of Richmond upon Thames)

Dan Butler (London Borough of Richmond upon Thames)

Len Charles (SPEAR)

Ken Emerson (London Borough of Richmond upon Thames)

Gareth Evans (London Borough of Richmond upon Thames)

Jo Harper (London Borough of Richmond upon Thames)

Trudy Jones (London Borough of Richmond upon Thames)

Ali Negyal (London Borough of Richmond upon Thames)

Stuart Nevill (SPEAR)

Desiree Shepherd (The Vineyard Community Centre)

Matt Thacker (SPEAR)

Katherine Thompson (London Borough of Richmond upon Thames)

Glossary

BBV                            Blood borne virus

CCG                           Clinical commissioning group

CEE                            Central and Eastern Europe

CDAT                         Community drugs and alcohol team

CHAIN                       Combined Homelessness and Information Network

CMHT                         Community mental health team

DCLG                         Department for Communities and Local Government

DHP                           Discretionary Housing Payment

DLA                            Disability Living Allowance

DWP                           Department for Works and Pensions

GP                              General Practitioner

HBV                            Hepatitis B virus

HCV                           Hepatitis C virus

HIV                             Human immunodeficiency virus

LGBT                          Lesbian, gay, bisexual or transgender

LHA                            Local Housing Allowance

MDT                            Multi-disciplinary team

MEH                           Multiple exclusion homelessness

NHS                           National Health Service

PIP                              Personal Independence Payment

SHP                            Single Homeless Project

TB                               Tuberculosis

UCH                           University College Hospital

WMUH                       West Middlesex University Hospital

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[2] Point prevalence among 16-65 year olds

[3] Lifetime prevalence of bipolar I according to NICE

[4] Lifetime prevalence according to NICE (Cannon & Jones, 1996)

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