Intended for healthcare professionals

Views And Reviews

There is no excuse for homelessness in Britain in 2018

BMJ 2018; 360 doi: (Published 26 February 2018) Cite this as: BMJ 2018;360:k902
  1. Victor Adebowale, chief executive
  1. Turning Point
  1.  Sarah.Snellaert{at} 

Homelessness is a neon sign that something is fundamentally wrong

The sight of someone on the streets is one many people find so difficult that they ignore it. They choose to walk straight past the person who is at their feet or asking for money.

Nothing is a better reminder of inequality and human suffering than a rough sleeper. These are human beings whose lives are likely to be cut short, given that homeless women die on average at 43 and homeless men at 47, compared with 77 for the rest of us.

In England, the number of people living on the streets increased by 16% in 2016, a statistic that matches anecdotal evidence that more are seen camped out in the shop doorways and alleys of our major cities. This is the most visible and stark kind of homelessness. But it goes on behind closed doors too, with almost 50 000 families living in bed and breakfast accommodation. Others without homes survive by going from friend to friend “sofa surfing.”

Homelessness is one indicator of a fundamental breakdown in a person’s life. According to the charity Homeless Link, four out of every five homeless people have some form of mental health problem, a high proportion have a physical illness, and others struggle with drug or alcohol misuse. As a result, more than a third say they have been admitted to an emergency department in the past six months.

The cost to the NHS of society’s failure to deal with homelessness and other examples of inequality has been estimated at £4.8bn (€5.4bn; $6.7bn) annually. A study by researchers at the University of York, based on a comparison of hospital admissions in deprived and relatively affluent parts of the country, concluded that the poor die young, and more expensively, than more affluent members of society. This is a perfect example of the inverse care law that says that those most in need of health and social care tend to get the least, as first outlined by GP Julian Tudor Hart in 1971.

This bill for inequality estimated by the researchers represents just under a quarter of the £22bn that the NHS needs to find in efficiency savings by 2020. The real challenge, though, is one that is solvable—how to provide preventive services in deprived communities that would have an impact on the hospital admission and death rates of poor people and reduce overall costs to the NHS.

The government response has included an increase in funding for homeless shelters. This April, the Homelessness Reduction Act comes into effect to enable councils to help those on the streets, to continue to house families, and to stop homelessness in the first place. The act is a triumph for organisations like Crisis that have persuaded the government to update laws for the modern era of homelessness.

But whether these reforms will reverse the seemingly inexorable increase in people living without a roof over their heads, and the concomitant impact on the health of those in this situation, is a moot point. In general, all the measures above would be laudable, but for the fact that local government itself is facing major cuts to the resources available to implement them thoroughly.

It is possible to take action that helps prevent premature deaths among this group and to provide the kind of interventions in the community that many take for granted. Turning Point’s homelessness primary care service in Camden is an example of this. When this service was launched, I was shocked at how neglected homeless people were by the health system in Britain, proof that the inverse care law was alive and kicking. I remember speaking to people whose only way of receiving health support was through visits to emergency departments. This was not just to get treatment for their, sometimes horrific, physical injuries, but because of their mental ill health and their desperate need for someone to notice them.

Homelessness is not inevitable. In the past 20 years there have been periods when it has fallen steadily, but these drops have not been sustained and we are starting to see the impact of this in 2018. Homelessness is not an episodic event, but something systemic. It is a neon sign that something is fundamentally wrong with policy across health and housing. The existence of homelessness and its increase raises the question of what was, or is, the intention of our public services.

Homelessness is the canary in the public policy coal mine—an indicator that we are failing to progress. Those left behind on the streets are an expensive reminder of our inability to look at them and to take a hard look at ourselves, our politicians, policy makers, and commissioners.

There can be no excuse for homelessness when Britain is ranked fifth richest country in the world. It is time that those in positions of responsibility were held to account.


  • Competing interests: I declare that that I have read and understood BMJ’s policy on declarations of interest and declare the following interests: none.

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