Homelessness: health

Support needs of applicants

Data on this page are from the Scottish Government publication Homelessness in Scotland 2020/21 unless stated otherwise. In 2020-21, 51% of applicants to local authorities who were assessed as homeless or threatened with homelessness had at least one support need, defined as a mental health problem, drug or alcohol dependency, physical or learning disability, medical condition, or difficulties with skills of independent living (Scottish Government 2021; Table 19) (664KB). The proportion remained relatively constant at around 33%-34% between 2007/08 and 2013/14 but has risen since 2014/15. This trend may reflect changes in the population applying for statutory homelessness support following the introduction of the preventative Housing Options approach.

For many individuals, these support needs were closely linked to their housing situation. The reasons given for failing to maintain accommodation prior to application (table 6 in Scottish Government 2021) included the following:

• Poor mental health, cited by 24% of applicants
• Lack of support from family or friends, cited by 25%. This is consistent with a study from 2015, which found that less than a quarter of homeless people felt they had someone they could call on in an emergency (Sanders and Brown 2015).
• Drug or alcohol dependency, cited by 13%
• Physical health reasons, cited by 8%.

Note that these categories are not mutually exclusive, since any one applicant may have multiple support needs.

Source: Table 19 in in Homelessness in Scotland 2020/21

Around 5% of people assessed as homeless had previously been assessed as homeless by their local authority within the last 12 months.

Health of homeless people

A recent data linkage project has provided an overview of healthcare utilisation and mortality among people applying for statutory homelessness support in Scotland (Waugh et al 2018). The full report can be found on the Scottish Government webpage on 'Health and Homelessness in Scotland'. 

In summary, this project compared 435,853 people who had been in households assessed as homeless or threatened with homelessness between 2001 and 2016 to two age- and sex-matched controls - one from the 20% least deprived areas of Scotland, and one from the 20% most deprived. It found that:

• An estimated 8% of the Scottish population as at June 2015 had experienced homelessness at some point in their life
• Those with experience of homelessness had a 1.9 times higher rate of A&E attendance than their peers in the most deprived areas, and 3.5 higher rate than their peers in the least deprived areas
• Those with experience of homelessness had a 1.7 times higher rate of acute hospital admission than their peers in the most deprived areas, and 3.1 higher rate than their peers in the least deprived areas
• Those with experience of homelessness had a 4.9 times higher rate of admission to mental health specialties than their peers in the most deprived areas, and 20.5 higher rate than their peers in the least deprived areas
• Interactions with healthcare services increased in the years prior to the point of homelessness assessment and peaked around that time, especially (though not exclusively) for healthcare activity relating to mental health, drugs, and alcohol

This is consistent with previous work from Fife and from North Lanarkshire and with surveys of the homeless population undertaken in Scotland and in England.

With regard to oral health, the Homeless Oral Health Survey carried out in Scotland between 2008 and 2009 (Smile4life 2011) found that:

• 85% of the sample (725 respondents) were current smokers and 31% (254) drank alcohol at least once per day
• 29% (236) were current drug users at the time of the survey, of whom the majority (81%; 191 respondents) were injecting drugs. A total of 68% (580) of survey respondents had used street drugs at some time.
• 58% (495) of respondents had symptoms suggestive of depression, based on the validated screening tool CES-D. 35% of prescribed medication among the sample was for mental ill-health.
• The self-reported prevalence of common physical health conditions was 13% for high blood pressure; 7% for epilepsy; 7% for heart disease; and 3% for diabetes.
• 98% had experience of dental decay. Of these, 52% had extracted teeth, 27% had decayed teeth and 22% had filled teeth. Up to 4% had suspicious oral lesions which required referral.

In England, a series of surveys with 2,590 homeless people accessing services found that 73% reported a physical health problem, and 80% a mental health problem (Homeless Link 2014). 90% of homeless people surveyed in that study reported being either temporarily or permanently registered with a GP: this figure is higher than found in previous, smaller surveys (Crisis 2005).

Relationship between homelessness and drug use

Research carried out in England has found considerable overlap between those using homeless services and those using substance misuse and criminal justice services (Bramley et al 2015). This is substantiated by survey data from a number of other sources:

• The Smile4Life survery reported that 68% of participants said they had used street drugs at some time. Of all respondents, 24% were injecting drugs at the time of the survey (Smile4Life 2011).
• Four out of five people start using at least one new drug after becoming homeless (Fountain and Howes 2002).
• 12% of people accessing specialist drug treatment in Scotland in 2017/18 were recorded as being homeless (Scottish Drugs Misuse Database Dashboard 2018). This is probably an under-estimate, as it may not include less severe forms of housing insecurity (such as ‘sofa-surfing’ with friends and family) and levels of missing data were relatively high.

However, the national data linkage project described above found that 51% of the people assessed as homeless or threatened with homelessness in Scotland between 2001 and 2016 had no evidence of health conditions relating to drugs, alcohol, or mental health (Waugh et al 2018). This may reflect the broader cross-section of the homeless population represented in local authority data compared to people recruited from homeless services, but may also be influenced by the inclusion of children in the dataset (21% were <16 years of age) or incomplete ascertainment of these issues from data on hospitalisations, prescribing, and interactions with community addiction teams). 

Mortality rates

Homeless people are at much greater risk of premature death than the general population. The national data linkage study described above found that people assessed as homeless by local authorities had a mortality rate 2.1 times higher than people of the same age and sex in the most deprived 20% of areas of Scotland, and 5.3 times higher than those in the least deprived 20% of areas (Waugh et al 2018). This is largely consistent with a previous study of more than 6,000 adults seeking homelessness support in Glasgow in the year 2000 (Morrison 2009) and a more recent study from England (Thomas 2012). The former also attempted to take into account existing illness using hospitalisations as a proxy measure, finding that homelessness was still associated with 1.6 times the risk of death. 

Data on cause-specific mortality from are shown in the table below. This compares the number of deaths among a cohort of people assessed as homeless by local authorities at some point between 2001 and 2016 (ever-homeless cohort; EHC) with the number of deaths among two comparison cohorts matched on age and sex: one drawn from the most deprived areas of Scotland (most deprived cohort; MDC) and one drawn from the least deprived areas of Scotland (least deprived cohort; LDC). 

Table 2: Ratio of deaths among an ever-homeless cohort (EHC) compared to two non-homeless cohorts (most deprived, MDC, and least deprived, LDC) in Scotland between 2001 and 2016, by selected causes of death and gender (Source: Waugh et al 2018)

(Ratio for assaults for the EHC:LDC comparison not calculated, due to small numbers and therefore suppressed cell counts in the LDC)