Working with asylum seekers and homeless people in East Sussex Jane Cook Public Health Clinical Specialist

Asylum seekers A person who may apply for asylum in the United Kingdom on the ground that if he were required to leave, he would have to go to a country to which he is unwilling to go owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion. Any such claim is to be carefully considered in light of all relevant circumstances’. Immigration Act 1971

Homelessness Homelessness is the problem faced by people who lack a place to live that is supportive, affordable, decent and secure. Covers circumstances ranging from rough sleeping to overcrowded unsuitable accommodation.

Statistics Asylum seekers – supported by UKBA. Dispersed to Hastings. 120 bed spaces Asylum seekers – supported by UKBA. Dispersed to Hastings. 120 bed spaces Single homeless – those not is priority need – Local Authority do not have a duty to provide accommodation as they do not fall under the priority need definition (1996 Housing Act). No hostels for homeless people in East Sussex. 120 meals plated at Salvation Army at the drop –in Single homeless – those not is priority need – Local Authority do not have a duty to provide accommodation as they do not fall under the priority need definition (1996 Housing Act). No hostels for homeless people in East Sussex. 120 meals plated at Salvation Army at the drop –in

Common issues Enforced mobility Enforced mobility Discrimination Discrimination Separation Separation Insecurity Insecurity Poor living conditions Poor living conditions Overcrowding Overcrowding Poverty Poverty Low expectation, lack of confidence and self esteem Low expectation, lack of confidence and self esteem Lack of knowledge Poor access to services Poor planning of services Exclusion Multiple and complex health problems Deterioration in health outcomes

Profile of rough sleepers 25% are aged between 18 and 25 SEU July 1998) 25% are aged between 18 and 25 SEU July 1998) Predominantly 20 – 50 years old Predominantly 20 – 50 years old 6% are aged over 60 years (SEU 1998) 6% are aged over 60 years (SEU 1998) 80 – 90% are male (SEU1998) 80 – 90% are male (SEU1998) Between 18 to 32% were in local authority care as children (Randall and Brown 2001) Between 18 to 32% were in local authority care as children (Randall and Brown 2001) The 4 week rule is the process by which newly homeless people become acclimatised to life on the streets. After that they become entrenched and it becomes more difficult for them to move back in to mainstream society (Crisis 1998) The 4 week rule is the process by which newly homeless people become acclimatised to life on the streets. After that they become entrenched and it becomes more difficult for them to move back in to mainstream society (Crisis 1998) 9% increase across England 9% increase across England

Profile of single homeless Numbers of single homeless women has risen significantly in recent years (Fitzpatrick 2000) Numbers of single homeless women has risen significantly in recent years (Fitzpatrick 2000) B.M.E. groups are more likely to sleep on friends and family’s floors (Crisis 2003) B.M.E. groups are more likely to sleep on friends and family’s floors (Crisis 2003)

Causes Relationship breakdown Relationship breakdown Loss Loss Leaving an institution Leaving an institution Leaving the armed forces Leaving the armed forces Financial problems Financial problems Redundancy Redundancy Unemployment Unemployment Abuse Abuse Violence Substance misuse Gambling Moving to look for a job/accommodation Lack of accommodation

Factors that increase the risk of homelessness Institutionalisation Institutionalisation Health Health Relationship breakdown Relationship breakdown Unemployment Unemployment Education Education Housing Housing Poverty Poverty Debt Debt Insecure Pollution Lack of planning and control of life Deprived neighbourhoods Isolation Environment less predictable Placelessness is a chronic stress

The average time between triggers that lead to homelessness and when homelessness finally occurs is 9 years. (Routes in to Homelessness Centre for the Analysis of Social Exclusion)

Where homeless people stay Hostels Hostels Squats Squats ‘Sofa surfing’ ‘Sofa surfing’ Bed-and-breakfast’ Bed-and-breakfast’ Homeless at home Homeless at home Street Street Prison Transitional housing Shared housing

Conditions Damp Damp Cold Cold Noisy Noisy Unsafe Unsafe Lack of privacy Lack of privacy Lack of space Lack of space Pollution Pollution Infestation Lack of storage Shared amenities Insecure Lack of planning and control of life

Health ‘The concept of health itself has emerged in recent years as something far more than just disease- free biological functioning. Health is powerfully influenced by cultural, social and philosophical factors, including the existence of meaning and purpose in life and quality of intimate personal relationships’. ‘Spirituality, religion and health: an emerging research field’ Miller,W.R., Thoresen,C.E. (2003) American Psychologist 58(1):24-35

Health of rough sleepers 30 – 50% of rough sleepers suffer from mental health problems 30 – 50% of rough sleepers suffer from mental health problems More likely to suffer from: respiratory problems respiratory problems Twice more likely to have muso-skeletal problems Twice more likely to have muso-skeletal problems Twice as likely to have digestive problems Twice as likely to have digestive problems 35 times more likely to commit suicide than the general population (Crisis 1996) 35 times more likely to commit suicide than the general population (Crisis 1996) The average age of death for rough sleepers is 42 years of age. The average age of death for rough sleepers is 42 years of age.

Health of single homeless people Only a quarter of G.P.s fully register homeless people seeking treatment (1995) Only a quarter of G.P.s fully register homeless people seeking treatment (1995) Single homeless people are 40 times more likely not to be registered with a G.P. than the rest of the population (Crisis 2003)  over use of crisis health care Single homeless people are 40 times more likely not to be registered with a G.P. than the rest of the population (Crisis 2003)  over use of crisis health care Mental health problems are up to 8 times more common in the homeless population Mental health problems are up to 8 times more common in the homeless population A third of young homeless people have attempted suicide - a fifth within the last year (Craig T., et al Off to a Bad Start 1996) A third of young homeless people have attempted suicide - a fifth within the last year (Craig T., et al Off to a Bad Start 1996) 81% are addicted to either drugs or drink (Crisis Home and Dry 2002) 81% are addicted to either drugs or drink (Crisis Home and Dry 2002) 50% have long term illness or disability (Crisis Missed Opportunities 2006)and have problems in accessing integrated care so present late in the pattern of illness 50% have long term illness or disability (Crisis Missed Opportunities 2006)and have problems in accessing integrated care so present late in the pattern of illness

Impact on health  rates of morbidity for all diseases  rates of morbidity for all diseases  mental health problems  mental health problems  respiratory problems  respiratory problems  gynaecological problems  gynaecological problems  gastric problems  gastric problems  infections  infections  foot problems  foot problems  musco-skeletal problems  dental problems  cardiac problems  psychosomatic disorders  nutritional problems Presents with multiple and complex problems

Homeless people each consume an estimated 8 times more hospital inpatient services than an average person of similar age, and then secondary care costs around £85 million in total per year. Compared to the rest of the general public, they are 40 times more likely not to be registered with a GP and have about 5 times the utilisation of AE (SI Unit 2010)

Harm reduction Internationally recognised term that defines policies, programmes, services and actions that work to reduce the: health,, social and economic harms to individuals, communities and society that are associated with the use of drugs, alcohol and tobacco (Newcombe 1992)

Principles of Harm Reduction Pragmatic Pragmatic Prioritises goals Prioritises goals Client centred Client centred Focuses on risks and harm Focuses on risks and harm Does not focus on abstinence – it does support those who seek to moderate or reduce their use Does not focus on abstinence – it does support those who seek to moderate or reduce their use Seeks to maximise the range of intervention options that are available Seeks to maximise the range of intervention options that are available

Harm reduction Strategy focuses on: BBVs- Hep c, HIV, Hep A, tetanus and influenza BBVs- Hep c, HIV, Hep A, tetanus and influenza Drug related deaths Drug related deaths Injecting behaviours Injecting behaviours Wounds Wounds Co-morbidity i.e. poly drug use, mental health issues/dual diagnosis, alcohol use Co-morbidity i.e. poly drug use, mental health issues/dual diagnosis, alcohol use Also takes in to account the families and carers of users Also takes in to account the families and carers of users Referral to specialist services Referral to specialist services Behavioural change Behavioural change Health promotion – harm reduction, safe sex, nutrition, mental health and wellbeing Health promotion – harm reduction, safe sex, nutrition, mental health and wellbeing

Drug related health complications DVT DVT Abscesses Abscesses Leg ulcers Leg ulcers Overdose Overdose Lowered immune system Lowered immune system Often drug use is replaced or supplemented by alcohol Often drug use is replaced or supplemented by alcohol

Solutions for clients Client centred care Client centred care Raise awareness Raise awareness Recovery model – emphasises personal aspiration, resources they have, progress is possible Recovery model – emphasises personal aspiration, resources they have, progress is possible Holistic Holistic Consultation Consultation

Solutions for commissioners World Class Commissioning World Class Commissioning Competencies Competencies Commissioning cycle Commissioning cycle HNA HNA Realistic outcomes Realistic outcomes Sustainability Sustainability

Solutions for providers/frontline staff Public health approach Public health approach Multiagency approach Multiagency approach Harm reduction focus Harm reduction focus Multi-skilled teams Multi-skilled teams Specific training Specific training Appropriate supervision Appropriate supervision

Principles Appropriate Appropriate Accessible Accessible Flexible Flexible Sustainable Sustainable Creative Creative Accountable Accountable Equitable Equitable Efficient Transparent Effective Acceptable Just