Clinical issues in homeless care

As part of our December Christmas issue special on homelessness, Dr Caroline Shulman looks at the clinical issues that arise when treating people who are experiencing homelessness

Health inequalities between the most and least deprived in society are stark, but no group has health outcomes that are worse than people who are experiencing homelessness. They often die young and have multiple long-term conditions at a young age. People who are street-homeless or in emergency shelters have a mean age of death in their 40s.¹ Standardised mortality ratios for inclusion health groups (homeless populations, sex workers, prisoners and people with substance use disorder) are a shocking eight to 12 times higher than the general population.²

Research suggests that nearly one in three deaths of people experiencing homelessness is ‘amenable to timely and effective health care’.³ Because of a range of barriers, people who are experiencing homelessness are much less likely to access primary care than the general population. However, they often have high rates of A&E attendances.⁴ There is no group for whom the inverse care law is more pertinent: those with the most need receiving the least. So what is needed to change this?

To answer this, it’s important to understand some of the routes into homelessness, the barriers people experience in accessing services and the role often played by complex childhood trauma.

Routes into homelessness
There are a number of factors associated with homelessness, which help shine a light on why homelessness is associated with such appalling health inequalities. Structural or political factors related to poverty, welfare policies, employment rights, housing supply and immigration policies are often underlying factors. Poor mental health, addictions, domestic violence and traumatic brain injury are all risk factors for homelessness. Homelessness is also a risk factor for deterioration in mental health, addictions, experience of violence and acquired brain injury. The interconnected nature of these vulnerabilities can hinder individuals’ ability to exit homelessness.

Adverse childhood experiences
Adverse childhood experiences are a major risk factor for homelessness. These are traumatic events or situations such as neglect, abuse, domestic violence and parental abandonment.⁵ Studies have shown that 50% of people who are experiencing homelessness have been exposed to four or more adverse childhood experiences compared with 3-5% of the general population.

This rises to 85% of people experiencing homelessness alongside substance misuse disorder and contact with the criminal justice system.⁶

The experience of multiple traumatic events in childhood and adolescence is described as complex trauma, according to the UK Trauma Council. Complex trauma often lies at the heart of multiple mental health presentations, including post-traumatic stress disorder (PTSD), psychotic disorder, depression, anxiety and dissociative disorders.⁷ It is also associated with increased risk of long-term physical health conditions, such as cardiovascular, respiratory and endocrine diseases.

By impairing the development of stable attachments, childhood trauma may cause people to view the world as unsafe, which can have a profound impact on how they think, feel and behave as adults. Adults may struggle to understand others’ perspectives or their own emotions. Emotional arousal can escalate quickly, but without self-soothing skills, can lead to conflict with others, relationship breakdown and self-directed harm, or substance misuse as a means of coping.⁵ Fear, feeling stigmatised or defensive can result in distress, which if not recognised and addressed or de-escalated, can result in behaviour that is challenging to manage and can contribute to poor interactions, further increasing barriers.

Morbidity
People who are experiencing homelessness often have high rates of tri-morbidity (the combination of mental and physical ill-health, and substance misuse disorder) as well as dual diagnosis and multimorbidity.

Mental ill-health and substance misuse
A recent survey of people who are experiencing homelessness found that 82% had a mental health diagnosis compared with 12% of the general population.⁸ It found 25% of respondents self-reported a dual diagnosis of coexisting mental health and substance misuse needs, with a further 45% reporting that they self-medicated with drugs or alcohol to cope.

Long-term physical conditions
What is often not recognised is the high prevalence of many long-term conditions, such as asthma, COPD, epilepsy and heart problems. Prevalence ratios are five to 13 times those of the general population.⁹ Around 63% of people who are experiencing homelessness reported a long-term physical condition compared with 22% of the general population.⁸ In addition, multimorbidity, frailty and other conditions associated with an older population, such as cognitive impairment, poor mobility and falls, are common and occur at a young age.¹⁰

A trauma-informed approach
What can we do to address this inequity? Recent NICE guidance sets out ways to promote high-quality integrated health and social care for people who are experiencing homelessness.¹¹ These include longer appointment times, multidisciplinary working and having a trauma-informed and psychologically informed approach. Central to delivering trauma-informed care is promoting engagement by providing a service that is inclusive, person centred, empathetic and non-judgmental.

As GPs, it is not our role to explore the roots of someone’s trauma or provide trauma therapy. However, it can be helpful to consider how trauma might be operating in a person’s situation. Instead of just asking ‘what is wrong with this patient’, we should consider ‘what has happened to this person’, recognising that trauma impacts on wellbeing and how people communicate, develop relationships and self-soothe.

These approaches have been found to help:

Recognise the need to provide continuity of care, with the understanding that trust and engagement can take time to develop.
Be aware of verbal and non-verbal triggers of distress as well as psychosocial reasons behind a patient’s use of language or behaviour.
Actively listen and respond compassionately and calmly. This will reduce the risk of conflict and help resolve potential escalation.
Help people recognise that their issues, such as substance misuse, are a coping mechanism. People’s lives can be transformed by having this acknowledged and validated.
Recognise that not all problems can be solved at once. Initially focus on engagement. Start from where they are and, where possible, with their priorities. Use shared decision-making.
Be aware of the risks of re-traumatisation, which can be triggered by reminders of trauma. Providing a safe supportive environment will help prevent this. If you suspect trauma, ask your patient if there is anything you need to know in order to provide them with care and ensure they feel safe.

Treating long-term conditions
People who are experiencing homelessness often have multiple long-term conditions. Consider what may help increase adherence to medication and follow-up:

Can you offer regular appointments with the same person, at a time that works for them?
Don’t assume literacy. A high proportion of people who are experiencing homelessness have learning difficulties or literacy problems. Check that instructions are understood and consider whether a regime can be simplified.
What interventions are available for your older frail populations? Consider whether these can be made available to this population, even if they are younger. Consider reaching out to a homeless hostel or day centre.
Review nutrition: are supplements needed? Would referral to a food bank be helpful?
Where are follow-up appointments sent to? Could a support worker facilitate attendance? Are there peer advocates in your area? Could social prescribers provide support?

Taking these issues into account when caring for our patients can help to address the health inequalities they face.

Dr Caroline Shulman is a former GP and clinical lead in homeless and inclusion health in London. She continues to undertake research, training and advocacy work in support of patients and frontline staff

References

ONS. Data on homeless deaths 2022. Link
Aldridge R et al. Morbidity and mortality in homeless individuals, prisoners, sex workers and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis, Lancet V 2018;391:241-50. Link
Aldridge R et al. Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England. Wellcome Open Res 2019; 4:49. Link
Vohra N and Paudyal V. Homelessness and the use of the emergency department as a source of healthcare: a systematic review. International Journal of Emergency Medicine 2022. Link
FEANTSA. Recognising The Link Between Trauma And Homelessness. Brussels 2017. Link
Chase L. Hard Edges: Mapping severe multiple disadvantage. Link
Powers A et al. Childhood trauma, PTSD and psychosis: Findings from a highly traumatized, minority sample. Child Abuse Negl 2016;58:111-8. Link
Hertzberg D and Boobis S. Unhealthy State of Homelessness: Findings from the Homeless Health Needs Audit 2022. Link
Lewer D et al. Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England BMJ Open 2019; 9:e025192. Link
Rogans-Watson R et al. Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Housing, Care and Support 2020;23:77 91. Link
NICE. Integrated health and social care for people experiencing homelessness. NG214. Link

READERS' COMMENTS [3]

Please note, only GPs are permitted to add comments to articles

Centreground Centreground 8 December, 2023 12:49 pm

In most areas , homeless Primary Care Medical Services receive a colossal increase in funding which can be in the region of 10 x the funding per patient as normal GP practices. This in my view is why homeless /inclusion practices often achieve outstanding in their CQC reports and we should expect nothing less. In my experience of working in and around such services, he appointments slots are extremely generous and often patients do not turn up more so than in other practices giving even more time to practitioners.
There is no reason therefore, that the Health Inequality gap from the medical services perspective at least, should not be improving.

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A Non 12 December, 2023 1:56 pm

Centreground Centreground – that entirely depends on where you are. In the mist areas there is ABSOLUTELY NOTHING. Its really great to hear where you are you have too much?? This isn’t the routine experience

Jasmin Malik 29 December, 2023 11:22 am

Great overview.
In response to some of the comments – specialist practices register approximately 25% of people experiencing homelessness in a borough, and the remaining 75% are registered at mainstream practices (statistics from an inner city London borough).

It’s also important to recognise the difference between providing health equality and health equity, and that those who are homeless have a longstanding history of multiple disadvantage which frequently starts from early childhood.

Good practice is frequently seen in specialist practices, but models and approaches differ.
There are also examples of good practice in mainstream serves, but this is often extremely difficult to establish. The Safe Surgeries initiative from Doctors of the World is a good starting point, however more is needed to aid services to embed it into everyday practice.