Integrated health and social care for people experiencing homelessness

Outcomes and learning

The care pathway has provided much needed treatment to people who found access to NHS dentistry particularly challenging. To date, over 300 individuals have benefited from the pathway. The mixed-methods evaluation has shown a high uptake of care, and a number of benefits of using the care pathway have been determined by patients and individuals supporting them. These include improved oral hygiene, enhanced nutrition, improved confidence and self-esteem, happiness, improved body image, learning to trust health professionals and getting a smile back. Outcomes often describe a catalyst for change in multiple areas of a patient's life.

Impacts were also identified at the staff level. Peninsula Dental Social Enterprise (PDSE) staff members found delivering the pathway 'very rewarding', 'humbling' and 'worthwhile'. Several reported a change in their own attitudes about homelessness.

The evaluation also enabled PDSE to identify gaps in provision and make recommendations for improvement, including working towards becoming a trauma-informed organisation. This work has led to the development of a successful model of inclusion and community engagement that supports co-production and involvement of all stakeholders in service design. It has been used to inform the development of similar pathways in other cities and settings and to improve oral healthcare and establish pathways for other vulnerable populations in the community, including asylum seekers and refugees.

The service has received multiple national awards and the increasing recognition of the impact of the clinic led to the team being approached to collaborate with several agencies supporting people affected by multiple and severe disadvantage in Plymouth, to develop a pathway aimed at creating an enhanced multidisciplinary team for people with complex needs. The overarching aim of this work was to create a comprehensive service, for adults with complex needs related to homelessness, health, contact with the criminal justice system and substance misuse issues, aligned to the principles of the NICE guideline. The proposal has been successful and following a tender bid, the model has been formally integrated into a broader health and social care initiative to improve care for people with complex needs in Plymouth. The criteria have expanded, and the service accepts referral from multiple agencies supporting people experiencing severe and multiple disadvantages. To our knowledge, the integration of the dental services into such an alliance is the first example in the country of integrated commissioning.

The care pathway has recently been evaluated from a cost effectiveness perspective. Over an evaluation period of 18 months, the PDSE programme served 89 patients experiencing homelessness, operating with a budget of £57,118 and generating £163,910 in health benefits. It yielded an incremental benefit to cost ratio (IBCR) of 3.02, meaning that every £1 invested returned an additional £2.02 in benefits. Health benefits were assessed using disability-adjusted life years (DALYs) averted due to dental caries, periodontitis, and tooth loss. Overall, the evaluation determined that funding a targeted dental programme provides timely, flexible and free access to dental services for people experiencing homelessness is cost-effective and results in costs savings to the wider NHS. Another evaluation has highlighted the factors that influence the integration of dentistry with other health and social care organisations.

For organisations wishing to develop similar pathways working in close partnership with community-based organisations is essential, alongside understanding the expectations and needs of the target group and working with them to co-develop services that are acceptable, accessible, welcoming and are designed around their needs. Ongoing community engagement, and the use of support workers and experts by experience to optimise the care pathway and its utilisation are also important factors. The pathway's ultimate success has been built on relationships and trust, integration into a wider alliance of support and a funding model that provides the time and support for clinicians to provide the care the patients need in a trauma-informed way.