The survey of over 2,000 UK physicians found that while most feel confident treating homeless patients' acute medical issues, many lack training on the complex needs of this population. Nearly 30% were unsure if they had discharged homeless patients without housing arrangements. Coordinating health and social services is key to improving outcomes, but physicians feel constrained by limited resources and bed pressures. Developing multidisciplinary homeless healthcare teams and advocating for patients' housing needs can help address the social determinants worsening their health.

1. 14 Commentary April 2016
FEATURE HOMELESS HEALTH
The survey sought members’ and fellows’
experiences and attitudes toward
homeless people, including rough sleepers
and members of the street community
(encompassing those living in squats,
‘sofa surfers’, hostel dwellers, and others
in insecure accommodation). More than
2,000 responses were received from
doctors working across all specialties,
and the demographics of respondents
were found to be broadly reflective of the
membership of the RCP.
The survey asked questions about frequency
of treating homeless patients, the settings
in which this usually takes place; education
and training focussing on homeless patients;
experience, comfort and confidence
treating homeless patients; treatment and
discharge; duty of care; and questions about
homelessness more generally.
Treatment frequency and settings
We found a roughly even split between
those who regularly treat homeless patients
(monthly and weekly), and those who treat
them rarely (yearly and only in the past) (see
graph ‘Part II Q1.1’). Only a small minority
(6.9%) state that they have never knowingly
treated a homeless patient.
Many homeless patients demonstrate
a tri-morbidity of physical illness, mental
health problems and substance misuse.
Unsurprisingly, the survey revealed that the
majority of encounters with homeless patients
occur in acute medical wards, general medical
wards, and accident and emergency wards.
Medical education and training
Current medical education and training on
homelessness appears to be lacking, with
a striking 95.3% of respondents indicating
that they have not received education
and training which focusses specifically on
homeless patients at any stage. Respondents
overwhelmingly rate their general education
as minimal or non-existent in preparing them
to treat homeless patients, with almost two-
thirds (65.7%) suggesting that training does
not adequately prepare clinicians to support
social needs of patients. The need for more
extensive and structured education on health
inequalities warrants serious attention, to
ensure the doctors of the future are equipped
to navigate the complexities of dealing with
homeless patients.
Confidence and comfort
Despite limited training, survey respondents
rated their confidence when treating homeless
patients quite highly. While 26.6% of
respondents reported feeling apprehensive
when learning their next patient is homeless,
48.8% do not.
Two-thirds of respondents reported that
they are comfortable asking if their patient
is homeless, and only 9.2% of respondents
report discharging homeless patients without
asking them if they have a place to go next.
However, a significant portion of respondents
(27.9%) were not sure if they had discharged
homeless patients without a place to go. It is
unclear if this is because they did not know if
the patient was homeless, or if they did not
know the outcome of the patient’s discharge.
For those who did not ask a patient if they
had access to secure accommodation upon
discharge, the reasons were many and varied.
The most prevalent free text responses
indicated ‘bed pressures’ and ‘time pressures’
as the driving factor. A number of respondents
emphasised that ‘the hospital is under huge
pressure for beds and cannot keep patients
who are medically fit’, stating that ‘such
patients are given information regarding
services locally for homeless people’. A number
of comments suggested that although
patients were regularly referred to services,
they did not follow through, perhaps because
a lack of trust with the institutions.
Attitudes to the homeless
Some respondents felt no obligation to
ask about a patient’s living arrangements,
expressing that accommodation for homeless
patients is exclusively the responsibility of
social services: ‘Social issues are not a medical
issue. There are medical implications, but
acute medical services are not the answer to
acute social crises’. While this view is held by
some respondents, more than half (56.5%)
of survey respondents stated that physicians
should address both physical health needs and
social problems in their patients.
Discharge planning presents an opportunity
to explore the patient’s social care and mental
health, and potentially prevent subsequent
hospital admissions. Coordination of services
is an essential first step to minimising the
burden of homelessness, and advocacy from a
clinician concerning the health consequences
of homelessness can be very effective (see
graph ‘Part VII Q3.3’).
The known link between homelessness and
ill health is further supported by the results
of this survey, with 90.7% of respondents
agreeing that homelessness can be caused by
health problems. Only 5.2% of respondents
indicated that they believe homelessness to be
a chosen state.
The health of the homeless: how physicians
can support vulnerable patients
‘27.9% were not sure if they had
discharged homeless patients
without a place to go. It’s unclear
if this is because they did not know
if the patient was homeless, or if
they did not know the outcome of
the patient’s discharge.’
It is well understood that homeless people often have more complex
health care needs than those in secure housing, and physicians have a
key role to play in reducing these health inequalities. In October 2015 the
RCP conducted a survey on homeless health, to explore ways to improve
the quality of care. RCP policy adviser Eloise Birbara and research
student Pete Mathes conducted the survey and examine the findings.

2. April 2016 Commentary 15
Survey participants were also asked their
opinions on the role of the state, the NHS,
and the individual physician in alleviating
homelessness. The view that the state could
do more to alleviate homelessness was
strongly supported, with 85.6% of respondents
indicating that more work is required.
Respondents were more ambivalent about the
role of the NHS in alleviating homelessness,
with 31.6% agreeing that there is little the
NHS can do to alleviate homelessness, and
44% believing the NHS can do more.
Regarding the role of the individual
physician in alleviating homelessness, there
was no clear consensus, with 37.9% agreeing
that physicians can do little to alleviate
homelessness, and 33.6% taking the position
that physicians could do more (see Graph ‘Part
VI Q7.7’).
There was a degree of despondency
amongst respondents regarding health
outcomes, with 45.3% of respondents
believing their homeless patients will continue
to have poor health outcomes regardless of
the treatments provided. One-third (32.4%)
of respondents, however, believe that health
outcomes will improve with their treatment,
suggesting that the role of physicians may
mitigate poor health outcomes for those
in this population. In order for this to be
successful, the coordination of health and
social services needs to be improved.
Dr Nigel Hewett is the medical director of
Pathway and secretary to the Faculty for
Homeless and Inclusion Health. He shares
the frustration of clinicians at the futility of
treating life threatening illness, only to see
the patient readmitted because none of the
underlying social determinants of health
have been addressed. ‘There is a growing
realisation that we can and should have a role
as advocates for our patients. For example,
a letter spelling out the life threatening
consequences of rough sleeping related to
a patients’ specific condition can be very
influential. But many hospitals with significant
numbers of homeless patients are developing
multidisciplinary care coordination teams to
support homeless patients and their clinical
teams. Pathway (www.pathway.org.uk) is
a charity set up to support and train such
teams and gather the increasing evidence of
improved outcomes and cost-effectiveness.’
Assessing results and finding
solutions
Dr Pippa Medcalf, consultant in acute
medicine at Gloucestershire Royal Hospital
and RCP lead for Health Inequalities,
welcomed the results and the discussion of the
issues involved. ‘Homelessness has increased
by a staggering 40% over the past 4 years
and while many GPs are doing a sterling
job in managing their day-to-day problems,
it is to hospitals that the homeless turn.
Homeless patients are five times more likely to
present than age matched, housed controls.
Secondary care is thus uniquely placed to
identify and treat the homeless.
‘This survey demonstrates that physicians
feel confident in dealing with the acute
medical problems of the homeless but less
confident about appropriate discharge
planning, with a cited lack of training in
caring for sick, vulnerable people who have
nowhere to go: no GP, no follow-up access,
nowhere to store medication. Physicians
are compassionate people and the survey
confirmed a genuine wish for more support
for the homeless. We know that this is an
increasingly large group of people with no
voice, who stand little chance of recovery,
frequently facing recurrent admissions to
hospital until, for many, an untimely death at
the average age of 42 years.’
Many secondary care providers must
continue to take practical steps to help their
homeless patients. Dr Medcalf concludes:
‘Respondents found it hard to discharge
someone to back to the very same hostile
environment that precipitated the admission
in the first place.
‘The RCP is determined to end this inequity
of health and support its members by raising
the profile of homeless healthcare. Working
with the Faculty of Homeless and Inclusion
Health standards are being set including
specific training, identified expert staff and
signposting of services. In Gloucestershire
Royal Hospital we have appointed a homeless
housing officer who has transformed our care
of the homeless so no one need be discharged
from the hospital back to the streets. Doing
nothing is not an option.’ n