Ms Niamh Randall:

It might be me. I apologise.

The existence of mental health issues can be a reason for people becoming homeless. Such issues can have a significant impact on people's experiences while they are homeless. A homeless person's mental health can really deteriorate over the period of time for which he or she is homeless. Some 58% of those who participated in the study to which I have already referred had at least one mental health condition.

There are high levels of problematic drug and alcohol use among the homeless population. Drug and alcohol use can put people at risk of homelessness and can be caused or exacerbated by traumatic experiences, including homelessness. We know there is a significant correlation between risky behaviour and housing stability. The poorer someone's housing type is, the greater the chance that he or she will engage in risky or harmful behaviour. People who are sleeping rough and those who are in emergency accommodation are more likely to use alcohol and drugs in unsafe ways and to use them in greater quantities. A health snapshot study that was conducted by the Simon Communities in 2011 found that 50% of homeless people who participated in the study were alcohol users and 31% of them were problematic drug users.

We know that people who are homeless can have multiple needs or complex needs. This means that a couple of issues can happen at the same time. Physical health issues, mental health issues and problematic drug and alcohol use can exist at the same time. This can lead to difficulties in accessing services and can make it difficult for people to have their needs met. We find that people can fall between two stools. It is often argued that if someone has a mental health issue, it should be dealt with in a mental health setting. If that person also has a drug and alcohol issue, however, that needs to be dealt with in a drug and alcohol facility. This means that people's needs are not necessarily met. As a result, problems can arise when efforts are made to respond effectively to people's needs. We would certainly recommend that people's needs should all be dealt with at the same time. Such needs should not be isolated so that they are dealt with individually.

People who are homeless encounter many barriers when they try to access health care. It can be difficult to access services. As a result of the cutbacks in services we saw during the period of austerity, there are greater waiting lists and longer waiting times. Some services have been closed, particularly in rural areas. This means people can have to travel great distances to access services which used to be readily available in their local communities. We know that people who are homeless often contact health services at a time of crisis. We need to intervene before a crisis hits. We need to look at prevention and early intervention. Other barriers to accessing health services include stigma, restrictive catchment areas, inflexible services, lack of discharge protocols, lack of specialisation in services, lack of case management teams and the dearth of services in rural settings.

I would like to speak about possible solutions. Housing First is critical if we are to address homelessness. Housing First programmes are internationally recognised as representing best practice in housing people who have experienced long-term homelessness and have complex and multiple needs. People with mental or physical health issues, including those with dual diagnosis, have complex needs. There are two key aspects to the Housing First approach - the immediate provision of housing without preconditions, including a requirement for housing readiness, and the provision of open-ended ongoing housing support for as long as is necessary.

I will comment specifically on health services. It is essential to increase access to general practitioner and primary health care services so that the health care needs of people who are homeless can be met and early intervention can be provided to prevent further chronic illness. The ongoing resourcing of primary care services is critical if we are to ensure interventions in homeless services are provided nationwide where they are required. Some really good examples of such initiatives are operating in the Simon Communities around the country. It is also important to look at the resourcing and delivery of step-up and step-down beds for homeless people who are being treated for chronic illness. We can discuss this further during the question and answer session.

It is essential to fill the posts in mental health services to ensure there is nationwide coverage of community mental health teams and, in particular, to ensure there is responsibility and accountability for people who are homeless within catchment areas. We also need to look at the development of specialist adult teams, as recommended in A Vision for Change and in the national clinical programme for the assessment and management of patients presenting to emergency departments following self-harm. We need to look at increasing funding for mental health services to 8.24% of the national health budget, as recommended in A Vision for Change. Trauma-informed practices and counselling services are needed to deal with the traumatic experiences that have led to people becoming homeless and to support people's recovery from homelessness. Such work should be resourced in social work settings, community and family services and homeless services. We need to ensure HSE-funded services are upskilled to manage and deal with dual diagnosis.

Harm reduction is absolutely essential and must be at the heart of homeless and drug service provision. The success of harm reduction approaches is vital because there is no conditionality attached to Housing First. It is really critical that we align harm reduction with the Housing First approach. The key to doing this is to look at expanding current harm reduction programmes and at what works best in other jurisdictions. The recent passing of the Bill establishing the State's first medically supervised injecting centre is really welcome. Immediate implementation is critical so that this legislation can have the greatest impact really quickly. This will save lives and keep people much healthier for much longer. We need to ensure there is greater expansion of and access to needle exchange programmes across static, outreach and pharmacy exchange models.

Drug treatment and rehabilitation is about ensuring national alcohol and drug services target the specific needs of homeless people who have alcohol-related or drug-related problems, or both, in line with the four-tier model. Access to aftercare housing is particularly important when people leave treatment. When people engage in drug treatment, it is a really difficult and challenging programme for them and it is expensive for the State. If they do not have anywhere to go to follow up on that, it does not make any sense. We need to ensure aftercare housing with support is provided for people. Rapid access to treatment is really important. People often have to wait in homeless services while they are on treatment waiting lists. Again, this does not make a huge amount of sense.

We also need to look at rehabilitation. There are actions in the Rebuilding Ireland action plan, but there is not enough detail about what this looks like. How are we going to support homeless people with drug and alcohol issues in the longer term?

On the specific commitments, we need some of the vagueness to be clarified.

We also need to look at developing, resourcing and implementing discharge programmes and in-reach services in general hospitals, mental health services and drug treatment services. Nobody should be discharged back into homelessness, yet that still happens. We also need to ensure that ring-fenced emergency accommodation options are in place for drug users experiencing homelessness who are detoxing or working towards methadone maintenance where they are trying to abstain from drug and alcohol use. It does not make sense, when people are dealing with this hugely challenging issue, that they may be in an environment where other people are actively using around them.

We greatly support the report of the Oireachtas Committee on the Future of Healthcare. It makes many very important recommendations including the expansion of counselling services in primary care settings, which is significant and could have a huge impact in terms of dealing with some of the trauma associated with the experiences of homelessness. The proposal to introduce universal access to primary care must continue to be a key priority.

We look forward to the publication of the new national drugs strategy, which we expect in the coming weeks. We made a submission to that process and we are happy to share that with the committee if there is any interest in it.

I thank the members for listening to us. They have received our full submission. We will be happy to take any questions they may wish to ask.