Delivering primary health care to homeless people: an evaluation of the integration, effectiveness and costs of different models

Primary health care for homeless people is delivered in various ways: health centres specifically for homeless people; mobile teams in homeless services such as hostels; GP practices with special services for homeless people; and generic GP practices that provide ‘usual care’ to homeless people. There is no evidence, however, about which schemes are more effective in addressing homeless people’s health needs. This study aims to evaluate the effectiveness and cost-effectiveness of these different models, with special reference to their integration with other services and how this impacts on a range of health, social and economic outcomes. The objectives are: 1. To identify the extent of provision of specialist primary health care services for homeless people in England, and the types of models that are found in different NHS Area Teams and in areas with different population sizes. 2. To examine the integration of the primary health care services with other services, particularly primary dental care, mental health, secondary health, substance misuse, homelessness sector, housing and social care. 3. To examine the effectiveness of the different models in engaging homeless people in health screening, in responding to their health and social care needs, and in providing continuity of care for health problems including long term conditions. 4. To evaluate over time the impact of the different models on service-users’ health and well-being, and their utilisation of other health and social care services including dental, emergency and secondary care. 5. To investigate the resource implications and costs of delivering services for the various models. 6. To compare the various models across a range of outcomes, reflecting service-user and NHS perspectives, using a cost-consequences framework. 7. To provide evidence for local commissioners of NHS services and service proivders regarding cost effective organisation and delivery of primary health care to homeless people. A mapping exercise will be undertaken to identify the location of specialist homeless health services in England and the services they provide. Eight case study sites (CSS) that represent the four models (described above) will then be evaluated to assess their effectiveness in providing care and treatment to homeless people. A case study design based on the principles of ‘realist evaluation’ (context + mechanism = outcome) will examine the effectiveness of the different models in terms of ‘what works, for whom, how and in what circumstances?’ The primary outcome is the engagement of homeless people in health screening, and this will be measured using six ‘Health Screening Indicators’. One of the secondary outcomes is continuity of care and outcomes over 12 months for five ‘Specific Health Conditions’ (hypertension; chronic chest disease;depression; alcohol related problems; drug problems). Other secondary outcomes are: oral health status and receipt of dental care; self-ratings of general health status and well-being; satisfaction with the CSS; and utilisation of health and social care services and costs. Differences in outcomes between models will be investigated in relation to the particular contexts and mechanisms of care, and the resource implications and costs. Outputs include a Guide on the integration, effectiveness and cost-effectiveness of the various models, targeted at health and social care service-commissioners, managers and practitioners.