A report on: Homelessness- Urban Health Issue – Southwark (London)

1. Introduction
2. About urban health
3. Types of homelessness
4. Homelessness: urban health issue in London and Southwark
5. About Southwark
6. Top reasons for homelessness in Southwark
7. Consequences of homelessness
8. Epidemiological data
9. Strategies for addressing this urban health problem in Southwark
10. Strategies adopted to resolve this problem
11. Services at Southwark
12. Conclusions

Homelessness- Urban Health Issue – Southwark (London)

 Introduction

Latest conjectures from United Nations Organizations preview that by 2025 more than 60% population will be living in cities. Most of these people are found to be living in megacities. Right now, there are about 20 mega cities in various countries. Populations always try to migrate towards megacities, in search of better livelihood. In such a case, urban health issues become a major concern.

About urban health:

The best method to calculate urban health is to calculate the mortality rate due to all reasons in a particular area. The greater the increase in mortality rate, the greater is the decline in the overall urban health. Another method is to calculate the number of potential years lost by a population; this is done by calculating the number of people who died at the age of 65, and the age at which they died (A). Subtracting the age at which they died at the standard age of the elderly population; (65-A). This will give an overall estimate of the number of potential years lost by the individual. Calculating these values on the population basis is also considered an important measure to assess the urban health of a population.

Looking at worldwide data, the urban health of almost all megacities of the world has declined in the previous decades; with the highest decline in the past five years. Various reasons for a decline in urban health are overall population increase, lack of education, a decline in food quality, inadequate water supply, sanitation, health care services, and housing etc. Among the many reasons stated above, any one factor will automatically cause the rest of the factors to increase. For e.g. if there is a hike in population, it will automatically lead to a decline in health care services, food quality, education, and homelessness etc.

Among all the urban health issues, one of the most talked of is homelessness, basically because this health issue is increasing at an alarming rate.

Homelessness refers to a condition with people who do not have a permanent dwelling. Homeless people are unable to maintain a regular, safe and clean dwelling place for themselves. Such people have to take night-time shelter in homeless shelter houses (made by the government), warming homes, women’s shelter (only for women), vehicles, tents, cardboard boxes etc. 2005 estimates show that one in every 65 people in the world is homeless. This is not at all a sign of mentally and physically healthy society.

Types of homelessness

There are basically three categories which come under homelessness:

• Chronic homelessness: This type of homelessness lasts for more than one year and is experienced by an extremely poor section of society, which is totally unable to sustain a proper livelihood. Such people are forced to live on roads and indulge in beggary.
• Intermittent homelessness: This type of homelessness refers to repeated incidents of homelessness, which are not continued at a stretch. For e.g. persons in jails, treatment programs, and hospitals are under shelter for some time and become homeless for some other time interval; this cycle continues at repeated intervals.
• Transitional homelessness: This is also known as crisis homelessness. Such individuals experience homelessness for a very short period of time due to some unexpected crisis like divorce, loss of job, eviction etc.

Homelessness: urban health issue in London and Southwark

Although this problem is not new to London, still, there is a need to address this problem in a different way, due to ever increasing number of homeless people in London. In the early 20^th century, homeless people were those who used to reside in dormitories. In 1903, there were about 30,000 people living in dormitories. As times changed, the exact definition of homeless changed, and old age homes also came under the heading “homeless”.

Latest estimates stated that more than 7,000 people slept in open, on streets and roads of London in the year 2014-15. This was a drastic hike of over 16% in comparison to the previous year. The most important point to note is that these estimates have completely changed the definition of homeless person. So, currently, a homeless person is one who does not have shelter to sleep or who are compelled to “rough sleeping”.

It is notable that about 0.4 million people per night are homeless in the European Union, making a total of 4.1 million homeless people per year. Similarly, 0.6 million people per night are homeless in the USA.

About Southwark:

Southwark is small, but densely populated borough of London. Most of the population residing here is young with about 60% people of age group 32-37. There is a lot of economic inequality in this city, reasons being, the difference in education, access to employment, and housing quality. The authorities and governance of this district of London have launched regeneration programs in the past two decades for the upliftment of this borough overall. These programs further led to changes in the population structure of this area. Obviously, the drastic rise in population leads to basic problems like unemployment, poverty, inflation, and homelessness.

The present report summarizes the urban health component of Southwark, a city in London; taking homelessness as one of the major health issues. The report will contain information from reliable sources like Public Health, England, London Health Observatory, and Southwark Council etc.

Top reasons for homelessness in Southwark

The main reasons for homelessness in Southwark are:

1. A desire for independent living: In the recent years, parents, friends, and relatives are no longer willing to accommodate a particular person with them. The increasing urge for a separate living has increased the problem of homelessness in Southwark. This is the leading reason for an increase in the number of homeless people at Southwark; accounting, to about 40 to 50% rise.
2. Overcrowding: The population of Southwark has increased at the rate of 18% in the last decade, and the overall number is still increasing (about 20% in the next decade). In such a case, the demand for homes is increasing. But the city is small with an area of 28.85km². Moreover, the number of immigrants is also increasing in this small place.
3. Tenancy: Since the number of immigrants is increasing in Southwark, so the number of people residing as tenants is also increasing by leaps and bounds. In such a case, most people are living under a short-term tenancy agreement. Termination of this agreement leads to homelessness. Latest reports show that about 15% people at Southwark are homeless because of this reason.
4. Increase in rent: Obviously, if demand for rented houses increases, the rent will also increase. This will make those people homeless who are unable to afford costly homes. It is important to note that in Southwark, the number of Black and Minority Ethnic Groups is increasing in number. Naturally, these people will not be able to afford such costly housing.
5. Relationships: With the rise in divorce and separation cases, the demand for a separate household has increased. About 10% people of Southwark have become homeless because of separation from their partner.

Consequences of homelessness

Poor housing harms the mental and physical health of the general population, individual and overall health of the society. If a person is forced to live on roads, then definitely this person will feel deserted and may suffer from mental illness. Children development of such people will be undermined and will suffer from psychological distress. Also living on roads may make the general population vulnerable to many diseases. The most important consequence of homelessness is the security issue. Homeless people are totally insecure, especially females.

Homelessness has further led to a decline in sexual health and increase in sexually transmitted diseases like HIV, gonorrhea etc. in this borough. The main diseases underlying London, especially Southwark, due to homelessness are hypertension, drugs related problems, childhood obesity, sexual health problems, increase in falls (applicable to old population), physical injuries, including hip fractures, mental ill-health, social isolation and violence related health problems.

The infant mortality rate in homeless couples is also increasing at an alarming rate in Southwark, London. This has also led to an increase in overall suicide rate. The problem worsens during winters (December to March), and the number of winter deaths in Southwark always exceeds the number of deaths in other seasons. The excess winter mortality index (WMI) in Southwark was calculated on the basis of ONS (Office of National Statistics) method (details given in Epidemiological data).

Considering this problem at the individual level, newborns of homeless people suffer from low birth weight. Also, their children suffer from the high risk of tuberculosis, and vitamin D deficiency. It is important to note that poor housing conditions will also lead to absence from school (for children) and work (for their parents). This may further result in worklessness and unemployment for homeless people. Such people become a completely different section of the society and are considered low and poor. They lose their relationships overall.

Mortality data (from communicable diseases) gives a further insight of this problem on an individual level. Aging of homeless population is quite evident from the above discussion. It is natural that if a population is constantly experiencing hypertension and mental illnesses, then its aging process will be enhanced.

Pointwise summarizing the top 17 consequences of homelessness:

1. Reduction in mental and physical health.
2. Increased incidences of mental illness.
3. Psychiatric disorders.
4. Personal security related issues.
5. Increased incidences of sexually transmitted diseases like HIV.
6. Childhood and adult obesity.
7. Sexual health issues.
8. Drug abuse.
9. Increased tobacco use.
10. The increase in accident cases and unintentional injuries.
11. Social isolation.
12. An increase in infant mortality rate.
13. Excess winter mortality rate.
14. Vitamin D deficiency.
15. Low birth weight of infants.
16. Increased incidences of communicable diseases.
17. Ageing 

Epidemiological data

In 2013/14, about 600 families had been declared homeless in Southwark. Out of these, more than 60% families were headed by single females. This is a drastic increase in comparison to the data of 2010. In London, the number of rough sleepers i.e. people sleeping on the road has increased by more than 65% since 2010. This is indeed, an alarming increase.

The WMI data of Southwark, London, was calculated from 2004-2011 based on ONS method. It was found that the EWD (Excessive Winter Deaths) index rose to 30% in 2008-11 in contrast to 15% in the year 2004-07. Interestingly, this ratio is higher in age groups of above 65 years, children of age less than 2 and pregnant women. Most winter deaths are due to development respiratory disorders, heart attacks, influenza, pneumonia, and CHD (Coronary Heart Disease).

The National Health Service (NHS) hospital of London reports has analyzed that the emergency hospital admissions have increased in London. For this data, an analysis of 82 million NHS hospital records was done. From these records, the overall number of 30-day hospital re-admissions was calculated. There were about 6 million emergency 30-day re-admissions in 6 years (2004-10). Out of these 70% re-admissions were totally unpreventable; with about 20% due to chronic disease, and 19% due to accidents. This data simply states the vulnerability of homeless people to diseases and accidents on roads. A significant increase in mortality rates of homeless people is evident from the above data.

Lancet reports of 2014 state that rates of occurrence of HIV, hepatitis, and tuberculosis have become 20 times more than previous rates. The rate of tuberculosis incidence is 8% in homeless people as against 0.032% in general public. Besides this, the rate of occurrence of Hepatitis C in homeless people is 36% in comparison to the meager 2% occurrence value for the general population. Scabies prevalence rate is 56%, HIV prevalence rate is 21%, body louse prevalence rate is 22% and hepatitis B prevalence rate is 30% in comparison to less than 1% prevalence rate for all these diseases in general population.

All the above Epidemiological data given above give a careful insight of the homelessness problem in Southwark and overall London, and also explain why homelessness is an urban health issue in London.

Strategies for addressing this urban health problem in Southwark

First of all, the government of Southwark has launched homeless prevention services in the city. These services pay utmost importance to homeless people and help them provide statutory housing immediately. Care has been taken to provide housing to those people also, who are in a critical condition. Critical condition relates to those people who are living in unhealthy, filthy houses; or those living in proper houses, but their tenancy agreement is about to expire, i.e.they may become homeless in due course of time.

Second, the cost of rents can be fixed so that drastic increase in rent after the expiry of tenancy agreement does not occur. This will significantly have improved impact on mental health of those people who are constantly suffering from the fear of becoming homeless.

One more subsidiary solution to this problem is increasing in usable space in the already existing houses. One example is an introduction of studio apartments (one room house) instead of a house or apartment with many rooms. This will reduce the cost of rented houses and make more housing available.

Social care agencies should be introduced on regular basis to address the health related issues of homeless people. These agencies should regularly check the health of these people, and provide medical care for them. In this way, the overall urban health can be improved.

Strategies adopted to resolve this problem

The London Borough Council helped 3088 households to become homeless in the year 2013/14. Among these, 10% households were helped to find alternate homes for themselves. The rest of the people were made to stay in their existing homes by applying the following methods:

• Homeless prevention fund was created and their rents were paid out via these funds. About 60% people were helped through these funds.
• Housing benefit was paid by Southwark Council, based on the rent, income, savings and personal circumstances of the particular person; this prevented about 14% people from becoming homeless.
• Debt advice was provided by the council to most people who are at the risk of homelessness. About 10% people were benefited by these pieces of advice.
• Legal advice was also provided.
• Home visits were given by the council to those people who were threatened to become homeless by their relatives and friends in sharing the household.
• About 4% people were helped by sanctuary scheme measures. These measures basically include prevention of domestic violence. Reduction in domestic violence will definitely reduce the separation and divorce cases; and will thus prevent these people (especially single mothers) from becoming homeless.
• About 1% households were helped by resolving service charged arrears on rented accommodation.

Southwark Council has committed 326 million pounds from March 2010 to March 2016 (five year period) to ensure that all Southwark Council homes are warm, dry and safe.

Services at Southwark:

First of all, there is a “START” team which offers support to homeless people. It also provides support to people who are at the risk of homelessness in the near future. The support can be medical and financial.

Southwark Homelessness and Housing options services and tenacity sustainment team are at its work always. This team checks tenancy agreements of those people who are at the risk of homelessness due to increased rent. If the increase in rent is genuine, then this service pays out the extra rent from homeless prevention fund.

SLAN (Southwark legal advice network) is on its toes always for helping out homeless people. The Southwark Council has also created RSL (Registered Social Landlords) team, for prevention of homelessness.

On 1^st April 2014, a hospital discharge protocol was introduced by the Southwark Council. The basic aim of this protocol is to reduce homelessness, by connecting housing and health with social care organizations. These social care organizations also take care of the address to which the patient should be sent after discharge from the hospital. If it is found that the particular patient is homeless, then the council, along with social care organization, works at its level best to provide a referral home to this homeless patient.

The council also takes care of victims of domestic abuse; if domestic abuse is curbed down, the cases of separation will also reduce, which will further reduce the incidence of homelessness.

A licensing scheme has been introduced by the Council, which aims at giving license to private landlords. This license has been given to smaller houses with multiple occupations (HMOs). Here, people live in shared houses so that they can afford the rent of these houses. The house is split into small beds; roughly, giving it the design of a dormitory. People of this house share basic amenities like kitchen, bathroom and television room. If more than 6 people share a house, then it is known as larger HMO.

An evaluation of homelessness services has Southwark is been conducted from time to time. Latest data rated the services at 56%.

Conclusions

Southwark Council also plans to build 11,000 new affordable homes in the borough. Work is being done on an improvement of the standard of privately rented houses. Licensing and accreditations are given to those rented homes and apartments whose services related to health, cleanliness, and hygiene is up to the mark.

It also tries to create awareness among local agencies which deal with the private rental sector (PRS) regarding the methods to prevent homelessness. In a way, Southwark Council is working at its best before the development of the crisis. It ensures whether the families with temporary accommodation are getting adequate health and social care services or not. The Southwark Council also carries out surveys from time to time to find out the reasons which may result in homelessness in the near future; and works on curbing such issues in advance. The Hospital Discharge Scheme discussed in the previous section is one of the best examples of this.

Awareness among the general public regarding the protocols adopted from time to time by the Southwark Council will also reduce this problem in the near future, and the borough authorities take utmost care to create awareness among people.

Southwark has finally shown a remarkable success in helping people stay in their own homes. Still, this borough has to find out more practical ways to solve the problem of housing, mental health, population hike, and domestic abuse.

To sum up, food, clothing, and shelter are the basic rights of each and every individual. And the Southwark Council is on its toes to provide the same.

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