Introduction

Homelessness is both a consequence and a cause of poverty and social and health inequality. It is also, in many cases, a ‘late marker’ of severe and complex disadvantage that can be identified across the life course of individuals (McDonagh, 2011). Poverty is a pervasive factor for those experiencing, and at risk of, homelessness, and with homelessness comes an increased risk of excess mortality. In Scotland, homeless people in Glasgow are 4.5 times more likely to die than their housed peers (Morrison, 2009). What, then, is the role of the National Health Service (NHS) and public services in preventing the severe health and social impacts of homelessness? This chapter reviews the opportunities to improve the health of homeless people and the challenge for the NHS, working with its partners, to play a full role in the prevention of homelessness. Through a better understanding of the diverse causes of homelessness and routes into and out of homelessness, public services can lead a collaborative approach to creating the right conditions for people to flourish. This can be summed up by the mnemonic we call ‘the 5Rs’, highlighting the individual and interdependent importance of ‘Rafters’, ‘Relationships’, ‘Resources’, ‘Restoration’ and, ultimately, ‘Resilience’ in the prevention and mitigation of homelessness. However, first, let us be reminded why homelessness is a public health and health equity issue.

Health and homelessness

Homeless people are not enjoying the right to the highest attainable standard of health, a right recognised within the European Convention on Economic, Social and Cultural Rights (Office of the High Commissioner for Human Rights, 2008). The right to health should be equally available, accessible, acceptable and of good quality to people experiencing homelessness. However, evidence demonstrates that homeless people experience poorer physical and mental health than the general population (Scottish Executive, 2005; St Mungo’s, 2013; Homeless Link, 2014).

Homeless people have a much higher risk of death from a range of causes than the general population (Morrison, 2009). Many of the health conditions that homeless people develop in their 40s and 50s are more commonly seen in people decades older (Crisis, 2011). In 2013/14, the average age of death for a Crisis service user in Edinburgh was 36 years.