Homelessness and public health
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k214 (Published 29 January 2018) Cite this as: BMJ 2018;360:k214
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
There can be no doubt that homelessness in the UK is reaching a crisis point, with rising numbers of people sleeping on the streets or in temporary accommodation.
As Mark Fransham highlights, the effect homelessness has on physical and mental health can be devastating. Research carried out by Centrepoint has revealed that 22% of the young homeless people who we have helped have self-harmed and 18% have even attempted suicide. A young person’s experience of homelessness is likely to have a long-lasting effect on their self-worth, confidence and general mental health, even after they reach the safety of one of our hostels.
There’s no denying that the rise in homelessness stems from recent welfare reforms and the current housing market, where rents have risen faster than wages, leaving a chasm in people’s budgets which housing benefit can increasingly no longer bridge. Austerity has seen deep, repeated cuts to local authority budgets and in a system under pressure, young people are often turned away without receiving the support they urgently need. These young people are then left with no other options but to sleep on the streets, or face other unthinkable decisions just to put a roof over their head for a night. Worryingly, Centrepoint research showed that 26% have stayed with a stranger to avoid sleeping rough, putting their safety at risk.
There is help out there, but it is not always easy to find. Young people especially are often left alone to navigate a complex web of localised services and patchy provision, a consequence of years of cuts to local authority and NHS budgets. Until February last year there was no single source of advice for 16-25-year-olds who are homeless or are worried about homelessness. That changed when our patron, HRH The Duke of Cambridge, launched the Centrepoint Helpline. Our free-phone and online service provides tailored housing advice to each young person, helping them find somewhere safe to stay and quickly connect them to local support services.
Experiencing homelessness at a young age can be scarring but those experiences do not have to define someone’s whole life. Early intervention is crucial, and the Centrepoint Helpline is an ambitious attempt to ensure that wherever they are, vulnerable young people find the support they need as soon as possible. Our research shows that the desperate measures young people take to find somewhere to sleep, including hurting themselves to take refuge in a hospital bed, can bring them into contact with the health service. We are here to get young people to a safe place as soon as possible, but we can’t do it alone. We need their health professionals - people they trust - to tell them about us.
If you’re worried about a young homeless person, or concerned someone is at risk of becoming homeless, please call the Centrepoint Helpline free on 0808 800 0661 (Monday to Friday, 9am to 5pm) or visit the website on https://centrepoint.org.uk/helpline
Competing interests: No competing interests
We welcome this week’s editorial by Fransham and Dorling highlighting the health consequences of rising homelessness (‘Homelessness and Public Health, BMJ 29 01 18). We would also draw attention to new work describing the truly extreme raised mortality penalties found in homeless and excluded populations. As one of our colleagues said “The figures are stark and shocking, dwarfing the known health differences between the rich and poor.”
In response to this health emergency we also wholeheartedly support their call for a comprehensive national strategy including action on housing supply, rent levels, security of tenure and raised rates of social security benefits. However, whilst we wait for national political leadership, Pathway and many colleagues across the health service have assembled a strong evidence base on “What works in inclusion health?” This shows that there are many health interventions that help us better manage the complex sets of health problems that so often arise as part of the mix when people are made homeless. The characteristics of good services for homeless people include serious patient-centredness, intense focus on the quality of relationships, and a willingness to push at the boundaries between services. Pathway will also shortly publish the Faculty for Homeless and Inclusion Health’s new service standards, our collective efforts to collate best clinical practice for services working with the most excluded.
It is undoubtedly our duty as concerned clinicians to push for wider political change in the interests of our patients. But at the same time health professionals can improve things for homeless people today. We need the NHS to support specialist homeless health services, and, given the extreme health risks associated, ensure high standards of care for all homeless patients, wherever they seek our help. Too many homeless people today report experiences of healthcare that are a long way from the compassionate, holistic and needs based services that we all aspire to offer . Fixing the UK’s housing crisis may take a while, but we can do more today to bring better care to some of our most vulnerable patients.
References
Dr Chris Sargeant, quoted by NIHR. See the NIHR summary of the work here https://discover.dc.nihr.ac.uk/portal/article/4000912/social-exclusion-h...
What works in inclusion health: overview of effective interventions for marginalised and excluded populations
Luchenski, Serena et al. The Lancet , Volume 391 , Issue 10117 , 266 - 280
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31959-1/fulltext
2013 edition of the Standards of the Faculty for Homeless and Inclusion Health available here. http://www.pathway.org.uk/wp-content/uploads/2014/01/Standards-for-commi...
The third edition is in press.
Turning Virchow upside down: medicine is politics on a smaller scale, Meili R and Hewett N; Journal of the Royal Society of Medicine; 2016, Vol. 109(7) 256–258
Three forms of identification and a letter from God, Stan Burridge letter to the BMJ
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4669 (Published 25 October 2017)
Competing interests: No competing interests
Re: Homelessness and public health
Homelessness is a major problem, which affects not only the people who are homeless but also the general population and they are directly affected by the infectious disease like TB, AIDS, etc. Homeless people live wherever they find themselves convenient, like on the streets, public shelters, etc. In the England scenario, the number of people sleeping on the streets are recorded and varies from 1768 in 2010 to 4751 in autumn 2017. The local authorities housing homeless families in temporary accommodation rise from 50,000 in 2010 to 78,000 in 2017. According to the survey 225000 hidden residing in London alone.
And when we look at the Indian homeless situation, it is more severe and harming not only affected ones but also whole society. According to census of 2011, India has more than 1.8 million homeless residents, of which 938,384 are located in urban area and 150,000 – 200,000 homeless alone in capital Delhi, despite the country growing in global economic stature still there is need to build about 60,000 - 65,000 houses yearly to give shelter for 449,761 houseless families by 2020. The rise in homelessness is not only confined to growing country like India but also in the U.S.A., U.K and most of the European countries.
Health Detriment
Homelessness has various public health implications. Homeless people are the most potential reservoir for the infectious diseases like tuberculosis and HIV and other associated health effects like agita, depression, skin diseases, unintentional injury, and malnutrition. Population living in the compromised physical environment like cold, damp and overcrowded places have greater health risks, poor nutrition, lack of facilities to maintain to personal hygiene and more potent chances of infectious disease through crowding, negligence towards disease and enforced lifestyle. The lifespan of the homeless people has found lower than the general population because of respiratory tract disease, sexually transmitted and chronic diseases. Chronic diseases often go unrecognized and untreated, even if the condition is detected and treated, lack of compliance and consistent follow up often results in disease progression, disability, morbidity and early death.
Homelessness arises from inadequate income supports, lack of affordable housing, change in the industrial economy leading to unemployment, de-institutionalization of patients with mental health problems, physical or mental illness, disability, substance abuse, domestic violence, relationship breakdown, childhood trauma, and neglect. Country migration like Rohingya Muslims migrated to India leading to the rise in the number and now they are living on the streets, under the bridges, etc.
Recommendations for Homeless People
Linking the homeless people with the program like Mahatma Gandhi National Rural Employment Guarantee Act. (MNREGA) which for rural areas provides employment opportunities. Development of guidelines to have a programme, which should be accessible, affordable, comprehensive. It should include mental health and substance abuse problems. A programme should include preventive components like screening for acute and chronic health problems, immunization and special services for women including family planning, antenatal and parental care. Homelessness in India needs a proper methodology or strategy to have a proper estimate of their number to support services for vulnerable people, an increased affordable housing, more public health, and security facility. There are various government authorities, NGO’s are working to support the homeless people, by providing primary medical facility as well as temporary home (shelters), Mohalla clinic provided by Delhi government which is planned to give the primary medical support.
Competing interests: No competing interests