An evaluation of the integration, effectiveness and costs of different models

Purpose

Primary health care for single people who are homeless is delivered in various ways: health centres specifically for this population; mobile teams in homelessness services such as hostels; mainstream GP practices with special services for people who are homeless; and generic GP practices that also provide ‘usual care’ to people who are homeless. There is no evidence, however, about which schemes are more effective in addressing the health needs of people who are homeless. This study aimed to evaluate the effectiveness and costs of these different models, with special reference to their integration with other services and how this impacts on a range of health, social and economic outcomes.

The objectives were:

1. To identify the extent of provision in England of specialist primary health care services for people who are homeless, and the types of models that are found in different NHS regions and in areas with different population sizes.
2. To examine the integration of primary health care services for people who are homeless with other services, particularly primary dental care, mental health, secondary health, substance misuse, homelessness sector, housing and social care.
3. To examine the effectiveness of the different models in (i) engaging people who are homeless in health screening; (ii) responding to their health and social care needs; and (iii) providing continuity of care for health problems including long term and complex conditions.
4. To evaluate the impact of different models over time on service-users’ health and well-being, and their use of other health and social care services including dental, emergency and secondary care.
5. To investigate the resource implications and costs of delivering services for the various models.
6. To compare the various models across a range of outcomes, reflecting service user and NHS perspectives, using a cost-consequences framework.
7. To provide evidence to NHS commissioners and service providers regarding cost effective organisation and delivery of primary health care to people who are homeless.

Timescale

Fieldwork: 2015 to 2019.

Research team

Maureen Crane (Principal Investigator), Louise Joly, Gaia Cetrano, Sarah Coward, Robert Calder, Carl Purcell, and Jill Manthorpe, King’s College London
Blanaid Daly, Special Care Dentistry, King’s College London
Heather Gage and Peter Williams, University of Surrey
Vic Rayner and Burcu Borysik, SITRA
Chris Ford, retired GP
Patient and Public Involvement Group

Funding

NIHR Health and Social Care Delivery Research

Methods

A mapping exercise was undertaken to identify the location of specialist homeless health services in England and the services they provide. Ten case study sites (CSS) that represent the four models (described above) were then evaluated to assess their effectiveness in providing health care to people who are homeless. 363 patients with experience of homelessness during the previous 12 months were recruited as ‘case study participants’ and interviewed at baseline, four and eight months. Medical records were obtained for 349 of these participants.

A case study design based on the principles of ‘realist evaluation’ (context + mechanism = outcome) examined the effectiveness of the different models in terms of ‘what works, for whom, how and in what circumstances?’ The primary outcome was the engagement of people who are homeless in health screening, and this was measured using six ‘Health Screening Indicators’. One of the secondary outcomes was the management of long-term health conditions, namely chronic respiratory problems, depression, alcohol problems, and drug problems. Other secondary outcomes were: oral health status and receipt of dental care; self-ratings of general health status and wellbeing; satisfaction with the CSS; and use of health and social care services and costs. Comparisons were made between models using regression analyses, adjusting for factors such as participant characteristics and service delivery features.

Read further on the NIHR page for this study.

Outputs

See below under the Outputs tab for the Final Report and accompanying briefing papers for (i) NHS primary care and integrated care commissioners, and (ii) NHS primary care managers and practice staff. See also: news item (6 October 2023) summarizing our findings.