Build Back Better- Homelessness

08 June 2020

Michelle Black and Dr Amy Stevens, Public Health Registrars (8th June 2020)

This is a blog about building on the momentum and success of cross sector work, forged in the COVID-19 response, to house rough sleepers. It also discusses the opportunity for developing public policy to sustain cross-sector work long beyond the pandemic years.

Public Health is an art and a science. The ‘science’ has informed the strategy to deal with the pandemic (the political decisions made on the back of the science will be argued for many years and is not the focus of this blog!). The ‘art’ of affecting change is the skill we now need to ensure the pandemic does not compound health inequalities further.

That COVID-19 is a risk is undisputed. We need to figure out very quickly how to accept this risk into our existing milieu of risks or the consequences for public health are dire. Getting public acceptability of the risk is difficult for many reasons. Firstly, the science is unclear and uncertainty is high. Second, the clarity of the strategy being pursued is unclear – is it mitigation? Long term or short term? Is the life of an elderly person with multi-morbidity worth the same as a depressed teenage who commits suicide because of the mental health impact of the lockdown? Can you have a strategy that saves both? As uncomfortable as these questions are, it is the reality of the situation we currently face and healthy debate informs (together with the science as it emerges) our interventions and communications moving forward. Third, the public is frightened because our vulnerability is exposed.

We are all susceptible to the virus. But crucially it is not 'the great leveller'. We have differential exposure (people living in lower socioeconomic circumstances (SECs)) may have more crowded living circumstances, have jobs which mean they are less likely to be able to work from home etc.) and differential vulnerability (prevalence of underlying health risks is higher in lower SECs) to the infection in society. Therefore the health and economic burden of COVID is felt more by the most deprived in society. This has caused (media) outrage. COVID-19 shines a light on existing health inequalities and on the platform that socioeconomic inequality provides for health inequality (as it always has).

So, whilst public acceptability to the risk changes and our strategy to deal with COVID-19 evolves it is a major opportunity for all who work in public health to harness this outrage and mobilise change at local and national level in the pursuit of policy which redresses health inequalities. With that in mind the focus of this blog is homelessness.


Homelessness highlights how difficult it is for society to re-distribute wealth and to produce coherent policy to address inequity. Most people want a society which provides the opportunity for everyone to live a healthy life regardless of the circumstances they are born into and there is no place for homelessness in this vision.  Why, therefore, does homelessness blight us? We have not found a way of addressing the structural causes of homelessness, namely, poverty and the high cost of housing relative to income. Neither have we found a way of providing systemwide support for the multitude of complex factors associated with homelessness, some of which stem from the structural causes, such as unexpected events, substance abuse, domestic violence and single parenting. The complexity of the causes of homelessness makes it a difficult problem for governments to solve. In the UK the Government’s Homelessness Reduction Act forms a major part of the central approach to tackling homelessness.

The Homelessness Reduction Act places a duty on Local Authorities (LAs) to prevent and relieve homelessness for all eligible people deemed at risk of homelessness. Eligibility is determined by an applicant’s immigration status. What this means is that LAs must provide advice on housing to all applicants but must only provide housing assistance (prevention or relief duty) to eligible applicants. This includes providing housing for those eligible applicants who after 56 days of receipt of relief duty are unintentionally homeless and in priority need (these are legal categories of individuals e.g. living with dependent children). Clearly people will fall through this safety net e.g. immigrants and people who are not deemed as priority e.g. victims of domestic violence. 

To get a sense of the demand, from April 2019 to March 2020 LAs in England assessed 298,960 homelessness applications.[1] Of these 147,180 (49%) were deemed as threatened with homelessness within 56 days and prevention duty provided. 135,310 (45%) were deemed homeless and relief duty provided. 16,470 (5.5%) were deemed ineligible for either duty. So, what happens to those ineligible for any duties? What happens once relief duty ends? There were 58,940 main duty assessments (these are assessments of people whose relief duty has ended) from April 2019 to March 2020 and 36,580 (62%) housed as they were deemed unintentionally homeless and in priority need. 14,320 (24%) were deemed homeless but without priority need and therefore not housed. The remainder were classed as intentionally homeless or not homeless. There are people behind these numbers, people assessing, and people being assessed. The result is that people will slip through the net and end up living on the streets. This is a huge loss on an individual and societal level, not just monetary costs, which are estimated at £1bn[2] but lives cut short due to hardship and poor health.

‘Everyone In’

The people who slip through the net are the most visible part of homelessness, termed ‘street homeless’ or ‘rough sleepers’. There are an estimated 4266 people experiencing street homelessness in England and this is thought to be an under-estimate.[3]

On 26th March 2020 homelessness policy changed overnight. As part of a national response to the COVID-19 pandemic the central UK Government wrote to all councils in England asking them to house all people experiencing street homelessness and those sleeping in night shelters and hostels. This scheme, termed ‘Everyone In’, was to be funded from the £1.6bn central allocation to councils to respond to the first phase of the pandemic. Each council was given £3.2M emergency funding to provide this emergency shelter.

Councils worked fast in partnership with the private sector (to procure hotel and other accommodation), the health sector and the voluntary sector (to provide meals) and the scheme has been a success in many areas. According to Government statistics, 5,400 people have been given temporary accommodation, which includes 90% of rough sleepers known to local authorities at the start of the pandemic. On the back of this the Ministry of Housing Communities and Local Government have announced capital investment of £433M for 6000 housing units (£160M and 3,300 within the next 12 months) together with a 37% increase in revenue support for the Rough Sleeping Initiative to ensure both the housing infrastructure and the support needed to help people move from the streets to homes is put in place.[4] In addition a further £1.6bn has been pledged to councils to manage the pandemic, including support for rough sleepers, but this funding is not ring-fenced[5] so of course there will be many competing pressures on these funds.

This funding and tentative political will presents an opportunity for local authorities to continue with the support provided during the pandemic for people experiencing street homelessness. However, recent media reports[6] highlight that there is a lack of clarity from the Government on exactly what support is available to LAs beyond the end of June, which probably relates to uncertainty of where funds will be directed given that the financial support for people experiencing street homelessness will no longer be ring-fenced. We can see from the success of the initial scheme that clarity, political will and local collaboration were vital to delivering the ‘Everyone In’ scheme. These same ingredients are needed to sustain it in order to provide an opportunity for a healthy life for some of the most vulnerable in society.

An opportunity to live a healthy life

People experiencing street homelessness and living in hostels have higher levels of morbidity and early mortality than the general population, and simultaneously face multiple barriers to accessing healthcare.[7] Research shows that a high number of deaths in people experiencing homelessness are caused by drug-related poisoning, suicide and alcohol, as well as chronic and potentially preventable diseases such as coronary heart disease, respiratory disease, and cancer.[8]

A recent Doctors of the World (DOTW) rapid needs assessment suggests there has been increased engagement with healthcare and addiction services by people experiencing street homelessness who have been housed in hotels.[9] This may be in part due to increased accessibility to support and healthcare, but also because provision of safe and stable accommodation and food has given people the opportunity to prioritise their health in a way that was not possible when their basic needs were not met. The link between housing and health and well-being is well recognised. The Health Foundation estimates that every £1 invested in housing support for vulnerable people delivers nearly £2 of benefit through costs avoided to public services including care, health and crime costs.[10]

The COVID-19 pandemic highlighted the need to address the vulnerable living circumstances of a population that has been long excluded from policies that provide an opportunity to live a healthy life. ‘Everyone In’ has the potential to act as a stepping-stone to a better future for many people. Now is the time to develop more sustainable housing support and build on the emergent relationships of trust between people experiencing homelessness and health and social care services. A return to pre-crisis conditions for this population would not only be short-sighted from an economic perspective, but would also be ethically and morally wrong. We must take the opportunity to reduce the health and social inequalities experienced by the homeless population by ‘building back better’. Here is a chance to create a public health success story from a devastating pandemic.

Building Back Better

There have been calls for development and scaling up of ‘Housing First’ initiatives to prevent homelessness post the COVID-19 pandemic. Housing First is an evidence-based model that aims to provide a stable, independent home and intensive tailored support and case management to people experiencing homelessness who have multiple and complex needs.[11] Research from Europe, Canada and the USA shows that Housing First ends homelessness for at least eight out of every ten people.[12]

The UK Government has already invested in Housing First pilots across England, but reports suggest for success to be realised there needs to be

  • adequate and consistent funding
  • access to sufficient affordable, secure, quality housing
  • delivery as part of a broader integrated approach which involves prevention of homelessness and specialist wrap-around health and social car[13]

Clearly the infrastructure to produce housing is a key requirement moving forward not only for Housing First initiatives but also for access to affordable homes for those at risk of homelessness in the future as demand for housing support is likely to increase because of the economic downturn precipitated by the COVID-19 response. As the construction industry likely struggles with revenues for private sector house funding there is a cross-sector benefit of public sector funding of social housing in terms of housing and employment.

Cross-sector approaches will be key to mitigating the impact of the pandemic on the people in society who are most vulnerable to that impact, namely, increasing unemployment, pressures on housing, depressed wages and poor mental and physical health. The onus is on national and local bodies alike to get local economies moving in a cohesive way with synergistic policy (welfare/housing/employment), which gives clear consideration to the impact of any policy on inequalities. Ensuring housing policy is developed in a cross-sector way to redress increasing socio-economic and health inequity will be a crucial part of the public health recovery.