Health without a home: through user involvement, the QNI Homeless Health Initiative has identified key ways in which health care for homeless people needs to be improved.
Many community practitioners have homeless and insecurely housed patients on their caseload. Yet it is often difficult for them to meet the needs of this highly vulnerable group, due to a lack of support and of specialist knowledge and skills.
The Queen's Nursing Institute (QNI) Homeless Health Initiative (HHI) is funded by the Big Lottery Fund, and offers a way forward for practitioners through peer networking, information sharing and support, and professional training opportunities and resources. In order to ensure the input of homeless people in informing its work, the HHI commissioned the user involvement organisation Groundswell to research homeless people's experiences with health care. (1)
Multiple risk factors
There are an estimated 380 000 single homeless people (adults with no children) in England. (2) Homeless families (adults with children) in England include an estimated 116 000 homeless children. (3) Rough-sleeping is the most visible, extreme aspect of homelessness, but the vast majority of homeless people live in hostels, squats or bed and breakfasts, or in insecure conditions with friends or family.
Homelessness creates multiple risk factors to health, which almost inevitably deteriorates as a result of the prioritisation of immediate needs such as shelter, food and warmth. Health problems can severely affect homeless people's quality of life and limit their ability to access routes out of homelessness. Homeless people suffer significant inequalities in terms of both health and ability to access services.
People who are homeless experience significantly higher rates of health problems such as respiratory disorders, skin and dental problems, musculoskeletal problems and sexually transmitted diseases. Those sleeping rough have a rate of physical health problems two or three times greater than the general population's. (4) Homeless children are 'more likely to have a history of low birthweight, anaemia, dental decay and delayed immunizations ... to suffer accidents, injuries and burns', and the development of a substantial proportion of them is delayed (p463-4). (5)
Homeless children are up to four times more likely to experience mental health problems (6) and their parents are also more likely to experience them: 'Homeless mothers had a 49% prevalence rate of psychopathology and an 11% rate of contact with mental health services in the previous year' (p465). (5)
Indeed, mental health problems are a leading cause of homelessness--in a third of cases, losing a home is associated with mental health problems. (7) Homelessness can create mental health problems for the first time and exacerbate those that already exist. Mental health problems have been found to be eight times as high among hostel and bed and breakfast residents, and 11 times as high among people sleeping rough compared to the general population. (8) Many have multiple needs requiring appropriate health care.
Barriers to services
Homeless people frequently experience great difficulties in accessing the health care services that they need. They are 40 times more likely to not be registered with a GP and four times more likely to use accident and emergency (A&E) than the general population. (9)
Many mainstream providers lack knowledge on homeless people's health needs, impacting adversely on the care provided. There are examples of good practice, such as allowing homeless people to register with a GP using the surgery's address as their own and homelessness training for professionals, and there are a number of specialist services that offer a range of flexible, accessible services (including outreach). However, provision may be patchy, with a lack of specialist services in many areas and a lack of knowledge in generalist services.
The Groundswell report (1) was commissioned with these issues in mind, along with the QNI's commitment to service user involvement. Focus groups with 25 homeless people were held in Grimsby, London and Gloucester, with professional facilitators who had personal experiences of homelessness. Recommendations to improve health care for homeless people were based on the findings (see Box 1).
The most important factor in a health service for the participants was the people, since what mattered was 'respect, good people, tolerance, care, compassion, friendly, no general rudeness.' Specific health issues varied according to circumstances--for example, rough sleepers identified cleanliness, safety and foot care.
Barriers to accessing services included waiting times, insufficient time with professionals, opening times and a lack of information. Service users expressed diverse experiences of staff attitudes, but frequently perceived these to be more negative due to their being homeless:
I was homeless and [the GP] didn't want me around ... he's a lot better now I've got a stable address and all that, he treats me with respect.
Different problems with A&E were noted, including a perception that triage and security staff often had a negative "gate-keeping" role.
Around 38% stated that their first port of call for health care would be a 'one-stop shop'--centres offering homelessness services and health care--but this may have been because many participants were accessed via these kinds of services. In an emergency, most said they would go to A&E or dial '999'.
Some of the participants reported having previously been discharged from hospital onto the streets:
They didn't find me anywhere to live, even though they said they would if I've been discharged on the streets.
I was beaten up and had stitches. Two o'clock in the morning, they're throwing me out. The following day I was vomiting blood.
The positive experiences described by participants included being discharged with enough medication for a week. However, some hospitals may be unaware of the national guidance on hospital discharge for homeless people.
Community practitioners are committed and highly skilled professionals, but caring for this vulnerable population--often with multiple health issues and sometimes chaotic lives--presents many challenges. This may include institutional barriers such as a lack of understanding of homeless health issues by providers. Like their clients, practitioners may also be unsupported and marginalised, sometimes feeling stigmatised and undervalued. There can be insufficient support, resources and appropriate supervision, and restricted career opportunities. (10)
Inadequate understanding and prioritisation of homeless health issues in local health economies means that homeless services are often vulnerable to cuts. In addition, practitioners working in generic services may be unsupported in addressing homeless people's health needs. If there is no analysis of homeless people's local health needs, these can remain 'invisible'.
Imagine being a doctor in an emergency room, and you have a homeless patient to release, they are in bad shape, and you know they have no home. Would it be unethical to let him or her stay the night in a warm bed? It absolutely would, but at the same time if in the situation, I would imagine having a hard time releasing that person because of their circumstances. However, special treatment can not be given to every patient so where is the line drawn?