New Report Investigates the Effectiveness of Key Aspect of the Homelessness Reduction Act 2017

  • New report by inclusion health charity Pathway and national homelessness charity Crisis finds the opportunity to prevent homelessness in hospital settings is frequently missed.  
  • Severe strain on the NHS, coupled with a deepening housing crisis, means people are often discharged either straight back onto the streets or into unsuitable temporary accommodation without any support. 
  • As we head into winter, vulnerable people with nowhere safe to stay will face disastrous worsening of ill health, adding an avoidable pressure on overburdened NHS services, as patients return again and again seeking help. 
  • Health services can play a crucial role in preventing homelessness. Crisis and Pathway are calling for better integration between health and housing services to ensure needless deaths can be prevented.  

People experiencing homelessness face shocking health inequalities and poor outcomes in comparison with the general population, with an average age of death of 45 for men and 43 for women. One third of deaths among people experiencing homelessness are caused by treatable illnesses.  

Produced by inclusion health charity Pathway and national homelessness charity Crisis, in collaboration with lived experience partners from both Pathway and Groundswellthis new report examines how the duty to refer is currently working in practice, drawing on evidence gathered from surveys and workshop discussions with hospital and local authority staff, in addition to analysis of existing Homelessness Case Level Collection data.   

Introduced in 2017 as part of the Homelessness Reduction Act, the Duty to Refer creates an obligation for various public bodies to refer service users who they identify as at risk of or experiencing homelessness to the relevant local authority. For patients, this means an opportunity to recover in appropriate accommodation and access the health and social care services which can help them onto a more positive life path. For hospitals, it is the chance to break the cycle of costly repeat admissions.  

The findings suggest that, while good practice exists among hard-working NHS and local authority housing staff, the effectiveness of the duty is significantly undermined by wider system pressures being felt across both the NHS and local authorities. Crucially, poor levels of integration between overstretched health provision and under-resourced housing services see people experiencing homelessness all too often falling between the cracks. At the same time, a frequent lack of the accountabilities necessary to ensure consistent adherence to the duty means that basic implementation of the referrals process is uneven; a postcode lottery with regards to access to services.  

To address this unacceptable situation, the report calls for change at both system and local level, including: 

  • Dedicated step-down and intermediate care facilities to help support people experiencing homelessness with complex needs, along with embedded housing officers in all hospitals to ensure effective integration between health and housing services.  
  • The establishment of integrated homelessness forums so health, housing, and social care work together to adopt best practice and co-ordinate services at the local level. 
  • To increase the impact of the duty to refer, Integrated Care Systems should be given responsibility and held to account for overseeing the operation of the duty in their areas, co-ordinating with local government housing services to drive compliance. 

 A referral mechanism can only be as good as the systems into which someone is referred, and until these wider systemic pressures are addressed the duty will fail to make the impact it was designed to. Moreover, the difficulties encountered by the duty in implementation also serve as an important indicator of the effectiveness of integration between health, care and support services more broadly, and thus the health of the system at large. As such, these findings and recommendations should be of huge interest to both national and local government, healthcare leaders and local authority partners. 

 You can download the full report here. Furthermore, you can reach out to Pathway at if you would like to discuss the report and any of its findings and recommendations further. 

The advent of the Duty to Refer was a significant step towards ensuring that health services play their part in preventing and responding to homelessness, however this report highlights an implementation gap between the clear aims of the Homelessness Reduction Act and the realities of implementing the duty to refer in busy hospital settings. People facing homelessness need more specialist support in hospital, and safe places to recover, including intermediate care for those who need it.

Alex Bax, CEO of Pathway

We know from our frontline services that preventing homelessness is more effective than allowing people to get to a point where they need emergency help. The Duty to Refer, where public services including hospitals are legally required to intervene to help prevent homelessness, could be a perfect example of that.  

 Not only would a fully functional Duty to Refer system save people from the hardship of homelessness, it would also ease the burden on the NHS and public services. It’s vital – and good sense – that the system is given the resources it needs to work properly.  

 But ultimately, without more genuinely affordable housing, the Duty to Refer system will be operating with its hands tied behind its back. It’s therefore vital that the Westminster government acts swiftly and provides the long-overdue investment to deliver the 90,000 social homes a year that we need.

Matt Downie, CEO of Crisis

We welcome the recommendations for improvements in this area to ensure that homelessness is identified on assessment, not on discharge. Although large turnovers of staff in hospitals can be problematic when implementing processes, the duty to refer for homelessness should have the same systemic monitoring as safeguarding referrals; recorded, monitored, audited, reported on and viewed with importance on an individual and systemic level. Specialist hospital in-reach teams can not only help to embed this practice, but also maximise the opportunity presented by an admission to advocate for vulnerable people, enabling them to feel cared for and be connected with wider services upon a planned discharge. 

Elizabeth Keat, Integration Lead, Homeless and Health Inclusion, Leeds Community Healthcare NHS Trust

Notes to editors  

The Homelessness Reduction Act 2017 places a statutory duty on Hospital Trusts, NHS walk-in centres and Accident and Emergency departments to refer (with consent) any patient who is homeless, or at risk of homelessness in the next 56 days. Homelessness may include patients residing in hostels or unsuitable accommodation, people in insecure accommodation or people sleeping rough. 

Pathway is the UK’s leading Homelessness and Inclusion Health charity. We work with the NHS and other partners to create improved models of care for people experiencing homelessness and excluded groups. In the last 3 years, the Pathway Partnership Programme has helped 9 NHS Trusts in England to create in-reach Pathway teams of doctors, nurses, social care professionals and peer supporters who support over 4000 homeless patients every year. Founded in 2009, Pathway works to improve the quality of healthcare people experiencing homelessness and excluded groups receive by: 

  •  developing and sharing best models of care like our hospital teams;
  • increasing specialist skills of workers in healthcare;
  • influencing policy; and
  • reducing stigma in healthcare against people experiencing multiple exclusion.

The Faculty for Homeless and Inclusion Health is an inclusive membership organisation for people involved in healthcare for excluded groups. Membership is open to nurses, doctors, allied medical professionals, social workers, public health experts, health advocates and support workers, commissioners, researchers and people with a lived experience of exclusion. Our aim is to improve the quality of healthcare for people experiencing homelessness and other excluded groups. The Faculty is hosted by Pathway. 

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