Using global examples to address complex care needs
By Integrated Care Journal-
As care services across the globe face enhanced pressure to respond to complex needs, providers and governments must begin sharing our solutions to these shared challenges.
Rising rates of rough sleeping combined with persistently high levels of re-offending have dramatically heightened pressure on health and care services in the UK. A problem that has been amplified by the pandemic.
These are of course not exclusive to the UK. It has been estimated that about 150 million people are homeless around the globe, equivalent to two per cent of the world’s population. While recidivism rates might vary significantly around the world, global rates of criminal recidivism are reported to be as high as 50 per cent and have not declined in recent years.
On any given night, more than 200,000 families and individuals experience homelessness in England. According to the charity Crisis, homelessness has been steadily rising over the past five years and reached a peak just before the pandemic – when the number of homeless households increased from 207,600 in 2018 to more than 219,000 at the end of 2019. Moreover, the Social Care Institute for Excellence (SCIE) forecasts that rough sleeping will rise by 32 per cent by 2026.
The success of the Everyone In scheme, used by the UK government to protect rough sleepers during the first wave of the pandemic, demonstrates that the State does in fact have the means to end homelessness. Some estimates suggest these measures prevented more than 21,000 Covid-19 infections and 266 deaths. But the success of this scheme was cut short in June 2020 when the funding was withdrawn and rough sleepers were forced back to the streets.
The UK needs a sustainable long-term solution to end homelessness, perhaps something on offer in Finland. In just eight years, the Scandinavian nation has managed to reduce its number of homeless people by 35 per cent. The country operates on a ‘housing-first’ approach, which follows the logic that once individuals have a home, resolving their other problems becomes easier.
Housing First means ending homelessness instead of managing it. The basic idea is to offer permanent housing and needs-based support for homeless people instead of temporary accommodation in hostels or in emergency shelters. Permanent housing means an independent rental flat with its own rental contract. Under this scheme, individuals are provided with a safe and secure home and receive tailored support to help them manage their lives.
The issues of homelessness and re-offending are intricately linked, with one perpetuating the other, creating a cycle of rampant health inequality.
In the UK 15 per cent of all current prisoners had been homeless immediately prior to custody, with only 3.5 per cent of the total population being made up of rough sleepers. What's more, individuals in contact with the criminal justice system are far more likely to suffer from mental health issues, with 42 per cent of men and women in prison and 17.3 per cent on probation suffered from depression, compared to just over ten per cent of the rest of the population.
Shockingly, recent Public Health England data has found that the mortality rates in prison are 50 per cent higher than the general population and many prisoners are living with the biological characteristics of someone 10 years older than them.
NHS England has identified a clear link between health-related interventions and a reduction in re-offending rates. For many offenders, release from prison can be a crisis point. They are transitioning from a secure environment where their health and housing needs are taken care of, to an unfamiliar environment where their care and accommodation is now their own responsibility.
Recently released prisoners often display low levels of help-seeking behaviour and a distrust of authority due to negative experiences with statutory services – a factor that has been found to undermine their ability to access healthcare services.
The successful rehabilitation of prisoners is highly dependent on good continuity of care as they transition back into the community. However, prison healthcare and community rehabilitation companies have reported that it is often challenging to establish links with community health teams.
There is no centralised organisation responsible for the care of offenders as they transition back into the community. Instead, this transition typically involves five separate organisations: the prison mental health care provider, the offender management unit, the community rehabilitation company or probation, the community mental health provider (usually differs from provider in prison) and the offender’s GP.
According to NHS England: “The sheer number of organisations with a responsibility for planning support through the gate and transfer of mental health care creates barriers to effective care co-ordination. Each handoff is an opportunity for information to be lost, trust to break down between prisoner and provider, and create a delay in care planning. ”
As a result, the Government has stated that a more “integrated care pathway from prison to the community is crucial for supporting recovery from substance misuse and reducing reoffending among people leaving custody. ”
The answer to reducing recidivism in the UK may be in imitating the Swedish prison system model. Indeed, Sweden has the lowest re-offending rate in Europe at 16 per cent. The Swedish Prison and Probation Service argued that its emphasis on rehabilitation, as opposed to retribution, is responsible for this stark reduction in recidivism. In Sweden, prisoners are called ‘clients’, in order to emphasise that they are people with needs who need to be assisted and helped. As the Director General of the Prison and Probation service explained, “our role is not to punish. The punishment is the prison sentence: They have been deprived of their freedom. The punishment is that they are with us”.
The challenges of reducing homelessness and recidivism are just two of a plethora of trials confronting health and care systems around the world. The UNHCR estimates that there are now more than 80 million forcibly displaced people worldwide. Worldwide, the UN predicts that the number of people older than over 65 is projected to double to 1.5 billion in 2050.
As we move further into the 21st century the pressure on health and care services to respond to more complex needs is rising across the globe. As more countries continue to share these challenges, health and care systems must also begin to share solutions globally to respond to increasingly complex needs.
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