Somerset Council: A specialist outreach healthcare service for people experiencing homelessness

People experiencing homelessness often suffer from multiple disadvantage, with a combination of problems such as substance misuse, contact with the criminal justice system and mental ill-health. Somerset Council and its NHS partners have successfully reframed their approach to homeless health, using insight-driven service design to deliver support that makes a real difference to the lives of vulnerable people. 

Somerset is a largely rural county, which in common with many places has a housing system under strain. Rough sleeping numbers are relatively high. In October 2024, Somerset Council identified 189 rough sleepers, with 58 people found to be sleeping rough on a single night. The issue is not restricted to urban areas – in March 2024, 25 per cent of Somerset’s rough sleepers were in rural areas. 

Analysis of local data has shown:

• 94 per cent of people sleeping rough were known to have multiple needs
• 87 per cent were known to have mental health needs
• 98 per cent had a physical health condition or disability
• 13 per cent presented as neurodivergent. 

Delivery partners in Somerset, led by the council and NHS, recognise homelessness as a health and wellbeing issue. For the past few years, they have pursued a tailored approach to delivering homeless and inclusion health. 

In October 2020, Somerset secured Health Equality Partnerships Programme funding to deliver a homelessness healthcare service pilot. It aimed to reach those who find it hardest to access treatment, recognising the difficulties they face and their increased risk of poor health and wellbeing. High-quality care would be delivered in a safe, sustainable, effective and person-centred manner, in the most appropriate setting for an individual. 

The pilot used a small team of outreach nursing staff linked with existing GP provision. It was expected to increase the uptake of preventative healthcare (wound dressing, infection control, testing and screening), increase the number of people receiving the correct care for their needs, and reduce unplanned or emergency admissions. 

Since 2020, the pilot has developed into a team of 15 nursing staff together with a county-wide outreach GP offer, delivering a comprehensive outreach homeless healthcare service. 

In 2024, using data from across the system, Somerset’s public health team began to evaluate this approach. They found significant impact in areas including visibility in data, appointments attended, limb and wound care and mental health. 

Between January 2020 and September 2024, people in Somerset experiencing homelessness attended a total of 28,888 outpatient appointments, 35 per cent of which were delivered by the specialist homeless healthcare service. 

Visibility in data

People who are socially excluded are more likely to be invisible in health datasets. Due to improved coding and the introduction of alerts on patient records, Somerset now has good visibility of this cohort within their data. 

It is increasingly possible for the NHS to identify those experiencing homelessness. For example, between January 2020 and October 2024, approximately 1,500 homeless people in Somerset accessed NHS services. 

Appointments attended 

The NHS identifies people in the most deprived 20 per cent of the national population as most likely to miss appointments. Prior to the specialist service, about 40 per cent of NHS appointments in Somerset for people identified as homeless were ‘DNA’ (did not attend). 

The most recent data showed that this population group were now more likely to attend appointments than the general population. With the support of the specialist outreach team, homeless patients in Somerset now attend approximately 82 per cent of appointments, compared with 77 per cent for the rest of the population. 

Limb and wound care 

Poor wound management, limb and foot health is common among people experiencing homelessness and can result in distress, anxiety and shame. 

In the first four years of the homeless outreach service, there were almost 400 specialist appointments where limb or wound care activity took place. Service user interviews found that at least 30 per cent of patients had previously been anxious about losing a limb. There have been no amputations involving this patient group since the service began. 

Service users have spoken of the impact of the specialist service on their wider wellbeing. One summed up what it meant to him: “Being on and off the streets my legs were getting worse. After using the nursing service for about a year, left leg fully healed now and right leg on the mend. This has been a life saver – I was having suicidal thoughts.” He said the service had made a huge difference. “I'm a lot happier about myself, I'm walking a lot better…my health is better, I’m looking healthier.” 

Mental health 

Local research showed that mental health was the most identified support need in the homeless population. In 2022, delivery partners successfully bid for funding to provide a specialist rough sleeping mental health service. Trusted relationships with the homeless nursing service have helped clients to attend mental health appointments and remain engaged. 

This is evidenced by data which suggests a correlation between the start of the homeless health approach and a significant rise in mental health appointments attended. Patients are increasingly being referred to a greater range of services, suggesting a better understanding of patient need. 

Drug and alcohol outreach 

Somerset Council is responsible for delivering on the MHCLG Rough Sleeping Drug and Alcohol Treatment Grant. Using its funding for 2022-25, Somerset implemented evidence-based drug and alcohol treatment and wrap-around support for people sleeping rough or at risk of it. This is delivered through a dedicated team including a team leader and nurse medical practitioner. 

They deliver an assertive outreach model of care and work closely with the existing homeless health and council rough sleeper teams. Community-based interventions and clinical appointments are offered, along with delivery of a proactive, recovery-orientated system of care. Other support includes opiate substitution therapy, needle exchange and naloxone distribution. 

However, the short-term nature of this grant has had an impact on what the team can achieve. Annual funding arrangements have been a barrier to attracting and retaining staff. 

Somerset’s homelessness healthcare service has been recognised by national award schemes, including:

• winner of the 2023 NHS Parliamentary Awards ‘Health Equality Award’
• finalist in the 2022 Royal Society for Public Health ‘Health & Wellbeing Awards’.

Andy Lloyd, Health Improvement Manager for Wider Determinants, said: “While short-term cost benefits are hard to demonstrate, Somerset is successfully delivering a trauma informed service to a population that the system has previously failed.”

Somerset Integrated Care Service (ICS) recognises that the service adds value and high-quality provision, and is working to resolve the current mix of recurrent and non-recurrent funding – which would enable development of a sustainable model for future commissioning.

Andy Lloyd said: “We are confident that with secure funding it will be possible to develop the existing offer into a long-term service providing accessible specialist health outreach services for inclusion health groups across Somerset. 

“This inclusion health outreach service would be embedded in the wider Somerset health offer, delivering on the aspirations for action on inclusion health.”