Mental Illness among Homeless in London Borough of Tower Hamlet

Abstract: The aim of the essay plan at hand was to outline the mental health issues that are being faced by the homeless population in the UK, with specific references to the borough of Tower Hamlets. The plan covered the main contextual factors and determinants of the urban health issue, the main implications and public consequences of the issue in both the City of London in general and the UK, and offered an outline for the critique of current interventions to combat the issue. The plan concluded with speculated recommendations and conclusions for the extended essay. 1 Introduction London, United Kingdom is host to over 10,000 homeless members of society with common afflictions including mental illness, drug and alcohol issues and health concerns (Story et al, 2007). This number of specific homeless far exceeds other national indigent populations making it unique throughout the UK. Alongside the establishment of pervasive symptoms among the population rests the requirement of continuous evaluation of caregivers in order to maintain proper public support structures. The borough of Tower Hamlets has been identified as an area of historic and on-going homelessness as it is a highly deprived area of East London. Deprivation and severe poverty has been identified as one of the most significant determinants of physical and mental health (NHS Tower Hamlets Clinical Commissioning Group, 2013). Combined with a lack of public or private methods of remedy, many homeless have no feasible alternative to living in the streets. In accord, Tower Hamlets has a soaring prevalenc e of these determining factors, which encourage the development of mental health problems among the afflicted population. Further, poor living conditions have the potential to add to the stress experienced by some individuals, which in turn leads to a form of sickness (NHS Tower Hamlets Clinical Commissioning Group, 2013). As a result of this evaluation, homelessness has been identified as a significant aspect of poor mental health in this borough (NHS Tower Hamlets Clinical Commissioning Group, 2013). It has been suggested that mental health issues may actually be a leading factor in the onset of homelessness, where the stresses of homelessness further exacerbate existing psychological issues. At every level of assessment surrounding the mental health of the indigent population of Tower Hamlets, there is a continuous need to re-evaluate and adjust policy in order to address the rising concerns. 2 Rationales Epidemiological data shows that common mental health problems such as anxiety and depression have been found to be over twice as high, and psychosis has been found to be fifty to one hundred times more prevalent in the homeless (Bassuk et al, 1986). This illustrates the clear need to identify the factors that drive these persons to these stages. Further, with such a high number needing sustained medical attention in order to move away from the homeless issue, there is the perception of public burden, which adds to the need to find an effective method of addressing the issue (Wright, 2014). The lack of adequate research in this area of mental stability and determinants reveals the shallow depths of current knowledge, requiring the undertaking of modern reviews in order to accurately assess the next step. Another key rationale is the need to address common social issues including drug and alcohol abuse in the homeless (Dunne et al, 2013). Whether as a result of being homeless or the co nsequence of abuse, drugs and alcohol dependency are established factors that are common throughout the indigent population (Wright, 2014). This commonality has been wrongly cited as the prevalent determinant in the homeless condition, with many persons not finding the drugs or alcohol until after experiencing the loss of becoming homeless (Wright, 2014). Yet, the prevalence of alcohol and drug abuse has been found to be widespread within the homeless community (Fazel et al, 2008) thus the essay will aim to shed light upon this aspect of substance abuse as among the largest contributing factors to homelessness. This focus on elements that are considered determinant in the creation of the homeless population will enable a relevant series of recommendations that are aimed at reducing the phenomenon. Further, this essay also aims to provide further insight to how the statistics were found to be markedly higher in the borough of Tower Hamlets than the proportion across other London boro ughs all together than the proportion across other London boroughs all together (NHS Tower Hamlets, 2011). With a defined rise in the factors impacting the homeless in this area, it becomes essential to identify the primary components. Alongside the benefit that the local population will derive from this exercise will be the potential for this experience to translate into other social areas that will assist in developing long term solutions to pressing issues. In order to fully explore the goals of this essay; gender, ethnicity and the age aspect of homelessness will be discussed, as there are marked differences between genders and races in regard to the issues faced in homelessness (Wright, 2014). As with each outside element including financial standing and health, the disparity between the sexes in the homeless population requires investigation. For example, single men between the ages of 25-44 have been identified as the most common demographic group associated with homelessness (Hwang, 2001), yet children have also been found at a high risk of facing homelessness, accompanied by a high risk of developing mental health issues (Tischler et al, 2002). While the presence of the homeless conditions in these two demographics may withstand scrutiny, the question of how this condition arose creates the opportunity to avoid it. Further, with a sustained outreach to those in peril of becoming homeless before the fact, there is opportunity for developing past the hardship, making this study crucial (Buckman et al, 2013). In order to properly assess the societal position and expectations of the homeless, this essay will assess what is considered among the highest concerns among members of this population (Iversen et al, 2011). Despite the contention that specific determinants play a role in the indigent condition, others argue that it is the perception of adverse social conditions on the part of the person that serve to keep the person in the homeless state. With correlations among the indigent and common belief such as the desire for work and affordable housing, there are foundations for building a path to a more sustainable form of living for many currently in the homeless condition (Fitzpatrick et al, 2013). This is an indication of the importance of considering not only the external conditions associated with the homeless, mental health and drug abuse, but there must be a corresponding effort to address the internal perceptions held by these individuals. The situation for those living rough is int ensified when substance misuse is co-morbidly present with existing mental health problems (Rees, 2009). This combination of conditions is credited with sustaining the homeless condition, making the opportunity to rise above the stage complex and unlikely (Dunne et al, 2012). It is the perception of lack prospects and potential that is credited with keeping many individuals in the indigent state. Among the homeless male versus the general public, there is a higher association with illnesses including schizophrenia by a 50% v 34%, personality disorders 37% v. 11%, substance dependence issues 74%5 v. 19% further increasing the need to study and identify the specific factors surrounding this ratio (Dunne et al, 2012). These statistics indicate the much of the mental disorders are amplified in conjunction with the homeless population which raises another area of concern; where the individuals afflicted as result of becoming homeless or did they become homeless as a result of becoming il lThis critical consideration will add to the assessment of determinants and the manner in which they work to keep the indigent population on the rise (Wright, 2014). In accord, the essay aims to discuss how the borough of Tower Hamlets has been identified as having the highest mental health needs in the UK, with over 45% of the population of the borough claiming incapacity benefit due to their ill mental health. This very high rate indicates the presence of a set of conditions that are expected to be identifiable, adding to the appeal of this study. As the literature confirms that mental illness is a significant urban health issue accompanied by crucial repercussions such as homelessness, the essay will aim to highlight the ways in which this issue relates to the London borough of Tower Hamlets. As the results are directly relevant to those in the Tower Hamlets, many other indigent populations exhibit similar conditions, which this study will assist to illuminate. 3 Urban Context and Determinants The literature surrounding homelessness and mental health indicates that factors in the urban context play a major role in the development of this urban health issue (Fitzpatrick et al, 2012). This is an indication that this area of research is not only necessary but vital to the effort to sustain and improve the state of the homeless population. Determinants such as poverty, exclusion, attainment and wellbeing all hold significant implications for homelessness (Frankish, Hwang & Quantz, 2005). Elements that are cited to aid in the determination homeless population causation include the lack of general or low strata employment opportunities (Fitzpatricket al, 2013). This perception of no means to find work is compounded by ill health and the absence of health care. As those in the poorer classes fall sick, there is a trend to allow this sickness to become overriding, thereby adding to the detrimental factors surrounding a persons living situation (Dawson et al, 2013). Outside social factors can have distinct impact on the determinants surrounding the homeless populations. With natural disasters and war placing many of these individuals in the homeless situations due to associated factors, there is a need to quantify each new social influence in order to minimize the harmful impact. Feeding directly into the homeless epidemic and the mentally unstable is the common lack of disability services that will have the resources to aid them (Wright, 2014). This scenario of inadequate infrastructure only adds support to the contention that each new determinant in the homeless cycle increases the likelihood that the person will not be able to escape the condition. With evidence supporting the position that it becomes harder to function in day to day society the longer a person remains indigent, there is a clear and present time factor that must be added to the determinants of the homeless (Wright, 2014). Additional factors such as difficulties in maintaining secure and good quality accommodation due to mental illness will also be discussed in the essay as contributors to homelessness (Breaky, 1992). Determinants to the homeless condition have been attributed to the high rate of substance abuse and addiction among the indigent population (Wright, 2014). This is an indicati on that there is truth to the argument that many people choose their addictions over a place to live comfortably. Further, this very aspect is magnified by the lack of affordable, quality housing in many areas (Buckman et al, 2013). With no avenue to find a roof, the drive to work towards making their life better has a trend of stalling as these determinant continue to hold the person back. This essay endeavours to shed light on recent changes to government policy, such as reforms in welfare support and social housing, the recession, and government cuts to public services in the UK had impacted those who were most vulnerable to homelessness. Each shift in public policy and perception has the potential to add or detract from the living situation of the indigent population (Wright, 2014). Yet, in many cases, available opportunities are overlooked due to the fact that the persons in question have no means to become acquainted with the policies. Individuals with mental health problems h ave faced considerable difficulties due to these changes such as understanding when they need to claim the benefits, how the new benefits work, and uncertainty about how the changes will affect their circumstances (Wright, 2014). Many times, the very complex nature of the policy or regulation diminishes the effectiveness of the intent by reducing access. As a further example of this issue raising modern concern, in some cases, individuals may also face difficulty getting access to, and using a computer to claim their benefits online (Dawson et al, 2013). These common issues that highlight the high risk of the mentally ill facing homelessness due to financial hardship and provide a possible explanation as to why there is such a high degree of mental illness among the homeless. Due to the fact that registration to a GP generally requires proof of a home address, homeless people are more likely to access healthcare through emergency services (Crisis & MORI, 2002). This creates many iss ues including access, payment, sustained care and exacerbated social expense. Further, this poses problems on both the individual and the general population as the individual may not receive the health advice and respect that they deserve for reasons such as the emergency department only being intended for emergency health conditions, and due to social stigma around homelessness; such as the homeless may be associated with mental ill health, substance abuse and lack of hygiene (Riley, Harding, Underwood & Carter, 2003). It is a common trend among the homeless to face a lack of insurance and the unwillingness to visit the doctor aside from the direst of circumstance. These factors have been cited as contributors of poor physical and psychological wellbeing which the homeless individual faces when trying to access public health care, which only serve to compound the homeless condition (Wright, 2014). In many cases social pressure to avoid using the medical services, serves to drive th e homeless even further from finding quality care, only serve to further add to the issue. A final determinant to be discussed in this essay is the cost of this urban health issue faced by the National health services, which in turn is passed on to the larger national population (Dunne et al, 2012). In many cases the variance of social support has changed alongside the political views of the ruling establishment. This condition causes many fits and starts to any existing system, which in turn serve to slow down both effective outreach and long-term strategy. Cost has the potential to become an overbearing feature of any policy creation effort (Dunne et al, 2012). In some cases the zeal to reduce the public budget for these issues is weighed against the need to devote time and resources to this part of the population (Fitzpatrick et al, 2013). With a common lack of representation among the law makers, the lower classes have often suffered the lack of finance and social support that is required to implement any effective strategy. Modern evidence shows that mental illness fo r the NHS is costly as it is the largest cause of disability in the UK. Social and informal care for the mentally ill is costing ?22.5 billion, where 13.8% of the national budget is spent on mental health (National Mental Health, 2012). This is a defining motivation for lawmakers on any side of the aisle to find a method of addressing the issue. Statistics also show that ?77 billion a year was being spent on welfare benefits for mental illnesses in 2009 (National Mental Health, 2012). This is a trend of rising cost that will only be reversed through study and relevant and considered implement of infrastructure. The lack of a coordinated strategy to reduce the homeless issue only creates a potential for the issue to become intractable and even harder to combat (Wright, 2014). The impact of these costs on the national economy was damaging, increasing national debts thus affecting the general population through increases in tax, public services, and as previously mentioned, cuts to nat ional healthcare (National Mental Health, 2012). This issue touches each person in society in a direct manner, meaning that with the easing of homeless condition there will be a corresponding easing of social pressure of the whole of society. Therefore it is necessary for these determinants to be discussed as contributing factors to the urban health issue. 4 Conclusions and Recommendations The aim of this paper is to critique strategies such as the Tower Hamlets Homelessness Statement 2013 to 2017, the Homelessness Act and other interventions that tackle homelessness and mental illness as separate entities (Crisis, 2009). This review of material will create the opportunity to identify strengths and weaknesses in the approaches that could in turn be amended. Further, this review will provide a basis for long term strategy based on the continuous need to refine public policy in order to reduce the burden on society as a whole (Wright, 2014). Yet, in every case the solution must be both ethical and motivated by the desire to enhance the homeless population’s potential to achieve stability. The recommendations that will evolve as a result of this study will involve coordinated treatment programs (Coldwell & Bender, 2007) such as Assertive Community Treatment (ACT), which aim to serve psychiatric outpatients whose mental illness causes serious functioning difficulties in aspects of life including work, social relationships, residential independence, money management, and physical health and wellness, all of which can have an impact on housing status (Dixon, 2000). Other possible avenues designed to create options including community housing initiatives, political action through policy reform, enhancing current infrastructure such as Habitat for Humanity and the National Coalition for the Homeless. This consideration of a wide range of evidence creates a variety of opportunities to explore and address the issues facing the modern homeless population (Iversen et al, 2011). It is expected that this study will conclude that the ACT is an effective measure in combating the co re issues which lead to and maintain homelessness, and aim to recommend that government funding should be utilised to promote programs such as ACT which will make lasting changes in the homeless community. Further, there is an expectation that there will be a combination of past and prior factors that have contributed to the homeless population and that it will require a well-rounded intervention method in order to provide better prospects. In the end, the base goal of this essay is to provide potential paths for further research which will in turn work to alleviate the dismal conditions associated with the indigent condition. 4 References Bassuk, E.L., Rubin, L. & Lauriat. A.S. (1986). Characteristics of sheltered homeless families. American Journal of Public Health. 76(9). 1097-1101. Breaky, W.R. (1992). Mental Health Services for Homeless People. pp101-107. Cited in: Homelessness: A National Perspective. Eds. Robertson, M.J. & Greenblatt, M. (1992). Buckman, J., Forbes, H., Clayton, T., Jones, M., Jones, N., Greenberg, N., Sundin, J., Hull, L., Wessely, S. and Fear, N. (2013). Early Service leavers: a study of the factors associated with premature separation from the UK Armed Forces and the mental health of those that leave early. The European Journal of Public Health, 23(3), pp.410–415.Coldwell, C.M. & Bender, W.S. (2007). The Effectiveness of Assertive Community Treatment for Homeless Populations With Severe Mental Illness: A Meta-Analysis. Am J Psychiatry. 164(3). 393-399.Communities and Local Government. (2009). Rough Sleeping England – Total Street Count. Retrieved from: http://webarchive.nationalarchives.gov.uk/20120919132719/http://www.communities.gov.uk/publications/corporate/statistics/roughsleeping2009 Accessed: 17th February 2014 Crisis & MORI. (2002). Critical condition: Homeless people’s access to GPs. London. Dawson, A., Jackson, D. and Cleary, M. (2013). Mothering on the margins: Homeless women with an SUD and complex mental health co-morbidities. Issues in mental health nursing, 34(4), pp.288–293. Dixon, L. (2000). Assertive community treatment: Twenty-five years of cold. Psychiatric Services, 51, 759-765. Dunne, E., Duggan, M. and O’Mahony, J. (2012). Mental health services for homeless: patient profile and factors associated with suicide and homicide. Mental health. Fazel, S; Khosla, V; Doll, H; Geddes, J (2008). â€Å"The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis†. PLoS Med 5 (12). doi:10.1371/journal.pmed.0050225 Fitzpatrick, S., Bramley, G. and Johnsen, S. (2013). Pathways into multiple exclusion homelessness in seven UK cities. Urban Studies, 50(1), pp.148–168. Frankish, C.J., Hwang, S.W. & Quantz, D. (2005). Homelessness and Health in Canada. Canadian Journal of Public Health. 2(96). 23-29. Hwang, S.W. (2001). Homelessness and health. CMAJ. 164(2). 229–233. Iversen, A., van Staden, L., Hughes, J., Greenberg, N., Hotopf, M., Rona, R., Thornicroft, G., National Mental Health. (2012). Development Unit. Factfile 3. The costs of mental ill health. Retrieved from: http://www.nmhdu.org.uk/silo/files/nmhdu-factfile-3.pdf Accessed: 16th February 2014 NHS Tower Hamlets. (2011). Homelessness: Factsheet. Tower Hamlets Joint Strategic Needs Assessment 2010 ­2011 . Retrieved from: http://www.towerhamlets.gov.uk/idoc.ashx?docid=f8390127-f61d-491b-8323-cea75d92a228&version=1. Accessed: 16th February 2014 Riley, A.J., Harding, G., Underwood, M.R., Carter, Y.H. (2003). Homelessness: a problem for primary careBritish Journal of General Practice. 473-479. Tischler, V., Vostanis, P., Bellerby, T. & Cumella, S. (2002). Evaluation of a mental health outreach service for homeless families. Arch Dis Child. 86. 158–163. Tower Hamlets Clinical Commissioning Group. (August 2013). Mental Health Joint Strategic Needs Assessment for Tower Hamlets. Tower Hamlets Health and Wellbeing Board. Tower Hamlets Homelessness Statement. (2013). 2013 to 2017 Consultation Draft. Retrieved from: http://www.towerhamlets.gov.uk/lgsl/851900/868_housing_strategy_and_polic/homelessness_strategy.aspx Accessed: 17th February 2014 Rees, S. (2009). Mental Ill Health in the Adult Single Homeless Population: A review of the literature. Crisis, PHRU. Retrieved from: http://www.crisis.org.uk/data/files/publications/Mental%20health%20literature%20review.pdf. Accessed: 16th February 2014 Story, A., Murad, S., Roberts, W., Verheyen, M. & Hayward, A.C. (2007). Tuberculosis in London: the importance of homelessness, problem drug use and prison. Thorax. 62(8). 667-671. Wessely, S. and Fear, N. (2011). The stigma of mental health problems and other barriers to care in the UK Armed Forces. BMC health services research, 11(1), p.31. Wright, J. (2014). Health needs of the homeless. InnovAiT: Education and inspiration for general practice, 7(2), pp.91–98. Mental Illness Among Homeless In London Borough Of Tower Hamlet Abstract: The aim of the essay plan at hand was to outline the mental health issues that are being faced by the homeless population in the UK, with specific references to the borough of Tower Hamlets. The plan covered the main contextual factors and determinants of the urban health issue, the main implications and public consequences of the issue in both the City of London in general and the UK, and offered an outline for the critique of current interventions to combat the issue. The plan concluded with speculated recommendations and conclusions for the extended essay. Introduction: Where 10,000 of the UK’s homeless population can be found in London (Story, Murad, Roberts, Verheyen & Hayward, 2007), mental health issues have been established as prevalent among the homeless in specific urban areas in the city of London. The borough of Tower Hamlets has been identified as an area of historic and ongoing homelessness as it is a highly deprived area of East London. Deprivation and severe poverty has been identified as one of the most significant determinants of physical and mental health (NHS Tower Hamlets Clinical Commissioning Group, 2013). In accord, Tower Hamlets has a soaring prevalence of these determining factors, which encourage the development of mental health problems. Thus, homelessness has been identified as a significant aspect of poor mental health in this borough (NHS Tower Hamlets Clinical Commissioning Group, 2013). It has been suggested that mental health issues may actually be a leading factor in the onset of homelessness, where the stresse s of homelessness further exacerbate existing psychological issues. Rationale: Epidemiological data shows that common mental health problems such as anxiety and depression have been found to be over twice as high, and psychosis has been found to be fifty to one hundred times more prevalent in the homeless (Bassuk, Rubin & Lauriat, 1986). A local audit in East London has shown that serious mental illness is more prevalent in the black rather than the white population (NHS Tower Hamlets Clinical Commissioning Group, 2013). The prevalence of alcohol and drug abuse has been found to be widespread within the homeless community (Fazel, Khosla, Doll, Geddes, 2008) thus the essay will aim to shed light upon this aspect of substance abuse as the largest contributing factor to homelessness. The essay will also aim to provide further insight to how the statistics were found to be markedly higher in the borough of Tower Hamlets than the proportion across other London boroughs all together (alcohol 26%, drugs 36%) (NHS Tower Hamlets, 2011). Furthermore, the gender, ethnicit y and age aspect of homelessness will be discussed, as there are marked differences between genders and races in regard to the issues faced in homelessness. For example, single men between the ages of 25-44 have been identified as the most common demographic group associated with homelessness (Hwang, 2001), yet children have also been found at a high risk of facing homelessness, accompanied by a high risk of developing mental health issues (Tischler, Vostanis, Bellerby & Cumella, 2002). The situation for those living rough is intensified when substance misuse is co-morbidly present with existing mental health problems (Rees, 2009). In accord, the essay aims to discuss how the borough of Tower Hamlets has been identified as having the highest mental health needs in the UK, with over 45% of the population of the borough claiming incapacity benefit due to their ill mental health. Furthermore, certain groups such as rough sleepers, domestic violence victims, sex workers and ex offenders are at a higher risk of homelessness and 70% of these individuals will be likely to have a mental health condition (Tower Hamlets Homelessness Statement, 2013). As the literature confirms that mental illness is a significant urban health issue among the population of Tower Hamlet accompanied by crucial repercussions such as homelessness, the essay will aim to highlight the ways in which this issue relates to the London borough of Tower Hamlets. Urban Context and Determinants: The literature surrounding homelessness and mental health indicates that factors in the urban context play a major role in the development of this urban health issue. The essay will endeavour to discuss determinants such as poverty, exclusion, attainment and wellbeing, which all hold significant implications for homelessness (Frankish, Hwang & Quantz, 2005). Long term unemployment and overcrowded households have played a major role in the development of mental illnesses, and have even lead to homelessness (NHS Tower Hamlets Clinical Commissioning Group, 2013). Additional factors such as difficulties in maintaining secure and good quality accommodation due to mental illness will also be discussed in the essay as contributors to homelessness (Breaky, 1992). Moreover, light will also be shed on recent changes to government policy, such as reforms in welfare support and social housing, the recession, and government cuts to public services in the UK, and their impact on those who were mos t vulnerable to homelessness. Individuals with mental health problems have inevitably faced considerable difficulties due to these changes such as understanding when they need to claim the benefits, how the new benefits work, and uncertainty about how the changes will affect their circumstances. In some cases, individuals may also face difficulty getting access to, and using a computer to claim their benefits online (Crisis & MORI, 2002). These issues highlight the high risk of the mentally ill facing homelessness due to financial hardship, and provide an explanation to why there is mental illness among the homeless. Due to the fact that registration to a GP generally requires proof of a home address, homeless people are more likely to access healthcare through emergency services (Crisis & MORI, 2002). This poses problems on both the individual and the general population as the individual may not receive the health advice and respect that they deserve for reasons such as the emergen cy department only being intended for emergency health conditions, and due to social stigma around homelessness; such as the homeless may be associated with mental ill health, substance abuse and lack of hygiene (Riley, Harding, Underwood & Carter, 2003). These factors will be discussed as contributors of poor physical and psychological wellbeing which the homeless individual faces when trying to access public health care. Moreover, the waiting time in emergency departments will affect both the individual and the general public as the individual may not want to seek medical help due to long waiting hours and discrimination, and the general public may have to wait longer to be seen for an emergency due to homeless individuals being seen for general health concerns. Another factor that is aimed to be discussed in the essay is the cost of this urban health issue faced by the National health services. Evidence shows that mental illness for the NHS is costly as it is the largest cause of disability in the UK. Social and informal care for the mentally ill is costing ?22.5 billion, where 13.8% of the national budget is spent on mental health (National Mental Health, 2012). Statistics also show that ?77 billion a year was being spent on welfare benefits for mental illnesses in 2009. The impact of these costs on the national economy was damaging, increasing national debts thus affecting the general population through increases in tax, public services, and as previously mentioned, cuts to national healthcare. Therefore these determinants will also be discussed as contributing factors to the urban health issue. Strategies & Interventions for Critique; Speculated Recommendations & Conclusions: The aim of the paper will be to critique strategies such as the Tower Hamlets Homelessness Statement 2013 to 2017, the Homelessness Act and other interventions that tackle homelessness and mental illness as separate entities (Crisis, 2009). The recommendations I will make will involve coordinated treatment programs (Coldwell & Bender, 2007) such as Assertive Community Treatment (ACT), which aim to serve psychiatric outpatients whose mental illness causes serious functioning difficulties in aspects of life including work, social relationships, residential independence, money management, and physical health and wellness, all of which can have an impact on housing status (Dixon, 2000). I expect to conclude that ACT is an effective measure in combating the core issues which lead to and maintain homelessness, and aim to recommend that government funding should be utilised to promote programs such as ACT which will make lasting changes in the homeless community. References Bassuk, E.L., Rubin, L. & Lauriat. A.S. (1986). Characteristics of sheltered homeless families. American Journal of Public Health. 76(9). 1097-1101. Breaky, W.R. (1992). Mental Health Services for Homeless People. pp101-107. Cited in: Homelessness: A National Perspective. Eds. Robertson, M.J. & Greenblatt, M. (1992). Coldwell, C.M. & Bender, W.S. (2007). The Effectiveness of Assertive Community Treatment for Homeless Populations With Severe Mental Illness: A Meta-Analysis. Am J Psychiatry. 164(3). 393-399. Communities and Local Government. (2009). Rough Sleeping England – Total Street Count. Retrieved from: http://webarchive.nationalarchives.gov.uk/20120919132719/http://www.communities.gov.uk/publications/corporate/statistics/roughsleeping2009 Accessed: 17th February 2014 Crisis & MORI. (2002). Critical condition: Homeless people’s access to GPs. London. Dixon, L. (2000). Assertive community treatment: Twenty-five years of cold. Psychiatric Services, 51, 759-765. Fazel, S; Khosla, V; Doll, H; Geddes, J (2008). â€Å"The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis†. PLoS Med 5 (12). doi:10.1371/journal.pmed.0050225 Frankish, C.J., Hwang, S.W. & Quantz, D. (2005). Homelessness and Health in Canada. Canadian Journal of Public Health. 2(96). 23-29. Hwang, S.W. (2001). Homelessness and health. CMAJ. 164(2). 229–233. National Mental Health. (2012). Development Unit. Factfile 3. The costs of mental ill health. Retrieved from: http://www.nmhdu.org.uk/silo/files/nmhdu-factfile-3.pdf Accessed: 16th February 2014 NHS Tower Hamlets. (2011). Homelessness: Factsheet. Tower Hamlets Joint Strategic Needs Assessment 2010 ­2011 . Retrieved from: http://www.towerhamlets.gov.uk/idoc.ashx?docid=f8390127-f61d-491b-8323-cea75d92a228&version=1. Accessed: 16th February 2014 Riley, A.J., Harding, G., Underwood, M.R., Carter, Y.H. (2003). Homelessness: a problem for primary careBritish Journal of General Practice. 473-479. Tischler, V., Vostanis, P., Bellerby, T. & Cumella, S. (2002). Evaluation of a mental health outreach service for homeless families. Arch Dis Child. 86. 158–163. Tower Hamlets Clinical Commissioning Group. (August 2013). Mental Health Joint Strategic Needs Assessment for Tower Hamlets. Tower Hamlets Health and Wellbeing Board. Retrieved from: http://www.towerhamletsccg.nhs.uk/Get_Involved/Tower%20Hamlets%20Mental%20Health%20Joint%20Strategic%20Needs%20Assessment%20Part%20One%20-%20Population%20Needs.pdf Accessed: 17th February 2014 Tower Hamlets Homelessness Statement. (2013). 2013 to 2017 Consultation Draft. Retrieved from: http://www.towerhamlets.gov.uk/lgsl/851900/868_housing_strategy_and_polic/homelessness_strategy.aspx Accessed: 17th February 2014 Rees, S. (2009). Mental Ill Health in the Adult Single Homeless Population: A review of the literature. Crisis, PHRU. Retrieved from: http://www.crisis.org.uk/data/files/publications/Mental%20health%20literature%20review.pdf. Accessed: 16th February 2014 Story, A., Murad, S., Roberts, W., Verheyen, M. & Hayward, A.C. (2007). Tuberculosis in London: the importance of homelessness, problem drug use and prison. Thorax. 62(8). 667-671.