Homeless healthcare

Gem Ashwell and Lucy Chiddick

I am optimistic in the people’s capacity to fight back, but in the short term there is so much to do and not enough people to do it
— Ken Loach, May 2016
Homeless man, London, 2016. Copyright  Neil Hester

Homeless man, London, 2016. Copyright Neil Hester

At the sharp end of health inequalities, homelessness is an outcome of social exclusion that is associated with appalling health outcomes. An increasing body of research has shown that those experiencing homelessness suffer from high rates of physical and mental illness, substance abuse, injuries and assaults culminating in an average age of death of only 47 and 43 years for homeless men and women respectively. Housing is a key social determinant of health and as evidenced above, a lack of housing should be viewed by medical professionals as a red flag symptom.

What can I do?

Internationally the poor health status of people experiencing homelessness is exacerbated by poor access to health care. The charity Crisis reports that homeless people are almost 40 times more likely not to be registered with a GP than the general public. However, the specialist generalist skills in primary care mean that we are well placed to provide holistic care and address the multi-morbidity associated with chronic homelessness.

A few suggestions include:

  • Be aware of all the resources in your local community and have leaflets available which provide this information

  • Remove barriers to accessing your service such as policies of requiring identity documents, remember this is not a regulatory requirement and patients without them should not be refused to register.

  • Homeless people often fear judgement, establishing mutual trust may require extra effort but is crucial in establishing a positive relationship

  • Take extra care to ensure homeless patients have choice and are able to participate in decisions about their health

  • Advocate for appropriate housing for your individual patients

  • Involve patients with experience of homelessness in helping to improve your service

Understanding the causes of homelessness leads to the conclusion that if we as health professionals want to effectively address this issue, we need to not only improve the health of homeless individuals but also advocate and campaign for policy changes to address the structural factors contributing to poverty, deprivation and homelessness.

Defining homelessness

Homelessness is not a single entity. As well as those who are ‘roofless’ and sleeping out, there are high numbers of people in the UK staying in temporary accommodation such as hostels and B&Bs, there are unknown numbers of ‘hidden homeless’, so called because they are ‘sofa surfing’ and unlikely to be included in formal figures on homelessness. Then of course there are those who do have a place to live but it is unfit or unsafe for habitation. Another group to be aware of as general practitioners are those in unstable housing who are at imminent risk of having no place to live. 

The causes of homelessness

The causes of homelessness are complex and can be understood as an interaction between individual and structural factors. Research on paths into homelessness has showed that childhood trauma and early adverse experiences are common. Other important individual factors include poverty, mental health and substance misuse problems, having been in the child welfare system or involvement in the criminal justice system. Structural factors causing homelessness include lack of employment opportunities, lack of affordable housing, welfare policies and income inequality. Studies show that when such structural supports are more limited, it takes fewer individual vulnerabilities to become homeless and rates of homelessness rise.

Our lives begin to end the day we become silent about things that matter
— Martin Luther King


I’m cold, I’m hungry, I have no place to live
I’m sat begging people for any spare change to give
Some look in disgust, treat me like I’ve done bad
Thinking I chose to loose all I once had
A family, friends, a little place of my own
Now I’m on the streets begging, lost and alone
Many people hurry by, they ignore the plea in my voice
I want to scream becoming homeless was never my choice.
— A homeless patient writing whilst waiting to be seen in a GP surgery


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