The efforts to get homeless people into emergency accommodation must not be wasted, as DDN reports. Homelessness has been long been regarded as complex, difficult, inevitable – and easy to ignore. The substance misuse sector has struggled to maintain outreach services in the face of disappearing funding and has tried to create care pathways with varying levels of success. A conference on homelessness and addiction last year (DDN February 2019, page 16), raised many questions – why don’t we take notice of the evidence to stop ‘thoroughly preventable’ drug poisoning deaths with simple and cost-effective harm reduction measures such as naloxone? Why are we still discharging from hospital onto the street? Why are care pathways so fragmented? Why aren’t we creating routes out of dependent drinking? Why is there no help for smokers? While COVID-19 has thrown everyone’s life into disarray, there is one group of people who might actually benefit as a result. Things couldn’t have seemed much worse for the street homeless population when housing minister Robert Jenrick announced £105m to provide interim housing to take thousands of rough sleepers off the street during the pandemic, including £16m for people in emergency accommodation to access specialist help for substance misuse. The money is also aimed at helping rough sleepers to secure their own tenancies, as part of the government’s commitment to ‘end rough sleeping for good’. ‘I am clear that there can now be no going back to the streets as people begin to move on from the emergency accommodation...’ Dame Louise Casey Dame Louise Casey, chair of the COVID-19 Rough Sleeping Taskforce called the ‘Everyone in’ initiative an ‘extraordinary effort’ and an ‘extraordinary opportunity’ to turn lives around if we get the next steps right. ‘I am clear that there can now be no going back to the streets as people begin to move on from the emergency accommodation that has been put in place,’ she said. In London the initiative has taken shape through the Homeless Drug and Alcohol Service (HDAS), commissioned by Public Health England and the Greater London Authority. The ’pan-London system’ involves the South London and Maudsley (SLAM) and Central North West London (CNWL) NHS Trusts, working with Change Grow Live and Turning Point (who coordinate logistics), We Are With You and Phoenix Futures. A 24-hour phone line is manned by recovery workers from the pool of organisations involved. Dr Emmert Roberts is clinical lead for HDAS and told DDN how the service was commissioned for three months in March, extended for another three, and is looking likely to carry on for longer. A ‘hodge podge of a system’ at the beginning, it has had to come a long way in a short time, he says. ‘It was chaos – getting people off the streets as quickly as you can. Once they were off the street, we could do more stuff.’ ‘We’ve been working with local hotels to provide education and training to minimise risks relating to alcohol withdrawal, naloxone training and how to use e-cigarettes.’ Dr Emmert Roberts The first challenge was to secure rooms in hotels, and this involved splitting the intake into three distinct cohorts. People with symptoms or who tested positive for COVID-19 needed to be isolated in ‘COVID care’ rooms. The next category was ‘COVID protect’ for those who tested negative but who had medical vulnerabilities. Everybody else was assigned a ‘COVID prevent’ room. Once this was achieved – which Roberts admits involved ‘abject chaos’ at first, because of the speed everything had to be put in place – there was a chance to tackle ‘the whole suite of drug and alcohol issues’. Anyone could call anytime from the hotels to ask for advice, and many of the calls related to alcohol withdrawals and prescribing issues. Harm reduction was a high priority, so naloxone was introduced and people were given a workbook of psychosocial interventions to complete in their hotel rooms as a way of bridging the gap left by lack of face-to-face contact. One of the big initiatives has been the opportunity to tackle smoking, with 2,000 e-cigarettes distributed alongside other nicotine replacements – a window to reduce tobacco harm as well as enabling people to stay in their rooms to avoid transmitting the virus. ‘Harm reduction initiatives can really work well with this population, as well as preventing COVID spread,’ says Roberts. ‘It showed that there is willingness among people to reduce their tobacco consumption.’ He hopes that funding being made available for a pan-London coordinator for tobacco harm reduction will improve access for people who are rough sleepers and help them to reduce their tobacco use long term. As Roberts stresses, each part of the initiative has been a learning curve, so supporting the hotels to house their guests safely has been paramount. ‘We’ve been working with local hotels to provide education and training to minimise risks relating to alcohol withdrawal, naloxone training and how to use e-cigarettes,’ he says. The other part of the project that needed to be bedded in fast was the strategic working between the partners. Where there were normally ‘turf wars’ between services there had to be a change in approach, so that people could stay with their original treatment providers when they moved location to prevent them from dropping out. The proactive partnership culture was also helpful for feeding into health alliances – the GPs and nurses working in the hotels, as well as the homeless charities steered by St Mungos. Much of the time and energy has been taken up through facilitating new referrals into treatment, says Roberts, and ‘a lot were people who have never been in the treatment services before or are generally hard to reach. We facilitate their involvement with local services and prevent any bad practice happening in the hotels, including dodgy detoxes and people not understanding about substance misuse.’ While ‘lots of things have gone well’, the team is bracing itself for an ‘uptick in homelessness’. ‘I don’t know what the future holds and we’re not out of the crisis yet so it’s very difficult to know what we’re going to return to or what the new normal is going to be,’ says Roberts. ‘I would hope that we’ve learned some lessons about how we treat homeless people within our services – but given that we don’t know what the lie of the land will be over the next few months, it’s hard to know if this will have any lasting impact.’ Getting people off the streets and into a safe place had to be done very quickly and in an emergency situation, so he is frank about it being ‘chaos’ at the beginning. But through bringing the health teams, homeless charities and substance misuse teams and hotel staff together, they have been able to help with all kinds of issues, including immigration and benefits. Each of the hotels in London has a resident homelessness sector organisation – mainly St Mungos – running the day-to-day life, with HDAS being the central coordinator for the substance misuse sector. ‘It’s been challenging and chaotic, but the fact we’ve been able to come together and have city-wide input has been very useful,’ says Roberts. ‘The government has agreed to try to end homelessness by the end of parliament in 2024 and the work we’ve done will hopefully help that.’ He is painfully aware that ‘the state of funding in the entire sector is quite dire at the moment, with over £250m of disinvestment over the past five years’, and that ‘this isn’t going to rectify that’. The abolition of PHE feels like another hammer blow. But there’s no denying that being plunged into this emergency situation has already had some amazing results for individuals who were invisible before COVID turned our world upside down. ‘This isn’t going to be a substitute for the overall disinvestment,’ says Roberts. ‘But it might go some way towards improving access for this particular population.’ And if you’re one of the 5,000 people in London or 15,000 people nationally who have entered a housing support scheme for the first time, that could feel like a wide-open door.