Alcohol problems, mental health problems, homelessness: all mutually reinforcing and hard to disentangle, they can create a vicious cycle from which it is hard to escape. Yet, too often, the current system of services which should be helping people, instead pushes them into silos. Services are designed and funded as if people fit into one box, rather than reflecting the reality that people’s problems are complex and interwoven and cannot be addressed one by one.
Drug- and alcohol-related causes are the biggest killer of people sleeping rough. In 2018, they accounted for more than half of all deaths. And data from the Combined Homelessness and Information Network (a database which records information on people sleeping rough in London, also known as CHAIN) shows that in 2018, seven in ten people sleeping rough with a recorded mental health problem in London also had a recorded drug or alcohol problem. Both poor mental health and alcohol problems frequently start before someone sleeps rough for the first time. But then people often use alcohol as respite, as a way to escape the horrendous physical reality or mental anguish and loneliness of sleeping on the streets. Sleeping rough and alcohol both have a corrosive impact on mental health, which compounds people’s problems and pushes them deeper into dependency and isolation.
This year, St Mungo’s published a report on people sleeping rough with drug and alcohol problems. We carried out interviews with our clients with lived experience of the issue. Many of them told us about the vicious cycle they had found themselves in, which they struggled to escape from. In many cases, at the root of these problems is complex trauma resulting from adverse childhood experiences like abuse and neglect.
Rough sleeping, alcohol problems, mental ill health: they can all be symptoms and causes of trauma, poverty and social exclusion. This can have a significant impact on people’s ability to seek out and accept care and support, which in turn compounds their problems. Crucially, we should not accept such problems being dismissed as ‘lifestyle choices’. It's essential to understand the currents of trauma and social exclusion which run underneath them to develop effective responses.
Our research provided further evidence that mental ill health, sleeping rough and drug and alcohol problems are strongly intertwined, both in terms of their impact on one another, but also in terms of their roots and causes. But this is just not reflected in the services supposedly set up to help.
Services currently try to tackle a single condition and direct a person down what they think is an appropriate ‘pathway’. There is little room for acknowledging other problems along the way and working together jointly on these issues. Siloed working and financial pressure can create perverse incentives to reduce provision and push people onto other service caseloads. It can result in barriers being erected and access criteria made stricter. It is far too easy for people to fall between the gaps that are left.
Now, there's a few ways to go about changing the system. One is simply that the system needs funding. Research done by WPI Economics and St Mungo’s has shown that £1 billion less is being spent per year on homelessness services (which help many people with complex needs, including drug and alcohol problems, gain and retain accommodation) compared to a decade ago. We’re calling for that to be reinstated. Without adequate funding, it’s more likely that services under huge pressure with limited resources will try and restrict the number of people who are eligible and they will find themselves pushed between services.
The other is about the way that the systems are designed. At a policy level, this means taking a whole system approach, joining up support rather than forcing people to fit into boxes. Pioneering work from the likes of Making Every Adult Matter (MEAM) and Fulfilling Lives have demonstrated the value of systems change in practice.
Some of the changes we can make to increase integration include joint funding and commissioning by local authorities and Clinical Commissioning Groups. A good example is St Mungo’s Assertive Contact and Engagement (ACE) service in Bristol which works to improve mental health support for people with complex and multiple needs who find it difficult to access mainstream services, including people sleeping rough and at risk of homelessness. The service is jointly funded and brings together mental health professionals and homelessness teams to reach some of those who are most vulnerable and isolated.
This kind of approach can make a major difference in helping people to rebuild their lives. Alcohol Awareness Week is a good moment for us all to remember the best approaches treat the whole person, rather than looking for divisible parts.
