Peer advocacy and access to hospital care for people who are homeless in London, UK, 2019-2023: a cohort study.

objectivesTo measure differences in hospital use between homeless adults using the homeless health peer advocacy (HHPA) service (clients) and non-clients in London.

designWe conducted a cohort study with linkage to Hospital Episode Statistics (HES) 1 year prior and postenrolment.

settingLondon, UK. POPULATION: People who are homeless in London aged over 18 years residing in a hostel, attending a day centre or being referred by a homelessness service; experiencing difficulties accessing healthcare; and speaking either English or Polish. Participants were required to provide consent for linkage to HES. To be classified as a client, individuals must have used the HHPA service at least once between January and July 2021; non-clients were those who had never used the service.

interventionPeer advocacy is the provision of support by volunteer-trained advocates with lived experience of homelessness to individuals to overcome barriers to accessing health services. OUTCOMES: The primary outcome was not attending a scheduled outpatient appointment ('did-not-attend') over 12 months postrecruitment, commencing from their baseline interview date. Secondary outcomes included the number of accident and emergency (A&E) and inpatient admissions (all and planned admissions) during that same period.

methodsWe estimated the probability of non-attendance using Poisson regression and the number of inpatient admissions and A&E visits using negative binomial regression models. Models included: (1) propensity score weights and (2) propensity score weights and imbalanced confounders. Sensitivity analyses assumed that participants who did not link to HES had no hospital attendance. Exploratory analyses examined differential effects of peer advocacy by clients' type of peer advocacy engagement (new vs ongoing clients; supported vs unsupported) and by clients' anxiety or depression symptom scores measured with the Patient Health Questionnaire-4 (PHQ4).

results153 clients and 158 non-clients were recruited between July and December 2021. Most were male (77.5%) with a median age of 48 years. Weighted regression models suggested no evidence of effect of peer advocacy on non-attendance (rate ratio (RR) 0.97 (95% CI 0.67 to 1.42)), no difference in the mean number of A&E visits (2.59 95% CI 1.93, 3.24 vs 1.76 95% CI 1.13, 2.40) but more inpatient admissions (1.65 95% CI 1.10, 2.20 vs. 0.53 95% CI 0.27, 0.82) for HHPA clients vs non-clients respectively. This was supported in sensitivity analyses. In exploratory analyses, clients with PHQ4 scores of 9-12 had greater probability of non-attendance at outpatient appointments (RR 1.98 (95% CI 1.0 to 3.89)) compared to non-clients. Those with scores of 6-8 had 5.86 (95% CI 2.73 to 9.0) completed appointments versus 1.87 (95% CI 0.41 to 3.34) among non-clients and 1.13 (95% CI 0.01 to 0.27) inpatient admissions compared with 0.13 (95% CI -0.01 to -0.27) among non-clients.

conclusionsFollowing COVID-related disruptions to the work of peer advocates and health services, we found mixed evidence on the effect of peer advocacy: with no evidence of impact on outpatient appointments or use of emergency services; but increased inpatient admissions.