Addressing mental health and substance misuse amongst rough sleepers: how can services be improved?

Published 07/02/2020   |   Last Updated 27/05/2021   |   Reading Time minutes

Homelessness and rough sleeping remain high on the political agenda in Cardiff Bay. With a new homelessness strategy launched late last year, an expert Homelessness Action Group making recommendations to the Welsh Government, and research into the continued use of priority need to be published shortly, there appears to be growing momentum behind calls for a more effective approach to preventing and tackling homelessness. The new strategy says, where it can’t be prevented, homelessness should be “rare, brief and non-recurrent”. Few would argue with those sentiments, but there is significant work to be done to make that a reality. New data released this week shows an increase in the number of people sleeping rough across Wales in October and November 2019 when compared with the same period in 2018.

As part of its on-going scrutiny of rough sleeping policy, the Assembly’s Equality, Local Government and Communities Committee held an evidence session in November 2019 which explored the support available to rough sleepers with co-occurring mental health and substance misuse problems.

During the session, the Committee explored concerns about the availability of integrated support for rough sleepers with co-occurring disorders. It heard from a range of expert stakeholders familiar with homelessness, mental health and substance misuse services.

In December 2019, the Committee published a short report (PDF, 194KB) based on the evidence it heard and made nine recommendations to the Welsh Government. On Wednesday, 12 February 2020, the Assembly will have the opportunity to debate the issues raised in that report, its recommendations and the Welsh Government’s response

Integrated services and improved commissioning

The Committee found limited evidence of integrated mental health and substance misuse services for rough sleepers with co-occurring disorders. While there were examples of best practice in integration such as the Community Care Collaborative, a social enterprise in Wrexham, these appeared to be the exception rather than the norm. The Committee heard criticism of the commissioning process for services and was told by some witnesses that they felt the commissioning system neither encouraged learning or best practice amongst service providers. The Committee also highlighted concerns about the culture and leadership of some organisations and that was a barrier to delivering integrated services.

Services that meet the needs of rough sleepers

The Committee’s report notes that two in five deaths of homeless people are linked to drug poisoning. It heard concerns that not enough is being done to tackle this; existing services are not meeting the needs of many rough sleepers and, in some cases, rough sleepers were choosing the streets over accessing services. Some witnesses called for radical action, such as the provision of injecting rooms (safe, hygienic places where illegal drugs can be taken) and changes to the law that would enable people receiving support to use drugs within their accommodation without putting the landlord at risk of being prosecuted. Witnesses told the Committee that many rough sleepers live chaotic lifestyles, and a “no wrong door approach” where people are helped to navigate the range of health and support services regardless of who they contact first would allow easier access to services. The Committee called for the Welsh Government to take more steps to support harm reduction initiatives like injecting rooms and to clarify whether the current devolution settlement would allow this to happen in Wales.

The Committee’s recommendation in this area was welcomed by the North Wales Police and Crime Commissioner, Arfon Jones. In a January 2020 letter (PDF, 1MB) to the Committee he commented that:

The level of drug related deaths have increased in recent years and as demonstrated within the report two out of five deaths of rough sleepers were drug related in 2018. An Enhanced Harm Reduction Centre would give rough sleepers a safe and clean environment to take substances but also to have access to health services, drug testing services and housing services. Despite the current legislation around Enhanced Harm Reduction Centres their success in countries around [the world] to reduce drug related deaths far outweigh the legal concerns.

Better training, better services

The Committee’s report highlighted the “enthusiasm, passion and vision” of the witnesses it took evidence from. It called for this “energy to be harnessed” to improve service delivery and design. What the Committee heard was happening in Wrexham and in Housing First projects across Wales could provide a model for the wider sector as it shows integrated services can be delivered.

The Committee found that there were not enough staff who have the right training and expertise to deal with the complexities of rough sleepers with co-occurring disorders. It called for the Welsh Government to review the training that is available to people who support rough sleepers. It also highlighted the added challenge of supporting rough sleepers who may also have neuro-diverse conditions like autism or ADHD. It called for the Welsh Government to carry out further research into the barriers faced by this group.

The Welsh Government’s response

The Welsh Government responded (PDF, 493KB) to the Committee’s report on 5 February and accepted all of the recommendations either in full or in principle.

The response highlights some of the work the Government is already undertaking, including:

  • actions in the Rough Sleeping Action Plan to develop joint working protocols for those with co-occurring disorders;
  • implementation of the Housing Support Grant to encourage the joint commissioning of services, and
  • specific actions in both the Substance Misuse Delivery Plan 2019 to 2022 and the Together for Mental Health Delivery Plan 2019 to 2022.

There is also a focus on workforce development to improve the training and skills of those working in the sector.

The Committee’s recommendation relating to injecting rooms, also known as Enhanced Harm Reduction Centres (EHRCs), was accepted in principle. But the Welsh Government’s response highlighted “significant concerns with the compatibility of Enhanced Harm Reduction Centres with current criminal law”. It noted a 2017 report by the Advisory Panel on Substance Misuse, which concluded that it ”…could not, based on the evidence available, currently recommend that EHRCs are implemented in Wales”.

What next?

Since the Committee published its Life on the Streets: Preventing and Tackling Rough Sleeping in Wales (PDF, 918KB) report in April 2018 it has regularly returned to this issue. It will do so again in April 2020 when the Minister for Housing and Local Government and the Minister for Health and Social Services will both give evidence. Committee Members are likely to follow-up many of the issues raised in the Committee’s most recent report, as well as assessing the effectiveness of services provided to rough sleepers over the current winter period.

With some key developments expected in the next few months, including another report from the Homelessness Action Group and an action plan to accompany the new homelessness strategy, Assembly Members are likely to take a close interest in developments as 2020 progresses.

Article by Jonathan Baxter, Senedd Research, National Assembly for Wales