Accommodation status (homelessness and rough sleeping)

Accommodation status is an indication of the type of accommodation that a patient currently has and should be based on the patient’s main or permanent residence⁴¹.

A person is legally defined as homeless if:

• they have no accommodation available in the UK or abroad
• they have no legal right to occupy the accommodation
• they have a split household and accommodation is not available for whole household
• it is unreasonable to continue to occupy their accommodation
• they are at risk of violence from any person
• they are unable to secure entry to their accommodation
• they live in a moveable structure but have no place to put it⁴²

The Ministry of Housing, Communities and Local Government defines rough sleeping as:

1. People sleeping, about to bed down (sitting on/in or standing next to their bedding) or actually bedded down in the open air (such as on the street, in tents, doorways, parks, bus shelters or encampments).
2. People in buildings or other places not designed for habitation (such as stairwells, barns, sheds, car parks, derelict boards, stations, or “bashes” which are makeshift shelters often comprised of cardboard boxes).⁴³

Research has shown that individuals with poor housing conditions have a lower mental and physical health status and are more likely to be in contact with health services, which also increases with age^44,45. Further research has additionally shown that those who are homeless or sleeping rough have increased contact with emergency health services, but less contact with preventative health services, such as GPs^46,47. There is also a strong relationship between housing problems and mental health, with reports showing that one in five people have experienced mental health issues due to housing problems⁴⁸.

Accommodation status must be considered as an area where social inequality translates to health inequality, and individuals who identify as vulnerable within this group should be identified to improve their health outcomes. Accommodation status can be seen both as a cause and a consequence to poor physical and mental health and can lead to a more preventative approach in improving health outcomes⁴⁹.

People who are homeless are more likely to have experienced trauma than the general population⁵⁰. If services are not taking trauma into account, especially considering that those who have experienced trauma may be reluctant to engage with health and social care services⁵¹, there is an increased risk that some will not receive the support they need.⁵²

The Homelessness Reduction Act 2017 defines that public authorities have a duty to refer an individual’s case (with consent) to an identified housing authority, which includes emergency departments, urgent treatment centres and hospitals providing inpatient care. Patients who are ‘at risk of homelessness’, for example through eviction, must also be referred within 56 days under this duty. A guide to the duty to refer has been published to support public authorities with referrals, however it should also be considered that it may be more appropriate to support patients to make a homeless application⁵³. Given the identified links between improving poor accommodation status and health outcomes within the Homelessness Reduction Act, it is crucial for this data to be collected and reported by health services to identify potentially at-risk patients, provide them with the appropriate support and ensure their experience in health services meets their needs.

Understanding a patient’s accommodation status, and whether it is unstable or at risk of being unstable, also benefits service and care planning for community care and discharging patients from inpatient care.

It should be noted that asking a patient’s accommodation status can be a sensitive topic, and questions should be considerate of this. A trauma-informed approach to healthcare aims to provide an environment where a person who has experienced trauma feels safe and can develop trust⁵⁴. There is an expectation within the NHS Mental Health Implementation Plan that mental health, learning disability and autism services will implement a trauma-informed approach for people sleeping rough accessing these services. Further information on trauma-informed care and how this can be used in practice can be found on the Trauma-Informed Care Implementation Resource Centre website.

Some patients may feel that their accommodation status will be used to discriminate against them, or that there are preconceived notions about how they will respond to support. Patients should be told the importance of this data being collected and ensure they are only providing information they are comfortable with sharing. For example, they should not be pushed to provide a postcode, or the postcode of a day centre should be considered sufficient for the purposes of the services delivered.

Example questions to ask could be:

• ‘what do you feel comfortable sharing about your current accommodation status’
• ‘might there be any problems with you returning to where you were staying before you came into hospital?’ 

Additionally, it is important to provide follow-up questions to check the patient understands what the question is asking and why it’s important, for example for them to receive appointment letters.

A clear need within deciding the appropriate questions to ask patients is the use of co-production and learning from the experiences of those who are, or have been, homeless. Many research projects touching on this topic have been published by Groundswell.

Information on what health services can do if a patient shares they are homeless or sleeping rough can be found on the Healthwatch and The King’s Fund websites^55,56.

It is important to note that there are a range of accommodation types within the data sets. Services should be working in collaboration with the patient to ensure the most accurate residence for them at the time they are being seen is recorded. The patient should be self-identifying their accommodation status and, knowing that accommodation status is not static, services should embed regular checks in their internal processes to ensure this information is still accurate.

Accommodation status type is now collected in the MHSDS via the Accommodation Type data item, which was implemented in v5.0 October 2021. Accommodation status will also be collected for the first time in IAPT v2.1 (from April 2022) using the same data table. The codes included have been significantly updated and the list reduced for MHSDS v5.0. The data item in the MHSDS no longer aligns with data items used in the Community Services Data Set (CSDS), which will be moving to the new data item (shown in Table 7) in April 2022. The priority for providers that submit to both data sets is to collect the new MHSDS v5.0 version of these data items.

The MHSDS and IAPT Data Set additionally have a ‘Settled Accommodation Indicator’ which indicates whether the main/permanent residence of the patient is settled accommodation. Accommodation Type will be looked at alongside this indicator and organisations should support patients if they are at risk.

Tables 7.1 and 7.2 identify the data items required to record and flow this data to the MHSDS and IAPT Data Set.

Extract from the Technical Output Specification; MHSDS table MHS003 and IAPT Table IDS003 - Accommodation Status

Table 7.1

Data item name - ACCOMODATION TYPE

Intermediary Database (IDB) Element Name - AccommodationType

Data item description - An indication of the type of accommodation that a PATIENT currently has. This should be based on the PATIENT's main or permanent residence.

Table 7.2

Data item name - SETTLED ACCOMMODATION INDICATOR

Intermediary Database (IDB) Element Name - SettledAccommodationInd

Data item description - An indication of whether the main/permanent residence of the patient is settled accommodation.