"My basic needs were not met at all" — Thousands of mental health patients experiencing homelessness

An investigation into how a hospital stay can lead to homelessness, the effects it has on those with mental illness, and why it’s often difficult to find new and suitable accommodation.

48 hours after Emma* is discharged from a year-long stay in a mental health hospital, she is homeless.

She has spent the last twelve months in a unit outside her city, focusing on her mental health and recovery.

She knows that coming back to the place she lived before to start a new life would not be easy.

But she does not know that her new housemate would ask her to leave after just two days.

"My mental health needs were too complex for her to have me living in the house", Emma says.

She found the house when she was still in hospital — and already expected that, because of her needs, it would not be the most suitable home. But running out of time and options she did not have another choice.

"I had worked really, really hard that year in hospital to turn my life around. I hadn't expected to come back and not even have a roof over my head."

There are basic needs that should be met for everyone — food, water, warmth, and rest. After the physiological needs come security and safety.

"We all want somewhere safe to live", is how Claire Terrington summarises the issue. She is an occupational therapist working in the Birmingham and Solihull Mental Health NHS Foundation Trust.

When Emma is discharged from the hospital, her basic needs are not met.

For the next three years, Emma is on and off homeless. Moving between unsuitable accommodation, trying to find something permanent to stay. Whilst trying to recover from something severe enough to keep her in hospital for a year.

Emma is not an isolated case. At the end of January 2021, more than 10,000 people who were in contact with mental health services were experiencing some kind of homelessness.

Homelessness has many faces. It can be sleeping rough, sofa surfing, living in homelessness hostels or temporary accommodation. It is what the name implies: not having a home.

Homeless in hospital

Last year over 100,000 people in England were admitted to hospital for a mental health problem.

In their housing report Brick by Brick, the charity Mind says that a mental health crisis and a hospital admission can lead to someone losing their home.

"Admission and discharge from hospital are key housing transitions for people experiencing mental health problems. The period after hospital discharge is high risk for a first or recurrent period of homelessness."
Mind, Brick by Brick

Deborah Stephenson, Associate Director of Accommodation Services at Rethink Mental Illness says that a safe and secure place to call home is one of the most important factors in supporting people severely affected by mental illness.

"Many people unfortunately struggle to find suitable accommodation when they leave hospital, which actively harms their prospects of recovery and increases their risk of relapse."

To mitigate the risk of homelessness, discharge planning should start as soon as someone is admitted to hospital, Claire Terrington says.

NICE guideline states that the discharge planning should be collaborative, person-centred and suitably paced. To do so, the inpatient team should work with the community mental health team, the patient and their family, carers or advocate.

The lack of housing professionals in inpatient settings

What if someone is in hospital and does not have housing?

Claire Terrington
Occupational therapist and head of personal care

Claire about personalised care, the right support for homeless patients and neighbourhood offices

"It's a huge issue", says Claire Terrington. Patients need support finding a home.

How this support looks, varies depending on the patient's mental health team.

When Claire Terrington was working in Assertive Outreach Services — a specialist team supporting adults with mental illness who have particularly complex needs — her team had a dedicated housing officer.

He knew everything there was to know about housing issues, housing laws, and the rights of patients.

"We found it really useful because when we had multidisciplinary meetings about a patient and we were talking about their housing situation, then he knew if something would work or not."

However, accommodation officers are a rarity in mental health services, data obtained through Freedom of Information requests reveals.

Only a third of trusts have dedicated housing professionals in their inpatient teams. Out of 38 NHS trusts with mental health wards that replied to the request, only 13 employ one or more housing support workers in their inpatient settings.

Trusts often said that "all staff would support a patient with a housing need" or "housing support is seen as a generic role and needs are met by the care coordination or other specialist mental health staff".

The lack of dedicated housing support can create anxiety around being discharged from hospital, says Deborah Stephenson from Rethink Mental Illness.

"It may inspire a lack of confidence around what level of support people feel they can rely on. People often don't know what housing support is available to them, and the risk of facing homelessness or trying to work through the system on their own can result in relapses."

Caroline Bernard is the Head of Communications and Advocacy at Homeless Link, the national membership charity for frontline homelessness services. She says that appropriately funded discharge schemes provide an important opportunity to engage and support people who may otherwise fall through the gaps in services.

"Key to the success of these schemes is strong partnership working between health, homelessness, housing and related services, offering individuals a range of support options, and ensuring the discharge process itself is handled sensitively, with good communication between the hospital and the patient."

Without accommodation officers or similar dedicated housing staff, the nurses on the ward are responsible for identifying housing issues on admission. They should work with the community care coordinator, local authority or housing department to secure housing.

The quality of the support then depends on how good the patient's team is at finding accommodation. Besides housing support, they also need to take care of the patients' other needs.

The more experience someone has with finding accommodation, the better are the outcomes, finds Claire Terrington. Over the years, she has been able to build up a network with housing providers in Birmingham.

"If you're clever and you've been around a bit like me you keep a list of places that are really good and you keep on contacting those people and you keep them on your good side. So if they got a vacancy, they'll phone you and say they've got a vacancy."


When different teams have to work together to secure housing for a patient, the outcome also depends on how well they communicate with each other.

Before Emma's discharge, her team in the hospital has tried to arrange a meeting with her community team back home. But her community team has either cancelled meetings or just did not show up. In the end, they had to drive to the city one hour and a half away.

"We literally had to turn up and say, 'you need to meet about this service user that's about to come back to your area'. It was really difficult", Emma remembers. "The two sides communicating was impossible."

Because of the communication problems, Emma's team wasn't fully aware that she was facing homelessness.

"But if they would have listened, if they would have communicated with us, then they would have known and would have had more time to help me out."

Lack of suitable accommodation

Having lost a home, it is hard to find a new one. Risk and a lack of accommodation limit available choices.

"Accommodation is massively important, but there is a huge gap. There aren't enough one-bedroom flats and there isn't enough supported accommodation either", Claire Terrington says.

"We don't have enough housing for people regardless of needs. We are overrun by people."

When Emma is looking for accommodation, she is often told that waiting lists are long and that there is nothing else to be done.

Less range also means less suitable accommodation that meets the patient's needs.

"There's a dearth of accommodation out there and that makes it less likely that any particular place is going to be good enough for an individual", says consultant psychiatrist Nuwan Dissanayaka.

Because of this, there is a huge competition for actually available and suitable housing.

And those who have a level of risk associated with their illness are often excluded from accommodation because of it, says Nuwan Dissanayaka.

Claire Terrington has made similar experiences with her patients: "Some people engage in really risky things before they are brought into hospital. And once that gets put on paper it's really hard to find them somewhere to live."

Housing issues are delaying discharges

Not having housing in place after discharge can sometimes lead to patients staying in hospital longer than they need to for the treatment of their illness. This is called a delayed discharge.

Claire Terrington knows that services try not to send anyone home without having suitable accommodation. "This is why we end up with people in hospital for longer. It's a real lengthy process to find anywhere — if we can find anywhere", she says.

In January 2021, there were 17,512 days of delayed discharge. Every day on average 565 patients spent additional time in a mental health hospital.

Mental health hospitals under extreme bed pressures

Delayed discharges negatively impact the finances and performance of the health and care system, according to the King's Fund.

When patients are staying in hospital for longer than they medically need to, the bed cannot be given to a new patient. This is especially critical when mental health units across England are already experiencing extreme bed pressures — not only since the Covid-19 pandemic.

Years of reducing the number of available beds has led to increasing bed occupancy rates. In 1988, there were over 67,000 beds for mental health patients available. Today, only around 18,000 of those are left.

To maintain patient safety standards, bed occupancy should not exceed 85 per cent. A higher bed occupancy leads to regular bed shortages. These are impacting patient care as directing patients to the bed most suitable for their care is less likely to be possible.

Between April 2019 and March 2020, every day on average 89 per cent of hospital beds were occupied by mental health patients.

Nuwan Dissanayaka says that there can be a pressure to discharge patients into the community when they no longer need to be in hospital for the treatment of their illness. Although they might not have housing in place yet, they could still be discharged.

"I think it is a very difficult decision, most difficult for the patient at the centre of it but those decisions are made sometimes because I guess services don't feel they have any other option but to do that."

Finding suitable accommodation for patients earlier on could decrease delayed discharges and consequently relieve some of the bed pressures.

From hospital to hostel

When Lily* was 20, she was discharged into a hostel.

After staying in an acute ward for seven weeks, she was deemed well enough to go home — only that she did not have a place to go back to.

"There was no real option about where to house me at that point", she says. Before her admission, she became estranged from her family and friends. Living with them wasn't possible.

"And then there was an idea that if I declared myself as homeless and stayed in a hostel that I would have quicker access to community housing. It was sold to me as the best and quickest way of alerting people to my homelessness and the severity of my situation."

Before Lily went to hospital, she slept rough for a few weeks, was often around people who were struggling with their mental health and substance misuse. Facing a similar environment again, frightened her.

According to Mind's report Brick by Brick, hostels are there to provide essential, emergency accommodation for people who are homeless. They should come with key workers and referral routes to some form of psychological support. But the report also says: "High demand and funding pressures limit the support options available."

Claire Terrington knows what staying in a hostel is like since some of her patients have been placed there. There were times where she got back in her car and cried about the thought of leaving the patient in this environment.

"The next day, we've spent all day to find another place for that person because it just isn't right for them.

"They're not pleasant places. They are often full of people who are drunk, using substances, noisy at night. You wouldn't feel safe and secure there at all."

Lily describes the hostel environment as frightening, having a substantial impact on her mental health.

She says: "It was troubling to be there."

After staying in the hostel for a week, Lily was readmitted to hospital. Fortunately not for long. Instead of going back to the hostel, she could stay with an extended family member.

Six weeks after declaring herself homeless, Lily was given a council property.

Today Lily looks back at it. And although the hostel was the quickest way of accessing social housing, she wouldn't have done it if there would have been other options.

Homeless in the community

The struggles don't end when someone is discharged from hospital into homelessness or unsuitable housing. They just continue in the community.

At the end of January 2021, there were 10,183 people in contact with mental health services who were experiencing some kind of homelessness, data obtained through Freedom of Information requests reveals.

Dissanayaka emphasises how difficult experiencing any kind of homelessness is while recovering from mental illness.

"Discharging somebody who has been in hospital because they've been mentally vulnerable to a situation which immediately destabilises their mental health isn't an effective way of dealing with it. Ultimately a fair number of those people will be readmitted to hospital or will suffer significant symptoms in the community."

For Emma, being discharged without suitable accommodation in place means advocating for housing, safety, and help on her own — whilst trying her best to recover.

She experiences a lot of pressure to make things work with the little resources she has.

"The mental health services were still expecting that I managed my crises and that my mental health was better. But actually my basic needs were not met at all, and I just felt really alone."

Deborah Stephenson from Rethink Mental Illness says that the uncertainty about where someone might live can contribute to a relapse in their mental health or an increase in anxiety and depression.

Navigating the (complicated) systems

Nuwan Dissanayaka works in an Assertive Outreach Team in Leeds where he sees people who have severe mental illness. Since homelessness is common among his patients, he helps them navigate the systems around housing and benefits.

Nuwan Dissanayaka
Consultant psychiatrist in Assertive Outreach Services

Nuwan about (the lack of) Assertive Outreach Services

"Navigating the very complicated systems that accompany housing and money is difficult for people who don't have mental health problems. So for those who have it's even more difficult."

Not every area has Assertive Outreach Services. And similarly to inpatient settings, community teams only rarely have special accommodation officers. Out of 38 NHS trusts who replied to a FOI request, only 11 have specialist housing staff.

In services without accommodation officers, it, again, comes down to the regular community mental health teams to secure housing.

Deborah Stephenson from Rethink Mental Illness would like to see joint work between housing and mental health teams in the community. She proposes the adoption of so-called community navigators who would link people with existing support to help them secure a home.

"People can develop a fear of 'the system' and there can be a huge amount of admin to get through in the process to secure accommodation which can seem really daunting.

"Support from one of these navigators to attend appointments, complete paperwork and make applications can help people continue to improve their mental health, secure a home and build greater independence in their lives."

The responsibility for this lies with the NHS and the Government.

A spokesperson from the Department of Health and Social Care said:

"We are spending over £750 million this year to tackle homelessness and rough sleeping, including funding for projects and staff to help ensure those discharged from hospital have a roof over their head.

"The Homelessness Reduction Act requires public authorities, including hospitals, to refer patients who are homeless or at risk of homelessness to their chosen local housing authority.

"We are taking action to support all people with a severe mental illness, including new models of care backed by an investment of almost £1 billion by 2023/24."

NHS England did not comment.

A home for Emma

Living room, kitchen, bedroom, bathroom. A place where she feels safe.

After three years of advocating for herself, Emma has found a home. She lives in a house with support workers staying overnight. For the first time, her living situation is suitable and sustainable.

"I feel like this is the only time, three and a half years later, that I'm actually starting to concentrate on my recovery. I finally don't have to deal with the housing situation, with staying warm and dry anymore."

In the UK, the charity Mind is available on 0300 123 3393.

If you need advice about your housing options, you could speak to the following people:

Get the data

Data on the accommodation status of patients and housing staff in inpatient and community services has been obtained through Freedom of Information requests. The full replies, data and analysis can be found in this GitHub repository. It also contains data on individual NHS trusts.

Get in touch

There are many things I couldn’t cover (yet). If you have anything to add, want your story to be told or simply want to talk about the issue, send me an email or message me on Twitter.