Homeless fall between healthcare cracks, but fresh approaches can help them

Outside the system. Deadly Sirius

My partner and I volunteered at a homeless shelter last month – the idea being to channel our spare time and seasonal spirit into something community-focused and productive.

I’ve worked in many inner-city and over-burdened Accident & Emergency departments overseas, so thought I had a good grasp of challenging most stereotypes, including ones about the homeless. But that went flying out of the window once I actually met the guests at the shelter and when I thought about the experience afterwards.

One of these is that although the word “homeless” conjures up images of people sleeping on the street, there are many people in different situations. These include those who have no permanent home (sleeping on sofas at friends’ houses maybe) or who are temporarily accommodated at a long-term shelter.

The UN identifies two categories: primary homelessness, or sleeping rough; and secondary homelessness, those with a roof over their head but no place of usual residence.

Go figure

Between July and September 2013, 28,380 applications for housing were made to local housing authorities in England, of which 13,330 were approved. A sample also revealed that 57,350 householdsin England were in temporary accommodation as of 30 September 2013. And it’s estimated that more than 2300 people slept rough around England last year, with about a quarter in central London.

Housing applications aside, it’s extremely difficult to find accurate statistics on the prevalence of homelessness; people may be difficult to identify given a lack of contact with routine services.

When it comes to rough sleepers, information from the CHAIN database estimates that 6437 people in London slept rough at some point during the 2012-2013 financial year. The data also tells us the majority were male (88%) and aged between 26-45 years (58%). Just under half were UK nationals (47%) and 11% were aged under 25.

All these figures above give us some idea of the size and diversity of the problem, and perhaps how we might start to provide the right care and health services for homeless people.

A rough life

Rough sleepers people are at increased risk of dying – and dying prematurely. Research from Canada that studied those in shelters and those outside them, estimated that mortality rates in rough-sleeping youths were between nine and 31 times higher than in the non-homeless population. Other healthcare challenges (and sometimes the very conditions that precede homelessness) include mental illness, drug and alcohol abuse. It’s estimated that around 41% of homeless Londoners have specific support needs relating to alcohol, 28% to drugs, and 44% to mental health. And are 35 times more likely to commit suicide.

Not only are homeless people at risk of premature death, but they also suffer disproportionately from a number of chronic health conditions including tuberculosis, seizures, chronic obstructive pulmonary disease and skin and foot problems.

The severity of diseases are often advanced because of the delay in presenting to a health professional, inability to complete a full course of treatment, or other factors such as poverty, mental impairment and the consequence of living a chaotic life with regular change.

Complex life, complex needs

On the whole, the health needs of the homeless population are extremely complex and not adequately addressed by mainstream healthcare and access to it. Getting to a doctor, for example, might call for transport they don’t have, or there may be difficulties in getting prescriptions. And when you’re trying to survive or find shelter, these take priority over getting help for an infected wound.

As Jeffrey Turnbull and colleagues put it:

[homeless people] are discouraged by a system that works for others but that works against them … negotiating a complex health care system is almost impossible for many … These problems are not unique to health care: they apply equally to the housing, judicial and social systems.

Help is sporadic. Often, the first point of call is the local emergency department, which is geared for high-turnover and acute care, not towards complex health and social needs. Those who end up there have longer stays, a higher triage category, and are more likely to require ambulance transport. One study suggested that homelessness was the most significant predictor of repeat visits.

Ways forward

A traditional model of healthcare has not and will never suit most homeless people or rough sleepers. But with more understanding of what these needs actually are, better communication and outreach, and some creativity, it’s possible that even an overburdened and time-short health system could do better.

It is interesting to reflect on a randomised trial from 1995 that identified compassionate care as a key way to address homeless people’s needs, improve their experience of healthcare, and reduce visits to emergency departments. Shifting focus towards issues of housing and social support has also been found to reduce the burden of regular visits to A&E.

Another innovative approach is Find and Treat, a service for homeless and other marginalised people with tuberculosis in London. Tuberculosis (TB) is a disease of poverty and inequality, and is transmitted especially in conditions of overcrowding and inadequate ventilation. The homeless population is especially susceptible, and often have difficulty seeking hospital-based diagnosis and with compliance to six months of therapy if diagnosed.

The service consists of a mobile, multi-disciplinary team, which finds cases of TB in the community through outreach services. And the unit also provides a digital X-Ray service for rapid diagnosis.

Winter is a rough time of year, especially for homeless people. When most of us are at our lowest point of health over the colder months, it is important to reflect on those who are much more vulnerable. While their health needs are complex, there are opportunities to help more. And in keeping with what the healthcare profession aims to do, we can practise compassion, understanding and humanity towards others.