Policymakers, practitioners and people with lived experiences of homelessness alike often pose the challenge that we need to drive prevention upstream. The arguments are very strong: not only would we help avert the negative experiences and outcomes associated with homelessness but, in doing so, we might also do it in a way that is cheaper and more effective. However, we often struggle to identify and implement those types of solutions.

At the Centre for Homelessness Impact, we have been reflecting on this challenge for a while. 

I am very excited that at CHI we have some ongoing projects hoping to drive prevention upstream (for example a screening tool for GPs to identify patients at greatest risk of homelessness, and using local authority data to target preventative support.) I always cherish the moments of excitement when I hear about an innovative service or intervention that we could try in the UK. A couple of weeks ago, I was chatting away with Dr Margot Kushel in one of the breaks during our Impact Forum in Manchester (if you missed it, you can watch some of it here) and I had one of those moments. Let me tell you a bit more about it…

Imagine you walk into a GP practice with a simple ear infection. The consultation goes as usual: the GP asks about your pain. When did it start? How acute is it? Then the GP does a couple of checks, writes a prescription and is about to send you back home.

Then, the GP notices a simple notification on their screen: ‘Last screening done 1 year and 3 months ago.’ And in red, bold letters: ‘Ask about housing circumstances now’. The GP diligently proceeds to ask two simple questions:

1. In the past two months, have you been living in stable housing that you own, rent, or stay in as part of a household?
2. Are you worried or concerned that in the next two months you may NOT have stable housing that you own, rent, or stay in as part of a household?

If you answered that you are worried about the future, the GP would put you directly in touch with someone who could offer help. That’s it - clear steps to preventing homelessness upstream.

The Homelessness Screening Clinical Reminder (HSCR) for veterans in the US

The interaction I describe above might sound fictitious, but it is not: it is simply a stylised example. 

In the United States, military veterans receive a range of health services from the Veterans Health Administration (VHA) including services from GP appointments, mental health appointments or support to deal with substance use, all the way to substantial surgeries and hospital stays. The VHA implemented a universal, very short screening questionnaire for current homelessness and imminent risk—the Homelessness Screening Clinical Reminder (HSCR)—across all their services. 

Working closely with their IT teams, they managed to embed an automatic alert so that whenever a veteran is in touch with any of these services, an alert would show if the last screening happened over a year ago. 

People identified as at risk could be then supported to resolve their housing problems through the HUD-VASH programme which pairs a Housing Choice Voucher (a subsidy towards housing costs, similar to Housing Benefit) and additional rental assistance, case management and supportive services. These services are designed to help veterans at risk of homelessness and their families to obtain permanent housing and access the health care, mental health treatment, and other support necessary to help them improve their quality of life and maintain housing over time.

You can see why Margot was excited about this. 

1. A universal, person-centred solution

Humans are not great at asking for help: they might not be aware of the help available to them or they might hesitate to raise their hand when in need (e.g. due to stigma or not wanting to burden others, among other things). In those cases, why not ask everyone?

2. Automatic reminders

The GP (or any other staff that might be in contact with people) doesn’t need to do the thinking - just the asking. This required some wizardry from IT technicians to show the reminders, but certainly a worthy challenge to take on. 

3. A system everyone interacts with

A twisted ankle, a rash, allergies, a small cut, ear pain, you name it … almost everyone is in touch with at least one health-related service in the space of a year. Interestingly, the fact that VHA offers multiple services under one roof and a unified IT system certainly made things easier. 

4. Simple, and short questions 

We know primary care providers are time-poor. So, any questions need to be kept to a minimum and very short. Whilst we can always be noodling over the precise language used for these questions, simplicity is key: Are you worried about losing your housing in the next two months? ‍

5. A clear offer of support 

I wouldn’t want to ask an uncomfortable question unless I knew I could help. These practitioners probably feel the same. Luckily, the HUD-VASH programme can do exactly that: offering to cover part of the housing costs alongside a range of other support to connect people to the services they need.

How could this be adapted in the UK?

The UK has some of the strongest housing legislation in the world, including England’s ‘Duty to Refer’ or Scotland’s plan to introduce an ‘Ask and Act’ duty as part of the new Housing (Scotland)  Bill. Whilst different, they share a similar spirit: ensuring primary care providers and social services play a role in identifying people who are at risk of homelessness and doing something about it.

A solution like this would go a long way in helping realise the ambition in those laws and drive prevention upstream.

Setting universal, regular reminders is certainly within reach for our ingenious engineers, and asking two short questions is certainly within the timeframes for the appointments of our primary care practitioners. 

Even if our National Health Service might grapple with technology systems that are more fragmented than those of the VHA in the US, there is still potentially a lot of value in introducing these questions in key parts of the system. These include 1) services that people interact with regularly, such as GPs practices, and 2) services that people interact with after an event that could ‘trigger’ an experience of homelessness, such as approaching JobCentre+ after losing one’s job or receiving welfare benefits. 

We could start with small steps. Why not introduce a pilot in one part of our health system, in a small number of areas, with a rigorous independent evaluation alongside? Then we would have evidence of whether primary care can indeed be used to prevent homelessness, rather than respond after the event.

• Guillermo Rodriguez-Guzman is Director of Evidence and Data at the Centre for Homelessness Impact

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