At least 56 homeless people have died on the streets and in temporary accommodation in the UK so far this year. It brings the total recorded to almost 300 since 2013, according to research by the Guardian and the Bureau of Investigative Journalism. The true figure is likely much higher as no official figures are collected, making it hard for health professionals to respond to the increasing number of deaths.
“Very often people are dying prematurely, and it’s just being put down as: well, they were homeless,” says Dr Tim Worthley, who is one of three specialist GPs at homeless surgery Arch Healthcare in Brighton, East Sussex. In 2011, he started to record how many homeless people who attended his practice died. “People would just die, and that was that. The least I thought I could do was to start keeping lists,” he says. During 2017, he recorded 17 deaths among the 1,100 patients who sought treatment, more than twice the death rate in Brighton as a whole. Of these, 14 were men, and three were women. The average age at death was just 46.
Rough sleepers and those in emergency or temporary accommodation do not typically die of exposure or other direct effects of homelessness, according to international research by the US-based National Health Care for the Homeless Council. Instead, they mainly die as a result of treatable conditions such as liver and gastrointestinal diseases, respiratory problems and the consequences of drug and alcohol addiction. But accessing treatment at an early stage in the UK can be very difficult for homeless people, who face bureaucratic barriers including needing a proof of address to register at a GP surgery when they are also often in personal crisis.
Although a lot of guidance on commissioning primary healthcare for homeless people has been issued since the 1990s, access varies greatly from region to region. A recent King’s College London study found that only 43% of homelessness projects were linked to a specialist healthcare service like Arch, with particular gaps in small towns and rural areas.
The more you push people to the margins, the more they fall out of the system and end up on the streets
Rough sleeping has more than doubled nationally since 2010, with thousands bedding down outside every night, while the numbers of homeless people in temporary accommodation has grown by 61% since 2010. Homeless patients often arrive at A&E with a combination of physical and mental health and addiction problems, and therefore spend much longer in hospital than the average patient.
“Because of the huge pressure on services, I see healthcare – especially GP surgeries and hospitals – as a conveyor belt that’s moving increasingly quickly, says Worthley. “In order to access healthcare, you need to be able to jump on at the beginning at the right place and you need to keep pace with it all. You need to play the game, get to your appointments, and you get treated.
“If you get on at the wrong point, or are limping too much, or can’t cope with the pace, or say no because you’re scared or whatever, then you fall off and don’t get the care. There are all these people falling by the wayside and not getting the care they need. And homeless people are absolutely among them.”
From October, key parts of the NHS, including A&E and all inpatient treatment centres, will be obliged to refer patients who are homeless or threatened with homelessness to a local housing authority as part of the Homelessness Reduction Act that came into force in April. However, GP surgeries are exempt, and with hospitals not being allowed to record a patient’s housing status on admission, there are concerns over how the new rules will work.
Some charities are taking matters into their own hands. Pathway has set up teams of specialist GPs, nurses and community workers in 11 hospitals in Bradford, London, Brighton, Manchester and Leeds to use hospital admission as a chance to help patients turn their lives around. The small charity, currently funded through private grants, has also created gold standard commissioning guidelines for homeless care.
It was set up in 2009 following the death of a rough sleeper shortly after he was discharged from University College hospital in London. The first Pathway team consisted of a senior GP, a specialist nurse and a practitioner with knowledge of the welfare system. Whenever a homeless person was admitted to the hospital, a member of the Pathway team was called to help guide both staff and the patient.
“With people who have been on the streets for a long time, they’ve usually got a lot of medical conditions which may be interacting with each other. For example, the orthopaedic surgeon may not be great at thinking about how a patient’s diabetes is being managed in the context of a twisted ankle and long-term drug dependency,” says Alex Bax, chief executive of Pathway. “The orthopaedic surgeon might be under pressure to get you out because they’ve got an elective list, so the Pathway teams become clinically engaged, advocating for better, more coordinated care for patients.”
After their time in hospital, the Pathway team, which is often created using existing NHS budgets, helps homeless patients find hostel accommodation, supported living and care homes, ensures access to drug and alcohol addiction services, benefits and legal advice, and helps with lost paperwork.
“Homelessness is in part a problem with housing and part driven by government welfare reform. The overwhelming cause of homelessness now, which is a staggering change, is the ending of a shorthold tenancy, which effectively means it’s because they can’t pay the rent,” says Bax. “The more you push people to the margins, particularly vulnerable people, those who are a bit more troubled, a bit more chaotic, the more they fall out of the system and end up on the streets. That’s what’s happening. It’s the vulnerable who get pushed right to the edge and then fall off. The government’s policies are herding people to the edge of these cliffs, and a lot of people are clinging on to the top.”
According to Bax, in order to get value for money from a dedicated Pathway team, a hospital needs to have about 250 homeless patients per annum, – which means at any one time there might be six to 10 such inpatients.
Campaigners believe that if this model was extended to more hospitals, it could help prevent homeless people, such as a man known to locals as Ben, from dying on the streets. The week before Ben was found dead inside a tent in Retford, Nottinghamshire, he had been receiving treatment in hospital for pneumonia. When it was time to leave, the 53-year-old did not want to stay in temporary accommodation, so he was discharged on to the streets. A member of staff at the hospital drove Ben back to the doorway nearly an hour away where he had been sleeping all winter, and a shopkeeper met him with new camping gear and blankets to withstand the winter chill. Days later, freezing Siberian air engulfed the British Isles and Ben’s body was found on the morning of 27 February.
Back in Brighton, Worthley believes Arch Healthcare, which uses Pathway’s approach to support patients in temporary accommodation or on the street when they are discharged from hospital, is making a difference. The service was first commissioned by Brighton and Hove CCG after a successful pilot in 2013 recorded significant improvements in patients’ health and readmission rates.
“Although many of the problems remain and we have more homeless people with relatively fewer resources, now the different teams in Brighton work more collaboratively to give these women and men better support and more dignity,” says Worthley.