The provision of care for homeless people is patchy and woefully inadequate, with new research by The Doctor showing huge variation in the services commissioned. And yet there are some rare but inspiring examples, which are responsive, compassionate and effective. Peter Blackburn finds out how they manage it
The greater the health and social care need, the worse the provision, states the inverse care law. It’s one of the better-known – and most regrettable – observations made about UK healthcare.
Homeless people have some of the most profound mental and physical health needs of the population. These are growing. The Doctor found visits to emergency departments had nearly tripled in seven years, in research published earlier this year. And yet provision is nowhere near matching demand. It is predicted that deficits in local authority homelessness services will increase fourfold in the next five years.
So where you do find examples of healthcare provision for homeless people that are not only effective, but achieve the things mainstream healthcare can’t always manage – integration, responsiveness, and overwhelming compassion – they’re exceptional in every way.
One such place is the Dawn Centre in Leicester. It has a day centre run by the YMCA, a large council-run hostel, a GP service run by social enterprise Inclusion Healthcare, a wide range of physical and mental health teams and specialists, local authority staff specialising in housing and homelessness, outreach teams and access to huge amounts of support, advice and guidance.
The best examples of integration are where the users can’t see the different parts that make up the service.
‘It wasn’t just a bed – it was like a whole team of people just surrounded me’
‘We pride ourselves on the fact that homeless people can come here and effectively not leave the building for the support and services they need,’ homelessness services manager Gary Freestone says.
‘The knowledge and relationships are our biggest strength… we have a far better opportunity with different agencies together.’
Offer of hope
Meshek Munroe (pictured below) and Nirvana Stretton became homeless in March and spent five weeks living in a car in Leicester city centre. Mr Munroe lost his job, and the couple had become cold, hungry and hopeless.
Within minutes of arriving at the Dawn Centre, he was given a warm, fleece-lined coat.
‘I could have cried,’ he recalls, ‘it was amazing’ – and from there GP appointments were made, assistance with mental health issues offered and, most crucially of all, a place in the hostel secured. The couple is now being helped to find a new home.
‘The main thing this place does is give people hope,’ says Mr Munroe.
Darren Evans, a 40-year-old alcoholic, had been sleeping in a park, begging for money to buy his next drink.
‘I came to the Dawn Centre out of pure desperation,’ he says. ‘It wasn’t just a bed – it was like a whole team of people just surrounded me. They got me in with the GP and looked after my health, they helped me out with clothing, food and all sorts really.’
As another service user says: ‘Unless we have a service like this here we are lost.’
The services in Leicester are not replicated everywhere, however – many homeless people have nothing to turn to in their areas, finds an investigation by The Doctor, collating data around homeless health services and staffing acquired from 143 of the 191 CCGs (clinical commissioning groups) in England.
Lack of services
Only 20 CCGs reported having clinical leads for homelessness – a position of responsibility for overseeing care for homeless patients recommended by some experts. And just 15 areas said they specifically hire or contract staff to work in homeless care.
Most revealing of all, the investigation – which asked every CCG in the country to detail the health services they specifically commission for homeless patients in their area – highlights a vast disparity in care offered to rough sleepers or the vulnerably housed across the country.
In 66 CCGs, specifically commissioned homelessness services were reported. In one case this is nothing more than a £500 annual budget for flu vaccinations, in others there are comprehensive GP and outreach services costing hundreds of thousands of pounds. But in 77 CCG areas there were no specific services detailed.
It is clear from their responses that many CCGs see the responsibility for homelessness as belonging solely to local authorities, despite its overwhelmingly strong link with poor health outcomes, and evidence that successful interventions cost society a fraction of leaving someone homeless.
On the rocks
While there is little central direction or investment in homeless services – an announcement of £1.9m to improve the health of rough sleepers attracted widespread derision last month – it has not stopped doctors taking the initiative in many local areas.
Rochdale GP Zahir Mohammed’s day-to-day experience at work has taught him how arbitrary people’s fortunes can be.
‘We have been having patients who have been fine in their lives and then suddenly they are down on their luck and in a downward spiral. You just never know what is going to happen around the corner.’
His practice hosts a drop-in surgery every day for homeless patients, and stocks homeless packs containing sleeping bags, breakfast and information about overnight accommodation.
‘It’s better they come and see us than sit in A&E – it’s better for everyone. For themselves, and the cost is huge otherwise,’ Dr Mohammed says. ‘We’re pretty flat out, and, I’ll be honest, it’s getting more and more difficult because the NHS is busier and funding is tighter, but this is our philosophy.’
More homes, more homeless
Dr Mohammed is one of many volunteers who also run another vitally important resource for the homeless. HART (Homeless Alliance Response Team) was inspired by a visit to a church project gathering clothes and toiletries for the homeless and now brings together GPs, nurses, therapists and mental health workers. Based around a soup kitchen, it cares for around 80 people.
Volunteer Mo Jiva, a Rochdale GP and chief executive of the Rochdale and Bury local medical committee, says: ‘You see improvements really quickly and the rapport that these people have with nurses and us is amazing.’
‘We have been having patients who have been fine in their lives and then suddenly they are down on their luck and in a downward spiral’
A broad pool of volunteers helps to keep it sustainable. ‘It’s one or two hours a month for many people, which isn’t onerous, but having that rota filled makes a really serious difference and that’s a big incentive.’
Twelve miles south, in Manchester, there is a cruel paradox. The building of new flats aimed at young professionals is taking place at a spectacular rate – triple that of Birmingham, according to a recent study – but with the increase in homes, there is an increase in the homeless, often sleeping in the shadow of the flashy new apartments.
On the streets
Official rough-sleeper counts in the city, bearing in mind that such figures tend to underestimate true numbers, have soared from seven people in 2010 to 123 in 2018.
It is in the face of this rocketing need – an obvious concern for anyone walking through Piccadilly Gardens or St Peter’s Square – that GP Gerry O’Shea and his team work, every day.
His Urban Village Medical Practice, in the east of Manchester, has around 11,000 patients registered, including 750 who are homeless.
The scope of its work is remarkable – including case management of homeless patients who are frequent hospital attenders, support with benefits, outpatient appointments and housing options, and simplifying registration.
Perhaps most fundamentally it offers flexible access, including a drop-in every day, to a range of services including drug assessment, mental health support and dentistry.
The service is commissioned and strongly supported by local health leaders now – but initially, Dr O’Shea says, it was about individual personalities driving change, which, in part, explains such patchy care around the country.
‘If we didn’t do what we do I don’t know if there would be any service in Manchester,’ he says.
As the service develops, Dr O’Shea (pictured below, second from right) and homeless service manager Rachel Brennan are looking to embed a ‘hub-and-spoke’ model – partly already in place – which is based on a large homeless hub where patients are registered and the wider team of health specialists are based, with smaller GP surgeries, particularly in areas of high demand, supported to provide a more significant service for patients than is often the case.
‘It’s what we need because of the increase in population of homeless people and the increasing complexity of the people we see here,’ Ms Brennan says. ‘It’s difficult work and people have to want to do it. It’s a vocation within a vocation really.
‘We think we’ve got this all-singing, all-dancing service, and it’s brilliant – you can have whatever needs you have met in the building, but when you ask people it’s really because they feel welcome when they are here, people remember their names, they’re asked how they are as well as getting their dressing done.
‘One of the barriers to healthcare is how they are treated by staff and other people. That is a challenge.’
Access is also important to the approach taken by the York Street Medical Centre in Leeds. It’s run as part of Bevan Healthcare, a community-interest company with another service in Bradford, and cares for people who are homeless, in unstable accommodation or have come to the UK as a refugee or to seek asylum. It offers GP appointments, an outreach service and a substance misuse service run by an external organisation.
‘Any city needs to be responsive,’ York Street GP Rhiannon Davies says. ‘You can have services but if they are not able to respond there and then you can’t help. You need to be alongside people at the moment they are ready for you, otherwise the barrier of days, weeks or a month means you lose that opportunity.’
Hearing Dr Davies speak, one immediately wonders how many homeless people have been ready to receive help, only to find there is little or none available in villages, towns and cities that do not have such initiatives.
York Street patients include Derek Goodwin. Released from prison a decade ago, he has lived largely on the streets between stints in hostels. Aged 43, he has severe COPD, ‘the lungs of a 72-year-old man’. About the only constant in his life has been his GP practice.
Mr Goodwin, who says he has passed out and been taken to hospital five times in recent years, explains: ‘I can get the help I need because of this place. I get treatment – alcohol support and counselling – and it’s a GP surgery for me too and I can see them about my COPD.
‘When you ask for help you want it there and then, not in a month’s time – you don’t know what you will be doing in a month. You could be brown bread.’
These practices and projects show what is possible.
It might seem daunting to take on healthcare for the homeless.
However, Dr Jiva (pictured below, left) says: ‘There are fears about a violent, druggie population, but these are myths that can be overcome – it’s nowhere near as bad as you think, and the outcomes are so much better than what you might think.
‘The first thing I thought was that I’ll need to sort my life insurance and medical indemnity, but it’s often been much more enjoyable than my own patient group.’
If it’s possible, and the financial and moral arguments have already been made, why are so few areas providing anything that could be described as comprehensive? The answer lies locally and nationally, according to those on the ground.
In a local sense money is tight and services are already strained. Few people innovate without headroom – and for many frontline staff the prospect of taking on the workload that HART in Rochdale or Dr O’Shea in Manchester have done might appear overwhelming.
And, nationally, political will is hard to find. In any given year empty promises around homelessness and eliminating rough sleeping are dropped like confetti at a wedding but action appears much less likely.
Urgent steps needed
In 2011, the Faculty for Homeless Health set a national strategy, and standards for healthcare for homeless people – including service-user involvement in commissioning and delivery of services and enhanced access to healthcare services for all homeless people in every area. Eight years on it’s hard to see that they are being met in any meaningful way.
So where should the health service, and the country, go from here? A first step would perhaps be to learn from the good work being done in pockets around the country and invest in taking those lessons elsewhere.
Among those The Doctor spoke to, those lessons were near-unanimous: research into the relationship between homelessness and health, training of and investment in NHS staff, reversal of cuts to support services and welfare and a proper house-building programme.
Earlier this year Ms Brennan published the results of her Winston Churchill Memorial Trust Fellowship, which saw her travel to Norway, Denmark and the USA to investigate successful ways of delivering healthcare to the homeless.
Ms Brennan’s conclusions are clear and could hardly be considered troublingly radical in a rich country with a universal healthcare system – and which can no longer hide from the costs of doing nothing.
They include bringing healthcare to homeless people, transitioning patients to mainstream healthcare settings, and ensuring healthcare professionals have access to training in homeless health.
Zana Khan, GP clinical lead for the King’s Health Partners, part of the Pathway Homeless Team at South London and Maudsley Mental Health Trust – a service that works with patients while they are in hospital in a bid to ensure their circumstances are changed before being discharged – and an academic in homeless health, also gave her checklist for change.
For Dr Khan the steps to take are: a single budget for health, housing and social care; ‘robust’ education of frontline staff; a policy change which would mean statutory bodies have to act to avoid homelessness in a person who accesses their services; and a commitment that no person should be discharged from a hospital to the streets.
Call for resources
BMA council chair Chaand Nagpaul (pictured below) said: ‘It is inspiring to see so many doctors and volunteers providing care and support to homeless patients across the country – but we need greater resources across the NHS and social care to reduce the number of people finding themselves on the street and to ensure comprehensive services are in place to help those who do fall through the cracks.
‘Given the clear cost of homelessness to the NHS it cannot be an option to have such patchy provision across the country.
‘CCGs should be encouraged to appoint homelessness leads to assess local need and coordinate care, and the resulting services must be properly funded by the Government.’
The point is, there isn’t really an alternative. Not in this country, not in this century.
As Mr Munroe says: ‘I just don’t think we would be here without these people. We owe them our lives. We would have frozen to death in the car otherwise. You need someone to pick you up when you are down.’
Read the first installment of The Doctor's research into homelessness
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