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Helping homeless people in hospital

Dr Pippa Medcalf FRCP MBE is the RCP’s lead fellow for health inequalities and inclusion health. In this blog she explores the link between health inequalities and homelessness.

On a filthy November afternoon at work I was shocked into action: I couldn’t bear discharging any more homeless people from a warm, comfortable bed in our acute unit back to the horrible cold streets with no hope, no support.

It seemed cruelty itself to show a little compassion and then immediately retract it, enough was enough. I took myself off, in my spare time, to learn from our brilliant GP-led Homeless Healthcare team, the wonderful team at University College Hospital and the Luther Street Clinic in Oxford.

Seven years on and we now have a team of three homeless housing officers and a specialist homeless nurse in our hospital and covering the mental health facility. Guidelines for homeless people in hospital are on our intranet, clean clothes in the cupboard, the duty to refer enacted and the mantra ‘Never discharge a homeless person without support’ pushed in ongoing teaching sessions across all departments.

The wonderful thing was that I was pushing against an open door. Not one person was against helping homeless people, indeed everyone from top to bottom was so happy to be able to help. It was a relief to have mechanisms in place and the feelings of being hopeless and helpless for a hitherto seemingly insurmountable problem vanished. A&E was a little harder to crack with the 4-hour stranglehold, but the solution? A brilliant A&E nurse champion!

And homeless people came to us. As a population they are 60 times more likely to attend A&E and five times more likely to require admission than age-matched controls. No need for screening or tracking, these are poorly people who need medical help. In England no homeless person dies from exposure – they die from reversible causes. Shame on us then that the average age of death in homeless people is in the mid-40s.

As you hurry past a thin, pale, silent beggar on the streets just imagine if they had a board above their heads saying ‘I have a death sentence on me, will you help?’

And do they complain? Write to their MPs? March on parliament? Go to the Patient Liaison Service office? No – broken by the system, let down by upbringing, lacking education and confidence, suffering addiction issues and usually alone in the world, they need our help.

The commonest causes of homelessness today are relationship breakdown with one partner being thrown out and lack of affordable housing. Neither seems impossible to address.

The RCP has been incredibly supportive in rolling out this work and other aspects of the shameful health inequalities which are present in the UK today.

Weirdly, perhaps the best thing to happen to homeless people was COVID-19. Just as I was mentally, gloomily, planning extra mortuary beds in mid-March, the government announced their ‘Everyone in’ scheme – and within a week thousands of homeless people were swept off the streets into hotels. Charities and homeless agencies supported them with food and methadone and advice, and hundreds of deaths were averted. Out of over 5,000 homeless people accommodated in London, only about 30 developed COVID-19. They were further isolated and there were just a handful of deaths. Now work goes on to stop them returning to the streets and avoid the night shelters reopening as a ‘solution’.

Homelessness is shocking, but it is soluble and compassionate doctors can make a difference. We must never, ever, discharge a homeless person, unsupported, back to the streets.

This is one of a series of blogs to mark the launch of the Inequalities in Health Alliance, a coalition of organisations which have come together to campaign for a cross-government strategy to reduce health inequalities.