What can Kent learn from global approaches to healthcare and homelessness?

I recently joined clinicians from the United States and Canada to discuss and compare what prevents people experiencing homelessness from getting the care they need. The same failure points surfaced repeatedly: rigid access routes, fragmented commissioning, discharge without a housing plan, and services designed around categories rather than people.

None of these problems are insurmountable but they do require solutions. We are fortunate that there are proven models across Kent and elsewhere that show how to design inclusive healthcare around people’s needs.

This blog brings together evidence on what works and will be of interest to anyone designing or delivering inclusive healthcare services.

Most health systems assume a person has an address, a charged phone, reliable transport, control over their diary and the ability to explain a complex situation in a short appointment. For many people experiencing homelessness, these assumptions do not hold.

As I said in the discussion, we design services around “an idea of what a patient is and how they’re going to behave”. When someone does not fit that model, the system is too often stumped.

In Kent, this can mean being refused GP registration due to not having an address, being informally labelled “difficult”, or being asked to travel an hour after being excluded from a local practice, all without a clear route of review.

The most promising responses to these challenges do two things: make services easier to access and invest in trusted relationships. The Dartford Health Hub brings care into a community setting and offers it on terms people can use.

Care navigators, peer advocates and outreach workers turn a nominal entitlement into real access. International experience with telehealth reinforces the same principle: access improves when services adapt to people, rather than expecting people to adapt to the system.

One Canadian service described care coordinators arranging transport, locating patients before prescriptions lapse, accompanying them to emergency departments and helping them remain engaged through fear or previous trauma.

Too often, a hospital treats the immediate clinical need and discharges a person to the street or to unsuitable accommodation. The treatment may be complete, but the conditions driving ill health remain, making deterioration and readmission far more likely.

Kent has models that show another way is possible. Through the Pathways programme and step-down accommodation in Dover, planning for housing and recovery starts when someone enters healthcare, not at the point of discharge. A health contact about a leg, kidney or dental problem can become what I believe is a “ tremendous opportunity” to improve the wider circumstances or “social determinants” of a person’s health.

People do not experience mental ill health, substance use, frailty, poverty and insecure housing as separate problems. Yet our eligibility criteria, funding streams and accountability arrangements often treat them that way, leaving providers to insist that another need must be addressed first. “We’re not commissioned to provide that” may be administratively accurate, but it is not an adequate response to a person whose needs are interconnected.

International examples show effective integration includes shared goals, joint pathways, aligned incentives and clear escalation routes. We can learn from mental health teams who address substance misuse and substance misuse teams who support common mental health needs, and housing specialists who work alongside clinical colleagues.

People experiencing homelessness face exceptionally high levels of illness and premature ageing. Support must be proportionate to this level of need. Longer appointments, outreach, and multidisciplinary teams all cost money. But under-investment creates “failure demand” when needs are not met early, so people return later to emergency departments, acute wards and crisis services with more complex and expensive problems.

Commissioning should take a system-wide perspective. For example, safe discharge can reduce readmission.

Better-linked information can reveal patterns such as repeat crises, and help commissioners understand system costs. But we should be cautious about how much hope we place in “better data,” since measurement will only improve outcomes if they lead to a change or learning.

Rather than solely relying on administrative data, commissioners should also work in partnership with people who have experienced homelessness to design new services such as mental health services.

Five priorities for Kent’s commissioners:

1. Ensure “no discharge to homelessness” by incorporating housing input from the point of admission
2. Commission low-barrier access through hubs, outreach, navigators and peer advocacy, with flexibility on location, timing and identification
3. Reward providers for contributing to shared outcomes around housing, health, public health, social care, substance misuse and community safety
4. Invest in prevention and step-down support, evaluating avoided crisis use and housing stability across the whole system.
5. Build lived experience into the design, delivery and review of neighbourhood services.

Across Kent and around the world there are examples of excellent practice. Turning these into consistent high-quality care and support requires us to treat homelessness as both a housing issue and a determinant of health.

Porchlight welcomes conversations with commissioners and partners who want to test more integrated responses to build inclusive health systems.