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It's taken the coronavirus crisis for people to see rough sleeping for the public health emergency it is

LOUISE CASEY and NIAMH MOHAN: There are lessons to be learned for future homelessness policy

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The poor health of the street homeless population, many of whom have underlying medical conditions, means rough sleepers have been classified by the government as being at high risk of severe illness from Covid-19. But the obvious problem is that they are unable to follow official guidelines to self-isolate, despite the significant risks of transmission between rough sleepers.

There has been a concerted, cross-government effort to solve this problem. It is an incredible effort, and will quell the immediate risk of outbreak – but the current crisis has made it all the more apparent that street homelessness is a major health issue. Over the last 10 years, rough sleeping has become an uncomfortable – and increasingly visible – part of British life, with numbers having risen throughout the last decade. While homelessness in general is a neglected issue, even more overlooked is the rise in those who are incredibly ill and living on the streets. 

We know that of those sleeping out for more that two years in London, 88 per cent have drug, alcohol or mental health needs. And these complex health needs are hard to treat on the streets – the awful statistic that 726 homeless people in England and Wales died in 2018 was the highest ever recorded by the Office for National Statistics. 

Rough sleepers are also three times more likely to experience a chronic health condition including asthma and chronic obstructive pulmonary disease (COPD), and the mean age at death for homeless people is 45 years old for men and 43 years for women. 

Add the threat of coronavirus into the mix and it raises alarms. The transmission rates among rough sleepers in shelters, encampments and streets would soar if an outbreak occurred. Given this, we need to act quickly to provide appropriate isolation spaces both for those with symptoms and for those with pre-existing health conditions, in accordance with public health guidance.

The government’s response to coronavirus: everyone in

Over the last two weeks, I have worked with the government and the Mayor of London to build a Covid-19 strategy to “get everyone in”. Local authorities and charities have done an amazing job and were determined to help people out of the streets and into emergency self-contained accommodation. It has required unprecedented speed in social policy. The collaboration across government with businesses, hotel managers, and charities has been extraordinary.

Emergency support for rough sleepers during the coronavirus outbreak has enabled greater coordination of a cross-society effort to set up and manage self-contained accommodation sites. There are now triage pathways for symptomatic and asymptomatic people to be helped off the streets and into sites with staff who provide specialist support.

While the solution is designed to help us deal with the immediate threat facing rough sleepers, looking at the extraordinary response has produced three lessons for the policy world to consider. 

The lessons of the Covid-19 strategy for future homelessness policy

1. Develop a cross-cutting model of operation

Because Covid-19 is public health crisis, the policy response is the same for all those with underlying health conditions or in the at-risk categories. The message is universal: anyone in the high-risk groups across, throughout the whole of society, must be protected. “Getting everyone in” is not just another social inequality initiative or homelessness policy operating in silo – it has become a public health emergency.

This collective, cross-cutting approach has involved a coordinated policy response from all government departments. While the coronavirus is extremely frightening for many, it has elicited a sense of solidarity and relentless dedication from volunteers, health and care workers, managers and policy people, who are focused on providing solutions. It has been testimony to the extraordinary strength and responsiveness of our public services, which are rising to the biggest challenge of our generation. This model of operating ought to be studied to see if it can be replicated in future homelessness policy.

2. Treat homelessness as a health issue

In the aftermath of this pandemic, the street homelessness response will never be the same again. Perceptions of homelessness have been transformed, and it is now seen for what it is: a major public health issue.

Having designated the street homeless population as part of the “at-risk” health group, we now have a duty to care and protect them. We must ensure we do not see a return of seriously ill people to the streets after this crisis ends. The step-down procedures for individuals to eventually leave their self-contained accommodation will be the first place we need to start – and we must look at future health treatment plans for the most vulnerable on the streets. Existing homelessness services will need to further integrate a health approach, one focused on the drivers of serious illness within the population, such as substance abuse, alcohol and mental health.

3. Remove the street as people’s last resort

This future treatment of rough sleeping as a major health issue will require a host of other policy action, especially around affordable housing solutions and prevention work. But this pandemic has underscored the point that no one should be on the street at all; we should always have somewhere/something for them to go to at all times.

We must work across welfare, care, health, prisons, and with landlords, to provide a better basic “protection floor” for people at risk of being made homeless. Our social safety net should not let people slip through onto the streets. If this pandemic has shown anything, it’s that, as a society, we’re better than that.

Dame Louise Casey is Chair of the Institute of Global Homelessness and is advising the government on its strategy to keep people who are homeless safe during the coronavirus crisis. She is also a Visiting Professor at the Policy Institute, King’s College London.

Niamh Mohan works as a Research Assistant for Dame Louise Casey.