Marcel Slockers

115 General discussion Effects of policy In our study, we did not observe significant changes in the total mortality of homeless people, but we did notice a change in the mortality pattern after implementation of the Plan of Action Social Care. The failure to reduce overall mortality is a surprising outcome that we did not expect. We did observe a statistically significant halving of the number of suicides and homicides. It should be kept in mind that our research design, an uncon- trolled before-after study, does not allow conclusions about causal relationships. We found ecological relationships between social policies and mortality that make it plausible that policies aimed at housing, employment, and improved contact with healthcare may be associated with fewer suicides and homicides within this vulnerable group. This relation- ship is supported by previous international research, in which similar shifts in cause of death patterns following the introduction of social policies aimed at housing and improved contact with social services were reported. Those studies also reported less unnatural death, and more cardiovascular disease and cancer. 1,2 There are several possible explanations for the lack of decrease in overall mortality. Some of the people who were counted as homeless in 2001 may have found housing before the start of the Action Plan Social for Social Support in 2006. 3,4 This may have caused a dilution of the effect on mortality. It is possible that we would have seen a decrease in overall mortality if we had not used the same cohort in the two study periods. For evaluating changes in mortality due to the Action Plan Social for Social Support, a comparison of mortality in the cohort 2001-2010 with that of the second cohort 2006-2015 would have been a better research method. This was not possible, however, because a detailed census survey, which could be used to form a homeless cohort, was only conducted in 2001. A second possible explanation is that despite the intensive policy program between 2006 and 2010, not enough homeless people were reached. Not every homeless person who was reported to the municipalities participated in a programme. Ultimately, over the years, between 41% and 58% of the registered homeless people received a personal support plan. By the beginning of 2014, of the 18,188 people who were offered a personal support plan, 11,019 in the four major cities appeared to have found a stable mix of housing, legal income, and contact with healthcare workers. 3,4 This means that about half of the homeless people received a personal support plan, of whom about 60% found a stable mix. This means that, of all homeless people, only about 30% found the stable mix. A permanently increased mortality rate among the large subgroup that remained homeless and did not find a stable mix probably had a diluting effect of the policy on total mortality. Finally, a third possible explanation is that we evaluated the effect on mortality in a cohort of people, a large proportion of whom had already suffered from long-term homelessness