As part of our Christmas special, Dr Seema Pattni offers guidance for how practices can identify, register and support patients who are experiencing homelessness
2 CPD hours
Key points
- There were at least 271,000 people recorded as homeless in England in 2022, including 123,000 children
- Patients do not require identification or proof of address to register at a GP practice; consider using ‘Right to Register cards’ in patient-facing areas to help people understand their rights
- Use consistent codes for homelessness to identify cohorts and audit care
- Ensure you have a back-up contact number for the patient and record this in their personal details section
- Be sympathetic to DNAs and consider exploring why the appointment was missed – the solution may be to offer afternoon rather than morning appointments
The most visible type of homelessness is rough sleeping, but this is just the tip of the iceberg. There are, in fact, multiple types of homelessness: from rough sleeping and hidden homelessness to statutory homelessness (see Box 1) and people who are at risk of homelessness.1
Unfortunately, people experiencing homelessness face extreme health inequity2 and enter a vicious circle of homelessness and poor health outcomes.
The situation isn’t improving, either. The number of people experiencing homelessness has been on the rise since 2013, and recent research by the charity Shelter found that at least 271,000 people were recorded as homeless in England in 2022, including 123,000 children. For general practice, this means more of our patients are at risk of homelessness and its associated mortality and morbidity.
Box 1: Types of homelessness
Statistics give an estimate of the scale of homelessness but do not capture the full extent of the issue. The factors below are often left out of the conversation
Transience
People who are experiencing homelessness can be transient in an area, which creates challenges for counts and estimates.
Rough sleeping
The Local Authority Rough Sleeping counts usually take place during a ‘typical night’ in winter (1 October to 30 November) but often councils just provide an estimate. Only a handful do an actual physical count, and if they do, there are still limitations. Counts are a snapshot of the situation and are considered an underestimate of the true picture. They are also not validated by the UK Statistics Authority.
Combined Homelessness and Information Network (CHAIN) reports are funded by the Greater London Authority and are considered more reliable because they monitor flow rather than a one-off snapshot, but they are also limited because they work with commissioned services only.
Hidden homelessness
It is even more difficult to quantify the less visible forms of homelessness, such as people who are sofa surfing and sleeping in inconspicuous places, such as vans, sheds or on night buses. The phenomenon of hidden homelessness also includes people who are at risk of homelessness, such as people with lower-paid jobs or insecure housing.
Women are often missed in counts because they tend to have different patterns for sleeping rough, tending to use hidden sites and squats and to sleep in the day rather than the night. They are also more likely to engage in survival sex, or sell sex to survive, than men.
Temporary accommodation and statutory homelessness
People in temporary accommodation are considered homeless. This includes people in shelters, hostels, refuges, B&Bs and temporary private or social housing. People who have approached their local authority and have an assessment outcome of ‘priority need’ are classified as statutory homeless as the local authority has a duty to provide them housing. These numbers are usually easier to collate via local authorities.
The role of general practice
Although everyone in the UK is entitled to free primary care, people experiencing homelessness encounter multiple barriers to GP registration. They also face hostility, with stigmatising, discriminatory and inflexible attitudes from healthcare professionals and institutions.
Communication barriers and lack of recourse to public funds create further difficulties in accessing healthcare. Past negative experiences of healthcare and healthcare professionals also discourage people who are experiencing homelessness from accessing healthcare, and affect self-esteem and prioritisation of health. Together, these issues lead to poorer health outcomes.
For practices, the prospect of understanding and managing patients who are experiencing homelessness can feel overwhelming, especially as models of care vary across the UK – ranging from mobile clinics and paramedic-led street outreach to fully integrated multidisciplinary services in GP surgeries.
But GPs can support patients who are experiencing homelessness. We are experts in managing complexity, long-term conditions and multimorbidity. We have good communication skills, enjoy continuity of care and have high levels of compassion. The reality, as with much of general practice, is that wider issues impede how we aspire to work with our patients.
Here is some guidance on how to organise your practice to support patients who are experiencing homelessness.
1: Get to know your health inclusion services
Your locality may have commissioned a specialised homelessness service, perhaps as a mobile clinic, street outreach or drop-in centre. Find out where and when the service runs, its referral process and inclusion criteria.
If there are no commissioned services in your area, you may find there are charities or organisations running relevant health projects.
However, it is often the case that communication about a new specialist service has not been widespread or effective; it is therefore worth making enquiries with your ICS, PCN, federation or local authority. If you are a London-based practice, you can find out what is available by contacting Transformation Partners in Healthcare for Homeless Health (see Box 2, resources).
2: Raise awareness of the right to register at a GP practice
Patients do not require identification or proof of address to register at a GP practice. But if turnover of admin and reception staff is high, it can be difficult for practices to maintain in-depth training on these aspects of ethics and law – as well as the practicalities. The human rights charity Doctors of the World provides both in-person and online training to help practices tackle the barriers that many migrants face when they try to access healthcare through its Safe Surgeries initiative.
Small changes can make a big difference. The homelessness charity Groundswell has created Right to Register cards that you can put in reception and other patient-facing areas to help people understand their rights, and to carry to show to health professionals. You can download and print them from its website.
Having access to the Language Line interpreting service in reception and consulting rooms can also support patients who cannot, or prefer not to, speak English.
When processing a registration request, some practices use the practice address as a proxy address. However, this can lead to an accumulation of unopened mail. Other practices ask the patient to nominate an address for correspondence, such as their hostel or a friend’s address.
3: Use Homeless Health Inclusion templates available on practice software
Software such as EMIS Web has clinical templates that can be used specifically for patients experiencing homelessness. It is unlikely that you will complete the template in the first 10-minute appointment with a newly registered patient, but it can be used as a guide on what to consider when consulting with a person who is experiencing homelessness. Questions cover tri-morbidity (the combination of mental health, physical health and substance misuse diagnoses), acquired brain injury, frailty, blood-borne viruses, housing, benefits and suggestions for referrals.
4: Choose your clinical codes and apply them consistently
There are multiple clinical codes available for people who are experiencing homelessness, and many relate to their type of homelessness. Decide as a practice which codes you will consistently use and in which contexts, and apply them upon registration and during consultations. This will help your practice to identify cohorts and audit care.
5: Review your practice’s correspondence and contact methods
Many patients who are experiencing homelessness do not have a reliable phone and often run out of credit, data or battery. Or they may not have a phone at all. They will not be able to hold on a line for several minutes, respond to SMS reminders or messages and take calls, and these limitations will create barriers in care. Asking patients for a back-up contact number is helpful (for example, a key worker or hostel line), and a preferable time of day. Ensure this is recorded in their personal details section, not in the consultation notes, where it might not be easily found.
6: Use sensitive language
Another aspect of trauma-informed care is the use of appropriate and sensitive language to avoid making people who are experiencing homelessness feel negatively about themselves, healthcare or healthcare professionals. The way we refer to groups of people evolves over time. Currently, ‘people who are experiencing homelessness’ is preferable to ‘homeless people’ or ‘rough sleepers’. The terminology is likely to change again in the near future.
7: Try to be flexible and adaptable if patients miss appointments or are late
People who are experiencing homelessness may not attend their appointment on time, or at all. While this is disruptive to the running of your clinic, the best approach is to explore why the appointment was missed. The solution may be as simple as offering afternoon rather than morning appointments.
It is also likely that these patients will require more time to develop trust and prioritise healthcare. If your practice can accommodate double-length appointments, consider implementing them.
8: Accept that you cannot address everything at once
It is an unfair expectation of yourself to think that you will be able to address all of a patient’s medical and psychosocial complexity in one consultation. Accept that you will both require time, follow-up consultations and consistency to work through issues. Discuss this with your patient and share the decision-making with them.
Working with patients who are experiencing homelessness can be challenging, but it has shown me that they are so much more than statistics. With all the experiences they have, they demonstrate a unique bravery and candidness when engaging in healthcare. It is humbling and rewarding to work with some of the most vulnerable people in society.
9: Look after yourself too
Stress, compassion fatigue and vicarious trauma are harmful and lead to burnout. Reflection and debriefing can support your emotional well-being. Peer support groups are also helpful – enquire through your local health inclusion service (see Resources, below).
Box 2: Resources
Organisations
• Transformation Partners in Healthcare, Homeless Health
• Crisis
• Deep End Practice Networks
Conferences
• Pathways from Homelessness (annual conference)
Courses
• UCL Institute of Epidemiology & Health Care: Homeless and Inclusion Health
• Homeless Link: Trauma Informed Care
• Fairhealth training: Includes training on adverse childhood experiences and trauma
• Aneemo training: courses for voluntary, health and social care staff and organisations working with populations with complex needs
• Queen’s Nursing Institute: range of resources and guidance
Dr Seema Pattni is a portfolio GP and careers coach in London. She was previously clinical lead for Homeless Health Inclusion in Haringey, north London
References
- Crisis. Types of Homelessness. 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 2018;391:241-50. Link
- Reeve K. Women and homelessness: putting gender back on the agenda. People, Place and Policy Online 2018;11:165-74 10. Link
- Doctors of the World. Registration Refused: A Study On Access To GP Registration In England, Update. 2017. Link
- Purkey E and MacKenzie M. Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care. Int J Equity Health 2019;18:101. Link
