“You can’t discriminate against someone who is ill based upon the colour of their skin, their sexuality, or disability. But you can discriminate against someone who is homeless,” says Stan, speaking from experience, as he was homeless for over twenty years.
Homelessness is a growing issue, and those sleeping rough often face difficulties in accessing healthcare, and receiving the treatment they need. In the last year alone, government statistics report there has been a ten per cent increase on homelessness and figures look set to continue to rise. Yet NHS policy lags behind its data, and homeless people continue to be marginalised from accessing the services they need.
Being homeless has an undeniable impact on your health – the life expectancy for a homeless person is just 47 years compared to the national life expectancy of 81 years. Yet despite these facts, access to healthcare by these individuals is limited, and there is currently no national framework produced by NICE or other regulatory bodies for treating homeless people. Should these patients be expected to use the NHS like everyone else?
While homelessness is on the rise, it continues to remain rare in England. In 2015, the government estimated that 3,569 people slept rough on any one night. With a population of 53 million, homelessness affects much less than one per cent of the population. Even within the healthcare system, where there is a disproportionate amount of contact with the population, dealing with a homeless patients remains relatively rare. Perhaps lack of policy reflects these low numbers.
Yet, the NHS is meant to provide services dependent on need, not numbers. “In a needs based NHS, our patients should be getting extra care, because they’ve got shedloads of health needs” argues Alex Bax, Chief Executive Officer at Pathway, an organisation that seeks to improve healthcare services for the homeless in hospitals.
Shut out of the system
Although homeless patients are technically entitled to the same care as everyone else, delivery of care fails because the system shuts homeless people out. “Access to primary healthcare is difficult for people living on the street” Stan says, “because of needing proof of address, identification or having to fall within the correct catchment area to receive care.” This forces many homeless people to use Accident & Emergency departments as their first point of access, often only presenting when their problems are impossible to ignore. “You end up with not just one or two minor health issues, but with a range of often extreme health issues that require hospital admissions and long term treatment plans” adds Stan.
It is Stan, and not me, who points out that this is a financially ineffective policy too. Hospital admissions are expensive. According to government data, an overnight hospital stay is estimated to cost £400 a day. “In my opinion, there have been a lot of cut to spend policies. The government cuts policies down to the bone, and then end up spending more to replace the loss of service,” says Stan.
It has fallen to independent organisations to produce systems which help these vulnerable people and stop repeated, long term hospital admissions. Pathway has created a framework to improve hospital care. They have created specialist teams, led by General Practitioners, that work within hospitals to support homeless patients. This includes extensive discharge planning, to stop patients being discharged back onto the street. Sadly, the nine teams working as Pathway teams across the UK still leaves a gap between need and delivery of care.
There are some specialist GP practices that deal with exclusively the homeless which are commissioned locally by Clinical Commissioning Groups (CCGs), but typically there will only be one of these per city in the UK. They are expensive to run. Melanie D’Souza, a GP who works in a specialist practice in Cambridge estimated her practice is five to six times more expensive than a mainstream GP surgery, and serves a much smaller patient body. A normal GP practice may serve around 3000 patients, Melanie’s takes care of only 480. These patients require more focused care as they have complex problems including alcohol addiction, brain injury, Hepatitis C, and mental health problems.
The impact of good care
But the impact a good GP can make on these complex patients is invaluable. “Getting into a specialist service in Watford set me on my own path to recovery” Stan tells me, “I had a GP who I could engage with and build up a level of trust.” By official measures, these services are excellent too. “All of the primary care services that have been inspected by the Care Quality Commission have been found to be outstanding,” says Alex, “whereas only around 8% of regular primary care services are judged to this level.”
This is in part due to the kinds of people drawn to working exclusively with the homeless. Alex describes them as “particularly committed.” Melanie credits her job satisfaction as her main motivation saying “these are really vulnerable people, and I am doing my best for them, and there is satisfaction in that.” Alex tells me that medical students who spend time with the Pathway teams find it inspiring. “They say: you’ve reminded me why I wanted to do medicine in the first place,” he says.
Homelessness is a healthcare issue
As the number of these practices is limited and homelessness continues to rise, it falls to ordinary doctors to engage with these patients. Acknowledging homelessness as a healthcare issue is the first step, says Alex. He tells of me of a physician in Canada who asks every patient he consults a simple question. It is: will you have trouble making ends meet at the end of this month?
“It must be a matter of central concern to a physician if their patient has nowhere to sleep tonight.” says Alex, “because it’s dangerous and unsafe. If you had something in your surgery or your operating theatre that was dangerous and unsafe, you would absolutely do something about it. And there is something in these patient’s lives that is dangerous and unsafe so you have to do something about it.”
“But, fundamentally, what these patients need is the same as anyone else: empathy, understanding, compassion and some professional and clinical knowledge” says Alex. If only policy reflected these principles too.