Frontline healthcare services need adapting to better support the often chaotic lives of people living rough on the street, according to a new study from researchers at the University of Bath.
The detailed ethnographic report, which involved the main researcher spending time alongside members of the homeless community on the street, concludes that better ‘adaptive services’ would make a positive impact on people’s lives and could begin to help turn around their fortunes. The research finds that health service providers currently have limited resources, flexibility and understanding on how best support their needs.
In the study, which draws on interviews conducted with over 100 people living rough in Dublin, the researchers suggest health services need to review access to ensure they do not place unnecessary barriers on homeless people. They suggest this might include increased access to walk-in slots including in hostels; new training for healthcare staff to manage challenging behaviour; education for health professionals to address the stigmas associated with homelessness; and increased efforts to promote and make accessible health services as friendly and responsive to homeless people’s needs.
Scale of homelessness
According to figures released this week by the charity Shelter, the number of people in England who are homeless has risen to 280,000, up 23,000 since 2016. In Dublin, according to figures from Focus Ireland, in November 2019 the rough sleeping count confirmed 92 people were out on the streets at night, with significant, additional numbers of people accessing emergency night shelter in the City.
The researchers suggest that the need for specific adaptive services is most pressing where there is greatest need. They highlight that those living rough face multiple healthcare challenges, affecting both their physical and mental health and adding pressures to complex and challenging lives. Homeless people have significantly higher mortality rates than the general adult population and they face a disproportionate burden of infectious diseases, including HIV, Hepatitis and Tuberculosis as well as higher rates of chronic diseases including asthma, heart disease, stroke, epilepsy and multi-morbidity. In addition, higher rates of schizophrenia, depression and anxiety add to a greater mental illness burden that has also resulted in higher suicide rates. Compounding all these problems, homeless people also have much higher rates of alcohol and drug-dependence.
Dr Austin O’Carroll, lead author on the study, Doctorate in Health from the University of Bath and GP in Dublin explained: ‘Doing this research has made me acutely aware of the range and depth of barriers to homeless people in traditional medical services. The most pervasive of these barriers was stigma, as not only was it a barrier in itself, but it protected service providers from the shame of providing inaccessible services. The most inaccessible services were the ones where homeless people did not even attempt to access – as ‘everyone knows’ there is no point attending that service. This is an internalised barrier and something that needs to be addressed urgently.’
Reflections from those sleeping rough on the street were grouped into four distinct categories. These focused on individuals’ dependence on benzodiazepine (sleeping pills) and challenging conversations where patients often lied to obtain what they wanted and doctors (they perceived) blamed them for their situation. It also highlighted an issue around how homeless people presented themselves and interacted, which often escalated tensions and added to distrust.
Among some of the depressing comments from those on the streets, respondents said:
So the doctor's surgery near the hostel I was staying in decided they wouldn’t see any of us without a member of the hostel staff present in our private appointments; maybe because they were scared of us. I went in one day with one of the staff to try and get a script from my inhaler. The doctor must have forgotten she was staff and thought she was my girlfriend. He was really rude to me, he wouldn’t look at me and he barely spoke to me.
Along with the stigma sometimes you feel the inferiority complex. I think a lot of addicts have an inferiority complex… A lot of people, when they got into drugs, you don’t know in the long term, the damage that you’re doing to yourself, in most cases. And when you do realise, I know for a fact that when you go into that hospital, you have all that burden on your back. You know that it’s your fault that your veins are as bad as they are, that your breathing is as bad as it is on top of your asthma or whatever… Just very, very small … I’m wasting people’s time.
I don’t care – I don’t care about my life. I just don’t see a reason why I should be here…I can see death, in me… And it is going to happen someday. I think it’s going to be very soon…
Co-author on the study, Dr David Wainwright, Senior Lecturer from the University of Bath’s Department for Health and member of the Centre for the Analysis of Social Policy (CASP), said: ‘Homeless people, sleeping rough, are a very needy group but also one which is incredibly difficult to reach. This creates significant challenges when it comes to devising and targeting policy interventions that can make their lives better.
‘Of course, there are multiple pressing factors that create this situation – highlighted in particular at this time of year. However, this study focuses on some clear and important interventions which can make a positive difference when it comes to their access to high-quality healthcare services, most significantly where there are large disenfranchised homeless populations.’
Although the specific research was conducted in Dublin, Ireland, the researchers suggest its findings are applicable internationally. In relation to the UK, they suggest many of the same barriers identified in Ireland, are applicable to homeless people in cities across England, Wales, Scotland and Northern Ireland.
The full research paper ‘Making sense of street chaos: an ethnographic exploration of homeless people’s health service utilization’ is published in the International Journal of Equity in Health,
The research was funded by the Irish College of General Practitioners.
Find out more about Dr Austin O'Carroll and his story via this University of Bath case study Helping the Homeless.