Sickness and stigma
The year is 2020. Paul is sleeping rough in a churchyard in Oldham, England. A pandemic is raging across the planet, but, pre-occupied with the task of finding a ‘home’ for the night, Paul has no idea, until he sees the streets of Oldham become almost completely empty, from one day to the next. Having to live on the street has almost certainly damaged his immune system, and, at age 45, Paul has already reached the average life expectancy of a homeless person in the UK.
In 2020, a homeless person died every nine hours in the UK. Shockingly, this figure is not all that different from figures before the COVID-19 pandemic, showcasing the dire situation for the 300,000 people without a home in one of the richest nations on the planet. Homeless-friendly healthcare aims to provide medical support to these people who would otherwise go without, particularly during this seemingly unrelenting pandemic.
Homeless people are at a much higher risk of chronic health issues, particularly chronic lung conditions, such as asthma and chronic obstructive pulmonary disease, that would make them particularly vulnerable to the coronavirus. Thus, they are greatly in need of medical help, and indeed NHS Patient Registration guidelines state that “people do not need a fixed address or identification to register or access treatment at GP practices”.
Infographic showing homeless health conditions (Image courtesy of Homeless Link)
However, 20% of homeless people that attempt to access GP services are turned away, due to lack of training or awareness of homeless health issues, administrative issues, and strict practice-based policies. These policies can make it difficult to register someone who does not have any ID, proof of address and utility bills, and other documentation that is typically required to register with a GP, despite the applicability of the aforementioned NHS guidelines in these situations. This results in barriers that make it difficult to receive help, for those that need it most.
This very vulnerable group has consistently faced stigma and exclusion from society, particularly when it comes to healthcare. These inequalities have been greatly exacerbated during the COVID-19 pandemic, despite the knowledge that homeless people are 5 times more likely to die from coronavirus compared to the general population. One of the most blatant examples of this disparity was the failure to include homeless people on the COVID-19 vaccination priority list released by the Joint Committee on Vaccination and Immunisation (JCVI) in December 2020.
Through the combined efforts of Dr. Zahid Chauhan and Homeless Link this was finally changed on March 11th, 2021, an example of cooperation between homelessness advocates that have been striving for a more homeless-friendly healthcare long before this pandemic.
Homeless Friendly – leading by example
Dr. Zahid Chauhan OBE has been campaigning for a more homeless-friendly healthcare system in the UK for years, both as a GP, and as a member of the Council of Oldham. Through the creation of his organisation Homeless Friendly in 2017, Dr. Chauhan has helped health services become more homeless-friendly in a very practical manner.
“The idea was to ask organisations to pledge to become homeless-friendly, to review and change their policies, and make things more accessible for homeless people.”, said Dr. Chauhan. “We train their staff, so they become part of our network. Then they display their pledges openly, in the reception area and with stickers on their door which say they are homeless-friendly, so any homeless person that walks in will know that they will be treated there with respect and dignity.” Creating this network allows them to work with charities and shelters and connect those homeless people to GP practices that they know will be homeless-friendly. “By doing this, we can improve access for homeless people by closing that loop of working with different organisations.”.
Dr. Chauhan at his homeless-friendly GP practice in Oldham (Image courtesy of Dr. Chauhan)
Much of the work of Homeless Friendly also revolves around campaigning for homelessness issues; on the JCVI guidelines on COVID-19 vaccination priority, Dr. Chauhan stated, “They said that everyone over 80 should be vaccinated first, but we know that the life expectancy of homeless people is only 43 or 44. We also know that, based on frailty, their real age would be 78 or 79. They are extremely vulnerable, but somehow, when deciding the national policy, this vulnerable group was ignored. So, we had to campaign and work hard to get them recognised.”
Dr. Chauhan made sure to lead by example; “We set up a clinic in Oldham”, he explained, “which was the world’s first clinic for homeless COVID vaccination. This gave us the opportunity to increase public awareness and run public campaigns. And by setting an example [with the clinic], we were saying to the local authorities that if we can do it, you can do it as well.”. Paul, who is from Oldham, was vaccinated at his clinic and is now the first homeless person in the world to have received his second vaccination dose.
Over the last 4 years, Homeless Friendly has made a great impact in Oldham and the nation as a whole, and has even resulted in the bestowal of the Order of British Empire on Dr. Chauhan for his efforts. He says that “it is difficult to quantify how many people have benefited, but it is likely hundreds or thousands, because we’ve changed policies and we’ve connected people. For example, in Oldham, every homeless person is now registered with a GP practice. And that’s what we’re trying to do with other regions and nationally.”
Homeless Link – joining forces
Homeless Link, a national membership charity for organisations working with homeless people, has also been working towards improving homeless health by forming partnerships across the nation. Rick Henderson, CEO of Homeless Link said, “One of [our] strongest legacies will be the growth and strengthening of local partnership working across government, the voluntary sector and health agencies, something which has greatly facilitated swift and positive outcomes for individuals.”
Homeless Link has also been fighting for homeless people’s right to register with a GP for years. Sue Christoforou, a Policy Manager at Homeless Link, has declared that we need to remove this barrier to healthcare now more than ever; “We can do this, in unison by, every single time one of our clients is refused GP registration, submitting a complaint to NHS England on that client’s behalf.”
An elderly man being treated in a hospital (Image courtesy of Homeless Link)
Homeless Link was also a frontrunner in the campaign for the prioritisation of COVID vaccines for homeless people and for people working with homeless people “We wrote to the Minister for COVID Vaccine Deployment to ask that working with people who have no home is treated as a priority occupation for vaccination, as a matter for urgency.”, Ms. Christoforou explained. “Homeless Link members have played a critical role, both by bringing political pressure to bear and by using existing local networks to make sure those at the frontline of homelessness and their clients get the protection they need.”.
Mr. Henderson has repeatedly emphasized the importance of working together, especially during this past year. “We helped to distribute millions of pounds in emergency grant funding to services across the country,” he said, “and tailored the support available through our leadership network.” He is very proud of how much progress has been made; “with over 26,000 people supported to move on from Everyone In (the initiative that gave many homeless people emergency accommodation during COVID), and hundreds of deaths prevented (according to the Lancet report), the sector has already had several big wins this year.”.
The tip of the iceberg – barriers to solutions
Dr. Chauhan stated that one of the biggest limitations to his work with Homeless Friendly is public policy. “The biggest barrier is when your national policies start discriminating against homeless people. So, every policy we make and every procedure we create and every system we come up with, is supposed to cater to the needs of all the communities, and not discriminate. It should be evidence-based.” Indeed, studies have found that public policy advocacy is key to reducing healthcare barriers for homeless people.
A 2019 study found that that flexible health services that cater to those who need them, and not the other way around, are also essential for making healthcare access sustainable. Dr. Chauhan said, “If you are a homeless person and you are only able to schedule appointments during specific hours, that service needs to think how they’re going to cater to the needs of your vulnerable group, instead of thinking that people need to adapt to the service provider. Your systems need to meet the needs of everyone in their situation.”
Dr. Chauhan feels that there needs to be changes in the mindset of everyone as a society. “We are not one of the poorest nations, we are one of the richest first-world countries. There is no reason why someone should be homeless in this day and age in this country.”
He suggests that society needs to stop stigmatising homeless people, that homeless people must stop being treated as if their diseases are their own fault and left to fend for themselves; “for example, if you smoke and get COPD and carry on smoking, we’re not going to stop treating you, are we? But when it comes to someone who is homeless and using drugs, which is addiction and mental health issues, we somehow give up on them and say they don’t need to be treated. But how is that possible? Is that not a clear discrimination?”
Another important barrier is the lack of contact between homeless individuals and clinics, as they usually cannot be reached at a fixed phone number or address and may find it difficult to get to clinics. Thus, forming partnerships between homeless shelters and GP practices, as Homeless Friendly and Homeless Link are doing, is invaluable.
Rick Henderson suggests that we must tackle homelessness at its roots: “Preventing homelessness must be a priority. However, as always, there is undoubtedly more work to be done to ensure that the government recognises the roles that poverty, inequality, an inadequate welfare safety net and a lack of truly affordable housing are playing in homelessness, and acts urgently to move the homelessness response upstream.”. His view is supported by a 2021 study, that states that homeless health can only truly be improved by addressing drivers of homelessness, such as poverty and lack of affordable housing.
A future without homeless charities
This is only the beginning. Although a lot of progress has been made in improving homeless health, much work still remains to be done.
Mr. Henderson said, “We will continue to campaign on the issues where we can make a difference, including putting forward a strong ask for sustainable long-term funding for services. Homeless Link is ready to offer our support and is looking forward to working with [everyone] to effect more positive change.”
Dr. Chauhan said “This will sound strange, but I think that Homeless Friendly shouldn’t exist. Because I hope that it becomes our societal objective to speak up for vulnerable people and to protect them, rather than just having organisations try to do that, and to not need to create organisations for that.”.
It is clear that homeless people are a very vulnerable group and should be treated accordingly. Improving access to healthcare for them will help to not only better their health, but could also help reduce the health burden on a national health service that has been struggling for years. As Paul says, “we will never be free of COVID unless everyone gets vaccinated. If we don’t, we will just continue to spread the virus and hurt the NHS.”
Follow Homeless Link’s work at https://www.homeless.org.uk/
Interviews have been condensed and edited for clarity.
Special thanks to Dr. Chauhan (Homeless Friendly), Louise Weaver (Homeless Link), The Oldham Times, Priti Salian (mentor), and the Solutions Journalism Network.
This article was published by Kinesis Magazine https://kinesismagazine.com/2021/05/14/making-healthcare-homeless-friendly/