Homelessness – our silent epidemic. Rough sleepers' engagement with, access to, and experience of healthcare is markedly different to that of you and I. Some of these differences may be plainly obvious, namely accesses to transport and possession of a smartphone. Other differences, for example, explicit displays of judgement and discrimination are less obvious. Both however, have a profound effect on rough sleepers' access to healthcare and subsequently, their health.
Rough sleepers commonly suffer from tri-morbidities: they are more likely to have ill physical and mental health, and suffer from substance abuse. Further, homeless people, as well as those who have slept rough previously, also have significantly higher levels of early mortality – especially from suicide. On top of all this, homeless people are also statistically less likely to access the healthcare services that they require.
I spoke to Janet (pseudonym), a nurse, who works part-time at a homeless organisation where she brings healthcare to rough sleepers. She explained to me the barriers rough sleepers face in accessing healthcare and why bringing healthcare out of its normal environment is so important.
The key reason Janet highlighted as to why rough sleepers may be unwilling to engage with healthcare is because “they feel judged for their drug usage and haven’t found healthcare to be sympathetic.” For Janet and her team, this served as the impetus to do what they do: bring healthcare to them. “By doing this we are creating an environment where they feel safe. The very act of bringing it to them demonstrates to them that they deserve good healthcare and that we aren’t judging them”.
Janet developed on this: “Often, staff might say that they kept leaving to go and use drugs or go out for a cigarette and infer from this that they don’t care about their health. However, the judging and impatience can actually lead to rough sleepers feeling less inclined to involve themselves. It is about being sensitive to what they have been through and how this might impact their behaviour.
Janet continued to say that occasionally Rough sleepers may also go into hospital and be offered a treatment and refuse it. "The assumption however on the part of healthcare professionals is that they are "ungrateful, and should simply abide by what is being asked of them“. This reminded me of the adage: ‘beggars can’t be choosers’. While this phrase may sadly be accurate in certain circumstances, in relation to healthcare, this dehumanises rough sleepers and suggests that they don’t have the right – unlike the rest of the population – to have some control over their health. However, as Janet pointed out, respecting their choices is important as it shows them that are allowed control over their health - something that is extra important when they may feel largely 'out of control' due to their addiction.
In relation to this, Janet said that, as a health practitioner, it is important to remember the difference between I want to, and they want to: “I might go in that day with a mental list of things I would like to discuss with the guests from blood screening for viruses, to contraception, to HPV vaccinations, but it’s important for me to be led by what they will tolerate that day. Often, with such trauma in their past and often present, they might feel more comfortable offloading, and telling their stories, traumas and experiences of assault and abuse. Again, after they have done this, they often feel more comfortable engaging with things on my mental list“. Here then, when working with those in a crises of homelessness, respecting their choices - be it to engage with healthcare or not to engage with healthcare - is highly beneficial, despite whether their choice goes against a doctor’s agenda or appears irrational or irresponsible. This respect and appreciation for their choices instils in them a sense of security and safeness that they otherwise do not receive.
Janet continued to say that negative experiences with a healthcare professional acts as a deterrent to rough sleepers returning, causing them to view the hospital as a negative space. Perhaps, if it is not them that has had a negative experience, it is a friend, thereby manifesting itself as fear of discrimination and judgement: “There is a strong consensus amongst those that I have worked with that they felt they did not have a good experience in hospital or someone they knew didn’t and this has manifested as their own dislike of hospitals - I saw one patient in the clinic who had a gaping wound on his arm because someone bit him – it was wide open and slowly getting infected but he refused to go to the hospital because that’s where his dad had died. He clearly had this perception of hospitals as bad and evil.”
Janet said that it was also not uncommon for rough sleepers to fear going to hospital in case they get sectioned, restrained under the Mental Health Act, or end up becoming an inpatient due to their poor health: “With addiction, it is the only thing you think about – from when you wake up, to when you got to sleep. It is your first priority and everything else comes second. Therefore, the thought and fear of not being able to take drugs is too much which often causes rough sleepers to avoid anywhere or anyone that may stop them.”
Janet did make the point however that some rough sleepers had said that they did have a positive and perhaps enlightening experience in hospital: “Sometimes we do get accounts of people saying that hospital saved them. Perhaps they were literally on the brink of death or feeling very suicidal, and they came to hospital and went on to live healthy lives. Often, an experience like that can be used as a reason for change.” This demonstrates that should healthcare be more inclusive, non-judgmental, and positive toward rough sleepers, this can have remarkable effects, and achieve exactly what medicine and doctors want: to save lives.
A further reason for rough sleepers' lack of access to healthcare that Janet signalled to me lies in the answer to the following question: How many of us find the experience of visiting a GP surgery or hospital relaxing or enjoyable? Very few of us. Thus, when these very natural and normal sentiments are compounded with the chaotic lives that rough sleepers live, it is hardly unsurprising that they choose to avoid healthcare environments even more. “The GP practice is a stressful environment. Already before you get there, you have the time pressures and appointment times looming over you and the potential consequences - ‘what if I miss it and I cannot get another one for weeks?’ . There are also the waiting times and people who are heavily addicted to drugs don’t have the largest attention span so they will leave. We must also bear in mind that rough sleepers have a chaotic lifestyle and attending a GP surgery or hospital is a chaotic experience in itself – there’s a lot of ‘go there, sit here, come here, do this.’ There is constantly people moving around, names being called, automated announcements. It is definitely a sensory overload.” Although manageable to someone who has a more stable lifestyle, often for rough sleepers this environment can be frustrating and demotivating, causing them to avoid attending healthcare services.
Rough sleepers’ lack of access to technology is another barrier they face in accessing healthcare: “A lot of them don’t have phones, and nowadays, especially with coronavirus, we are being encouraged to book online in advance as opposed to walking in. What is a rough sleeper meant to do in this situation?” In reference to this, prior to my interview, a woman had come into the respite session and said that her mobile phone had no charge because someone had stolen her charger. This would clearly prevent her from booking an appointment if she needed to do so. Partnered with this, from my experience volunteering at the homeless centre, the mobile phones that a lot of the guests have are not smart phones that are marketed on their easy internet access. Rather, they tend to have Nokia’s or brick phones – the kind my generation would associate with the retro snake game. In terms of booking an appointment online, this type of phone would make that virtually impossible.
The last hurdle that Janet indicated to me was regarding transport: “Getting to an appointment is difficult and expensive for people with lifestyles like you or me – let alone for a rough sleeper. It is also important to remember that rough sleepers also move around a lot so often may not remember where their GP is or they may actually have never been there. If they have been to prison, that can add another layer and complicate things even further.”
While I may not be a health practitioner, my interview with Janet clearly highlights some critical gaps in healthcare delivery for rough sleepers. Firstly, we need to consider the financial and technological barriers that they may encounter, namely in access to smartphone technology and lack of money to spend on ever-inflating transports costs. Secondly, we need to consider how the geography and sensory experience of a GP clinic or hospital effects rough sleepers, and begin to assess the ways in which it could be made more friendly and inviting for them. Importantly, we must also consider the effects that judgement and discrimination from health practitioners may have on rough sleepers' willingness to attend a clinic and engage with healthcare professionals. Unsurprisingly, these negative experiences have long-lasting effects, causing homeless people not to visit again, thereby exacerbating their ill health. For Janet, bringing healthcare to rough sleepers demonstrates to them that they deserve to be cared for and be healthy, that they are not judged or forgotten, and allows them the control over their health that they deserve. Perhaps, through plugging the gaps highlighted above, we could allow rough sleepers to feel like this within traditional healthcare settings as well.