How can health services

Background Homelessness affects many people in contemporary society with consequences for individuals and the wider community. Homeless people experience poorer levels of general physical and mental health than the general population and there is a substantial international evidence base which documents multiple morbidity. Despite this, they often have problems in obtaining suitable health care. Aim To critically examine the international literature pertaining to the health care of homeless people and discuss the effectiveness of treatment interventions. Design of study Review and synthesis of current evidence. Method Medline (1966–2003), EMBASE (1980–2003), PsycINFO (1985–2003), CINAHL (1982–2003), Web of Science (1981–2003) and the Cochrane Library (Evidence Based Health) databases were reviewed using key terms relating to homelessness, intervention studies, drug misuse, alcohol misuse and mental health. The review was not limited to publications in English. It included searching the internet using key terms, and grey literature was also accessed through discussion with experts. Results Internationally, there are differing models and services aimed at providing health care for homeless people. Effective interventions for drug dependence include adequate oral opiate maintenance therapy, hepatitis A, B and tetanus immunisation, safer injecting advice and access to needle exchange programmes. There is emerging evidence for the effectiveness of supervised injecting rooms for homeless injecting drug users and for the peer distribution of take home naloxone in reducing drug-related deaths. There is some evidence that assertive outreach programmes for those with mental ill health, supportive programmes to aid those with motivation to address alcohol dependence and informal programmes to promote sexual health can lead to lasting health gain. Conclusions As multiple morbidity is common among homeless people, accessible and available primary health care is a pre-requisite for effective health interventions. This requires addressing barriers to provision and multiagency working so that homeless people can access the full range of health and social care services. There are examples of best practice in the treatment and retention of homeless people in health and social care and such models can inform future provision.